Synonyms

Rapport; Therapeutic relation

Definition

“Clinical issues” are the aspects that should be taken into consideration when performing clinical interventions with older adults. The term “clinical” is here used primarily for those professionals who work in behavioral health (i.e., nonsurgical, nonmedication), both at an assessments and intervention level, with older individuals.

Background

Don’t tell us, show us (Moreno’s Psychodrama Dictum)

The importance of giving attention to clinical issues in working with older adults has been well emphasized in the last years in emblematic articles (Knight 2004) and in psychological association professional practice guidelines. A representative example is the Guidelines for Psychological Practice With Older Adults originally developed by the Division 12, Section II (Society of Clinical Geropsychology) and Division 20 (Adult Development and Aging) Interdivisional Task Force on Practice in Clinical Geropsychology and approved as an American Psychological Association (APA) policy in August 2003. Their main aim is to assist psychologists and gerontology practitioners in evaluating their own readiness for working with older adults, and in seeking and using appropriate education, training, and supervision to increase their knowledge, skills, and experience thought to be relevant for this domain of practice. The specific goals of these professional practice guidelines are to provide practitioners with (a) a frame of reference for engaging in clinical work with older adults and (b) basic information and further references in the areas of attitudes, general aspects of aging, clinical issues, assessment, intervention, consultation, professional issues, and continuing education and training relative to work with this age-group.

The APA Guidelines for Psychological Practice With Older Adults are organized into six sections; the third concerns “Clinical Issues” and comprises three specific guidelines: The first is Guideline 7, which states that “Psychologists strive to be familiar with current knowledge about cognitive changes in older adults.” According to this guideline, from a clinical perspective, one of the greatest challenges facing practitioners who work with older people is acknowledging when to attribute subtle observed cognitive changes to an underlying neurodegenerative condition versus normal developmental changes. Multiple moderating and mediating factors, like lifestyle, contribute to age-associated cognitive changes, maintenance, or decline within and across individuals.

Guideline 8 states that “Psychologists strive to understand the functional capacity of older adults in the social and physical environment.” Here it is strained that the majority of older adults maintain high levels of functioning, suggesting that factors related to health, lifestyle, and the match between functional abilities and environmental demands more powerfully determine performance than does age (Baltes and Smith 2008). The degree to which the older individual retains “everyday competence” (i.e., the ability to function independently vs. rely on others for basic self-care) determines the need for support in the living environment. In adding aids in the older adult’s living environment, it is important to balance with the person’s need for autonomy and active and safe quality of life. Changes that have impact in functional capacity may immediately lead to modifications in social roles and may place emotional strain in the individual and informal carers. Older people must deal not only with the personal implications of these losses but also with the challenges of finding meaning in a more limited lifestyle. For some older adults, spirituality and other belief systems may be particularly important in dealing with these losses (Ribeiro and Araújo 2013).

Guideline 9 states that “Psychologists strive to be knowledgeable about psychopathology within the aging population and savvy of the prevalence and nature of that psychopathology when providing services to older adults.” This last guideline stresses that although the majority of older adults have good mental health, it should be taken in consideration that approximately 20–22% of older adults may meet criteria for some form of mental disorder, including dementia. For those living in a long-term care setting during their later years, estimates are much higher, with almost 80% suffering from some form of mental disorder. Older adults may therefore present a broad array of psychological issues for clinical attention. These issues include the majority of the problems that affect younger adults and those experienced due to late life events and tasks. These represent challenges that are specific to late life and include developmental and maturational issues and social demands. As examples of developmental issues we can mention the decrease of sensory acuity and increased likelihood of losing significant people and, as a social demand, retirement.

Knight and Poon (2008) proposed CALTAP (Adult Lifespan Contextual Theory for Adapting Psychotherapy) with the aim of providing a metatheoretical framework to guide an integrated psychotherapeutic approach with the elderly. In this theory the author advocates that an intervention with older people should take into consideration the positive (i.e., cognitive and emotional complexity) and negative (i.e., physical decline) factors of the maturation process of the client, as well as specific sociocultural environments (i.e., values and beliefs), the surrounding context (i.e., living in an institution vs. community), the cohort effect (i.e., influences like education that affect the members of a particular generation), and the challenges of old age (i.e., chronic disease). Together, these contextual and individual factors contribute and influence the problem presented by the older client and his/her expectations and degree of involvement in psychotherapy, as well as to the options of intervention appropriate to a particular case. It is therefore crucial to recognize the intricate interaction between the older adult and his/her environment.

Therapeutic Relationship with Older Clients

To rightly respond to functional, personal, social, cognitive, and psychopathological challenges of older clients it is indispensable to establish a meaningful therapeutic relationship. For the therapeutic process with older adults to successfully unwind theoretical and technical expertise are also necessary. However, independently on the orientation of the intervention, the therapist must have the ability to establish a deep connection with the client – the therapeutic relationship (Fagan and Shepherd 1970; Duffy 1999; Haley 1999; Zarit and Knight 1996). Regardless of the elderly intervention context, the communication skills of the therapist are one essential ingredient to the success of the intervention (Woolhead et al. 2006). Listening and responding accordingly is always important, requiring more attention when the older person has hearing difficulties. Speaking in a simple, direct, clear, and objective way, taking into account the nonverbal communication and without using technical language, is essential. It is also important to be present in the relationship, “not paddling against the current,” with the therapist open to the flow of experience, recognizing their limits as professionals and with attention to their own prejudices.

Accordingly, geropsychologists must work to actively reduce ageism. Ageism as a pervasive discrimination against older adults is widespread. The nondominant group (older adults in this case) is viewed as homogeneous and portrayed as having a variety of negative characteristics. People in old age are viewed stereotypically as alike; alone and lonely; sick, frail, and dependent; depressed; rigid; and unable to cope (Frazer et al. 2011). This pervasive view portrays all older adults in a negative light, ignoring the incredible heterogeneity of aging and old age and the strengths and positive attributes of older adults. Those geropsychologists working in clinical settings must be particularly cognizant of their own ageist thoughts and beliefs, and acknowledge its impact and try to prevent and minimize them within the therapeutic relationship. Rogers (1951) formulated this issue in a fundamental way: Can the therapist meet with this other individual as a person in the process “of being,” or will he stay tied to his own past or the client’s past? If the therapist relates to the older client as old, rigid, limited, immature, ignorant, unstable, or sick, each of these concepts will limit the relationship. Confirm means accepting the potential totality of the other. If the therapist accepts the other as something fixed, as “diagnosed and classified,” as shaped by the past, he will be doing his part to confirm this restrictive hypothesis. On the other hand, if he accepts the client as in process of “becoming,” he will be doing what he can to confirm or make real the potential of the individual.

Instead of giving unconditional positive regard, most of us give “value conditions,” depending on the satisfaction of our needs and expectations. When we care and we have no qualifications or conditions, there is the “unconditional positive regard.” Rogers (1951) argued that this quality of absoluteness, along with congruence and empathy, would be essential to foster a more confident human being capable of enjoying life more fully. It is then the therapists’ responsibility to create these favorable conditions for the flourishing of the older client. In this sense, the quality of the relationship has a major weight (though, certainly, other variables such as the therapeutic setting, client motivation, theoretical soundness, and the training and experience of the therapist are also important). By “quality of the relationship” it is meant the ability to establish good contact, i.e., the ability to listen to the other (literal and latent meanings), to produce a real action that can enhance change in the other, and to detect central aspects that can be worked through with the client with the aim of fostering well-being. The therapist’s attitude is based on empathy, willingness to help, and mostly on accepting the patient’s experience without judgment.

Fagan and Shepherd (1970) in a classic text on Gestalt Therapy refer to five aspects that the therapist should take into account for the clinical relationship to be effective: (1) accurate assessment and diagnosis; (2) having control of the therapeutic session (i.e., it is the therapist who wields the session for the client’s benefit); (3) solid theoretical and practical knowledge; (4) humanity and compassion toward the client; and (5) commitment and openness to continue learning. To make a therapeutic intervention involves the therapist as a whole person and constitutes therefore a challenge. Nevertheless, it is a condition for fostering the well-being of the client and will enable the older client to build self-support skills and a more realistic and adaptive view of life.

Working with Older Adults

The therapist working with older adults should be able to work “outside the box,” i.e., be more flexible concerning place, duration, and frequency of sessions and to have the ability to take on multiple roles (Haley 1999) in order to respond to customers that often have multiple physical and psychosocial problems and diverse and complex needs. Before starting a clinical intervention, the geropsychologist should pay attention to the entire therapeutic setting – i.e., all the details concerning the environment, the physical layout of the room, and the prevention of possible interruptions (Frazer et al. 2011). If these aspects are attained and an environment where there is trust, openness, and acceptance is provided, patients will express themselves without fear of censorship and engage actively in the therapeutic process. This is why it is important to identify resistances, make them explicit, and not pretend they do not exist. The resistance decreases when people take responsibility for how the interaction functions (Egan 1986).

Depending on the case and on the theoretical framework of the therapist during the therapeutic process several techniques (e.g., challenging, clarification, breathing and body awareness techniques) may be used to explore the material provided in favor of the natural course of the session and, therefore, consolidate and increase awareness and individual power and responsibility, even when the older client is very frail and this seems nearly impossible. Techniques are means not ends and should not divert the therapist from the creative and unique relationship with the older client and from the attention required to the emerging themes and needs in a session. In this sense, there are no “recipes” that the therapist should follow but tools and flexible guidelines that can be used. Moreover, the use of techniques can often mask the quality of a relationship.

Change, support, and problem solving are not made only on the basis of technical aids but come mainly from the relationship between the therapist and the patient. It is the quality of the relationship that will dictate (adduced to the sensitivity of the therapist) the time to use certain techniques (e.g., role play). Accordingly, the personal qualities and advocated values of the therapist are the most important and powerful tools regarding the ease of the therapeutic process. In this sense, the therapist should trust in his/her intuition and be authentic, since the techniques are received in the light of the attitudes of the facilitators that employ them (Egan 1986; Corey et al. 1983; Corey 1990). In short, the techniques are valuable and important but should be used with caution (Yalom 2005; Corey et al. 1983). If the therapist has a solid background and supervised experience, it is less likely to abusively use the techniques (Corey et al. 1983). Those therapists working with older people also benefit in being more flexible in their roles (i.e., feeding the patient, helping to call for other people, fostering other relationships) and more active and participatory (i.e., speak about themselves, give examples) (Knight 2004).

The conceptual framework and the therapist’s personality often dictate the choice of which technique to use, but this is also influenced by the link established with the client. There is always a huge variability of possibilities (i.e., the use of animals for people with dementia (Crowley-Robinson et al. 1996)), depending on age, purpose, and level of functioning of the patient but also on the expertise and creativity of the therapist. However, the therapist should recurrently question the appropriateness of a certain technique. When it is possible and meaningful, it is important to ask the client their willingness to participate and to acknowledge any possible resistance. The clinical/therapeutic setting is a field for authentic human interaction and learning. In this sense, the techniques should not be seen as tricks but tools to be used in support of patient needs.

The therapist’s countertransference analysis (“how I feel with what the client said/did? What does it mean to me?”) is crucial in a relationship that is often regulated by unusual changes on the therapeutic context. For instance, in many intervention cases the older client is bedridden (Altschuler and Katz 1999; Smith 2006). However, the transference and countertransference, which depend on the previous relationships of the client and of the therapist, may lead to therapeutic impasse and resistance to treatment (Knight 2004). Taboos (e.g., certain themes should not be spoken with older or younger people) and the complexity of the institutional contexts (e.g., the clinician can have different roles in the same institution; different professionals dealing with the client make clinical decisions more complex) can make the management of this dynamic an enormous challenge. In this sense, the therapist has the responsibility to examine personal prejudices in relation to age, disease and gender, and any beliefs or conflicts with their own parents and grandparents that he may bring as relational patterns to the therapeutic relation. If this does not happen, the therapist may be limiting the possibilities of helping clients to develop. In general, the therapist is blocked where he/she often has difficulties as a person (Perls 1976).

When clients are considered experts in their own lives, they feel mobilized and encouraged to use their resources toward their goals (Smith 2006) and to be active and interventional agents in their own change process (Smith 2006). This perspective about patients as being a repository of resources, rather than being seen as a confluence of problems, favors the therapeutic alliance. To promote the quality of life of the elderly – in face of the complex amount of problems, difficulties, diversity of personality profiles, and the multiple needs and desires people often have to deal with in the last phase of their life cycle – the availability of a wide range of therapeutic possibilities is crucial. Numerous psychological therapies have been demonstrating their effectiveness in supporting older people. Attention to issues concerning education, training, and supervision are therefore core aspects in providing all the technical capacity to the therapist and in helping to understand each person within a biopsychosocial framework. It is also important to acknowledge that all geriatric care occurs within a team context (see the “Interprofessional Care” entry for this purpose) and that integrated care is the preferable model. Clinical geropsychologists should additionally know how to use multiple methods of assessment, including brief assessment tools.

The focus on the relationship, the “meeting” that the encounter between two persons (therapist and client/group) allows, updates some of the principles that have been repeatedly confirmed by research and due to the vicissitudes of the context or of daily life therapists tend to forget. Such principles allow human flourishing and can be summarized in the importance of humanization of health services and interventions, the imperative need of adequate training and supervision in interventions with older patients, the importance of empowering and giving personal responsibility to the individual, and the crucial role of both creativity and dignity interventions. The answer to the wish to grow in all stages and contexts of life can be the authentic creative encounter that the therapeutic relationship enables and therefore should be promoted.

Cross-References