Heritage Clinic

a division of The Center for Aging Resources, a nonprofit agency

447 N. El Molino Ave.

Pasadena, CA 91101
(626) 577-8480
Fax (626) 577-8978
www.centerforagingresources.org
 Evidenced Based
Mental Health Interventions for
Older Adults
Janet Anderson Yang, Ph.D.
Heritage Clinic
a division of the Center for Aging Resources
Pasadena, California

2
Introductions
Do you:
1. Work directly with older adults as a care manager?
2. Work directly with older adults as a therapist?
3. Supervise an older adult program?
4. Dont work with older adults now but expect to in the
future?
5. Other?

3
Outline
Introductions

Overview of mental health services for

older adults

Evidenced Based Practices

Highlight on Evidenced Based Life

Review & Reminiscence Therapy

4
Overview of Mental
Health Interventions with
Older Adults
1. Cohort differences
2. Health changes
3. Developmental changes
4. Cognitive changes

5
Cohort
Differences: older old
1. May have lived through Great Depression,
WWII, 50s
2. Value on frugality & independence
fear of institutions, system
3. Stigma of mental health treatment
institutionalization, shock tx
4. Less familiar with talking interventions
5. Tendency to somaticize

6
Cohort Differences:
Adaptations Needed
1. Often do not self refer, need to collaborate with
referring party
2. May need to pursue a client
3. Use less threatening language
a) Counselor vs. psychotherapist or mental health
worker
b) Stress or nerves vs. anxiety
c) The blues vs. depression
d) Talking about problems vs. psychotherapy (terms:
mental ---- psycho)

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Cohort Differences:
Adaptations (cont.)
5. Provide education about process of treatment
6. More rapport building time
7. Help to meet concrete need can aid rapport
8. Demonstration of understanding of age-specific
issues (B. Knight)

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Health
Changes
1. 80 % adults over 60 have chronic illnesses
2. Many have multiple chronic illnesses
3. Multiple medications: 90% take 1+ med; 40% take 5+ meds;
12% take 10+ meds
4. Physical mobility impairment
5. Vision impairment; hearing impairment
6. Chronic pain
7. Physical illness is a risk factor for suicide
8. Older adults fatigue more easily 9
Health Changes:
Adaptations
1. Offer treatment in consumers home, nursing
facility, assisted living, etc.
2. Intervene at a slower pace
3. Assess & learn about consumers medical illnesses
4. Record & learn about all medications
5. Communicate with consumers primary care
physician
6. Become knowledgeable about practical services
and devices for disabled persons
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Health Changes:
Adaptations (cont.)
7. Use large fonts for printed material
8. Assess consumers hearing acuity; use voice
amplification devices
9. Speak loudly, enunciate clearly; be sure
consumer can see your face
10. Assess pain and become knowledgeable about
pain control interventions
11. Evaluate for over use of pain medications
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Developmental
Issues
1. Losses
2. Death & dying
3. Retirement
4. Grandparenting
5. Family role changes
6. Social status changes
7. Wisdom

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Cognitive Changes/
Dementia
Normal age associated
changes
Mild cognitive
impairment
Changes with dementia
Changes in delirium

13
Cognitive Changes:
Adaptations
1. Have consumer evaluated for contributing
medical causes
2. Evaluate type and degree of cognitive impairment
3. Expect a slower pace; use repetition
4. Communicate in simpler sentence structure, e.g.,
one chunk at a time
5. Treat co-occurring mental illness, e.g.,
depression, psychosis, anxiety, behavior
6. Monitor progression or lack of progression
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EVIDENCED BASED PRACTICES

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RESOURCES
NREP website:
http://www.nrepp.samhsa.gov
Conduct Advanced Search
Check Older Adult (55+); Mental Health Treatment

Therapy Advisor website

Geriatric Therapies
Geriatric Depression
Caregiver Distress
http://www.therapyadvisor.com/taTreatment.aspx?dis
lD=37&trlD=10
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Outline of Evidenced
Based Interventions
Outreach Models
Prevention Models
Treatments for Depression
Treatments for Anxiety
Integration with Medical Care
Suicide Prevention
Caregiver Interventions

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OUTREACH MODELS:
Gatekeeper Program
The Gatekeeper program was developed
to train and encourage non-traditional referral
sources to identify and refer older adults living in
the community who are at risk for mental health
problems, but not typically receiving mental health
services. Studies of the Gatekeeper program have
found differences in individual characteristics
between individuals referred by gatekeepers and
those referred by medical or other traditional
sources.
Reference: SAMHSA Older Americans Substance Abuse & Mental
Health Technical Assistance Center
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Gatekeeper Program
Follow up research found that while initially,
gatekeeper-referred elders utilized very few services
compared with traditionally referred elders, after one
year, gatekeeper-referred elders showed no difference in
service utilization.
Florio et al, 1996; Florio, E.R., Dyck, D.G., Rockwood, T.H.,
Hendryx, M.S., Jensen, J.E., & Raschko, R. (1996). A model
gatekeeper program to find the at-risk elderly: Client
characteristics and service needs. Journal of Case
Management, 5, 106-114

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Prevention Models
for Older Adults
Chronic Disease Self-Management
Live Well, Live Long
Promotoras/es
Exercise

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The Chronic Disease Self
Management Program
Includes community workshops for older adults with chronic
health problems.
Facilitated by 2 leaders, one or both of whom are non
professionals with a chronic disease themselves.
Subjects covered include:
1) Skills to deal with frustration, fatigue, pain, isolation
2) Exercise
3) Appropriate medication use
4) Effective Communication
5) Nutrition
6) How to evaluate new treatments
Reference: http://patienteducation.stanford.edu/programs/cdsmp.html
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Live Well, Live Long
Steps to Mental Wellness
Group intervention encouraging health promotion
behaviors that contribute to mental wellness and a
sense of well-being.
Interventions performed in community
organizations such as senior centers.
Address depression & anxiety symptoms early to
reduce distress and disability older adults may
face.
http://www.asaging.org/live-long-live-well-health-
promotion-older-adults
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Promotoras/es
Community lay leaders spend time in the community
providing health education and health promotion.
Some have some level of formal health training, such as
nursing or midwifery, others have learned their skills from
a parent or mentor.
Promotoras/es have been one of the major outlets for
health care for rural populations in Mexico, and migration
has brought this trend to California.
Based on the respect and trust in the community,
promotoras/es are able to transmit health messages and
services to this population.
Reference: HIA, UC Berkeley, School of Public Health
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Evidenced Based Practices
for Older Adults: Depression
Medications Brief Psychodynamic Tx
Electro Convulsive Supportive Therapy
Therapy (ECT) Interpersonal
Cognitive- Behavioral Psychotherapy
Tx Integration with
Problem Solving medical care (e.g.,
Therapy IMPACT)
Reminiscence & Life Behavioral Activation
Review Therapy Acceptance Commitment
PEARLS Therapy (ACT)
Healthy IDEAS Exercise 24
Cognitive Behavior Therapy
for Late Life Depression
An active, directive, time-limited, and structured
problem-solving approach program.
Includes strategies to facilitate learning with older
adults, such as:
repeated presentation of information
using different sensory modalities
slower rates of presentation
greater use of practice
greater use of structure and modeling behavior
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26
Problem Solving Therapy
Structured cognitive behavioral therapy for
depression and other mental illnesses.

e.g., P. Arean, M. Hegel, S. Vannoy, M. Fan & J.

Unuzter. Effectiveness of Problem solving
therapy for Older, Primary Care patients with
Depression. The Gerontologist (2008).
48(3).311-323.

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Problem Solving Therapy:
Treatment Steps
1. Clarify & define the problem
2. Set realistic goals
3. Generate multiple solutions
4. Evaluate & compare solutions
5. Select a feasible solution
6. Implement the solution
7. Evaluate the outcome

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PEARLS
Program to Encourage Active, Rewarding
Lives for Seniors
For people 60 years and older
Minor depression or dysthymia
Receiving home-based social
services from community
agencies
Includes eight 50-minute
sessions with a trained social
service worker in the client's
home over 19 weeks
Ciechanowski et al. (2004). Journal of the
American Medical Association 29
PEARLS
Program to Encourage Active, Rewarding
Lives for Seniors

Counselors use 3 depression management

techniques:
1) Problem-Solving Treatment, in which clients are
taught to recognize depressive symptoms, define
problems that may contribute to depression, and
devise steps to solve these problems;
2) Social and physical activity planning; and
3) Planning to participate in pleasant events.

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 Pleasant Events Schedule
First developed - Peter Lewinsohn
Different Versions
California Older Adults Pleasant Events
Schedule
http://oafc.stanford.edu/coppes.html

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Interpersonal
Psychotherapy*
Originally developed by Gerald Klerman and
Myrna Weissman with younger adults. Later
applied to older adults. Based on work by Adolph
Meyer and Harry Stack Sullivan.

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Interpersonal
Psychotherapy for
Depressed Older Adults,
2006. Hinrichsen, G.Y.
Clougherty, K. Washington
D.C: American
Psychological Assoc. Press

33
IPT:
Based on the connection between
interpersonal issues and depression,
including
1. grief,
2. role transitions and
3. interpersonal disputes.

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Relate Depression to Interpersonal Context
Review current and past interpersonal
relationships as they relate to current depressive
symptoms. Determine with the patient the
nature of interaction with significant persons;

expectations of patient and significant persons

from one another, and whether these were
fulfilled;
satisfying and unsatisfying aspects of the
relationships;
changes the patient wants in the relationship.

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Identification of Major Problems Areas
Determine the problem area related to

current depression and set the treatment goals.

Determine which relationship or aspect of a

relationship is related to the depression and what
might change it.

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Interpersonal
Psychotherapy
Clinician takes an inventory of present and past
relationships to determine areas of focus.
1 or 2 interpersonal problem areas are chosen for
treatment focus.
16-20 session time frame.
Present focused.

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Interpersonal
Inventory
To get an
understanding of
your social support
network, please
give me names of
Intimate
7-8 people & place
them on these
circles based on Close
how close they are
to you. Extended

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Evidenced Based Practices for
Older Adults: Anxiety
Cognitive Behavioral
Therapy
Relaxation Training
Cognitive Therapy
Supportive Therapy
Psychotropic medications
Problem Solving Therapy

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Cognitive
Behavioral Therapy
Psycho-education
Self monitoring
Relaxation training
Thought stopping
Thought challenging
Exposure to sources of anxiety

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Relaxation Training
Breathing
Meditation
Progressive muscle relaxation
Imagery creative or memory based
Importance of practice
Usefulness of making audio
recording for client
Script

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Integration with
Medical Care

Shared care of depressed elders between on-site

mental health professional and primary care
physician, located in primary care setting; close
attention to outcomes.
IMPACT (Improving mood: promoting access to
collaborative treatment)
PRISM-E (Primary care research in substance
abuse and mental health for the elderly)
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IMPACT
Improving Mood, Promoting Access to
Collaborative Treatment
In the IMPACT model, integrated care is provided
by a collaborative team.
Services are provided in the Primary Care medical
clinic.
Primary care physicians identify individuals with
depression.
Patients are referred to a care manager
who works within the same office suite.
Care manager works with the regular
physician & consulting psychiatrist.
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IMPACT
Treatment includes:
psychotropic medications
educational videotape & booklet about
depression
initial visit with a depression care manager
6 - 8 brief sessions of Problem Solving Therapy
behavioral activation
regular and repeated assessment and tracking of
depression using the PHQ-9
stepped care, i.e., treatment is adjusted if the
patient is not improving.
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IMPACT
Improving Mood, Promoting Access to
Collaborative Treatment

Antidepressants are changed or dosages adjusted if

improvement is not indicated. Psychiatrist consults
with primary care physician to help adjust
medications.

The care manager aggressively follows up on patients

who have not returned for follow up visits.

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IMPACT
Improving Mood, Promoting Access to
Collaborative Treatment

Collaborative care approach found to be two times as

effective than care as usual.

Most patients saw a 50% or greater improvement in

depression at 12 months.

Health care costs were found to decrease by about

$3,300 per patient over 4 years.

Unutzer, J. et al. (2002) Journal of American Medical Association

(Dec.).
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Suicide Prevention
Models
SUPPRESS

PROSPECT

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PROSPECT:
Preventing Suicide in Primary Care
Elderly Collaborative Trial

The intervention components are:

recognition of depression and suicide ideation by
primary care physicians,
application of a treatment algorithm for geriatric
depression in the primary care setting, and
treatment management by health specialists.
Depression scores and suicidal ideation were
reduced in intervention group; but results are
equivocal.
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 HIGHLIGHT ON
LIFE REVIEW &
REMINISCENCE THERAPY

49
Erik Erikson

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Stage (age) Psychosocial crisis

I (0-1) -- infant trust vs mistrust

autonomy vs shame and
II (2-3) -- toddler
doubt

III (3-6) -- preschooler initiative vs guilt

IV (7-12 or so) -- school-age child industry vs inferiority

ego-identity vs role-
V (12-18 or so) -- adolescence
confusion

VI (the 20s) -- young adult intimacy vs isolation

VII (late 20s to 50s) -- middle generativity vs self-

adult absorption
VIII (50s and beyond) -- old
integrity vs despair
adult
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Integrity
Erikson: the 8th stage, conflict
between integrity and despair; the
approach of death stimulates review of
life to prepare for death.

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Eriksons Eighth Stage
The primary task in old
age is to come to an:
acceptance of ones one
and only life cycle as
something that had to be
and that, by necessity,
permitted of no
substitutions.

53
Eriksons Eighth Stage
This involves: a consolidation of ones
understanding of the life one has lived, to be
achieved through the struggle between integrity
and despair, including mourning for:
time forfeited and space depleted,
autonomy weakened,
initiative lost,
generativity neglected,
identity potentials bypassed,
too limiting identity lived.

E. Erikson: The Life Cycle Completed, p.63.

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Psychosocial Crisis
Integrity vs.
OLD AGE VIII Despair.
WISDOM

ADULTHOOD VII Generativity vs.

Stagnation. CARE

YOUNG Intimacy vs.

VI
ADULTHOOD Isolation. LOVE

Identity vs.
ADOLESCENCE V Identity
Confusion.
FIDELITY
Industry vs.
SCHOOL AGE IV Inferiority.
COMPETENCE
Initiative vs.
PLAY AGE III Guilt.
PURPOSE

EARLY Autonomy vs.

II Shame,
CHILDHOOD Doubt. WILL
Basic Trust vs.
Basic
INFANCY I
Mistrust.
HOPE
1 2 3 4 5 6 7 8
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56
Robert Butler, 1964
Robert Butler suggested that later life is a time for
people to review their lives, allowing a return to
consciousness of past experiences, especially
unresolved conflicts; this can bring serenity and
wisdom; (can also bring depression and
obsessiveness).
The goal of life review is to expiate guilt, resolve
internal conflicts, reconcile relationships, and
renew ones ideals.

57
Wong & Watt (1991)
6 types of reminiscence
1. Integrative: to achieve reconciliation & coherence;
resolving conflicts
2. Instrumental: problem-solving
3. Transmissive: storytelling & leaving a legacy
4. Escapist or Defensive: avoiding pain in present
5. Obsessive: ruminating on failure & guilt
6. Narrative: factual & informative

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Reminiscence as
Therapy
Structured activity to access and process thoughts
about past experiences
Done individually or in groups
May include writing assignments

59
Reminiscence as
Therapy
Integrative reminiscence refers to reappraisal of
losses, shortcomings and difficulties, reviewing
values, and personal meaning
Instrumental reminiscence refers to recall of
problem solving and positive adaptation and
reactivating positive self concept

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Reminiscence & Life
Review as Therapy
Watt & Cappeliez (2000)
Group Integrative Reminiscence (reappraisal of
past events) & Instrumental Reminiscence
(using memories of past successful coping and
identifying appropriate coping strategies)
Both reduced depression

61
Serrano et al (2004)
Reminiscence therapy focused on
retrieving special, successful happy
memories associated with decreased
depression

62
Questions from Serrano, et al, (2004)
What is the most enjoyable moment from your
childhood you remember?
What moment sticks out from your adolescence that
you always remember as great and was not like any
other?
Can you recall a day as an adult when you set out to
accomplish something, that you were able to achieve
and that made you very happy?
How did you have fun, recall something important
that happened during your adult years.

63
Phillipe Cappeliez (2011)
Positive:
Improving self identity gaining continuity,
meaning, self efficacy
Problem solving
Preparing for death reconciling discrepancies
Associated with increased life satisfaction,
decreased depression, higher subjective health;
improvement in meaning & personal
continuity

64
Arean et al (1993)
Group Reminiscence treatment
involving reviewing ones life history,
including positive and negative
events, led to decreased depression,
and increased perspective and
satisfaction with what had and had
not been achieved

65
Life Review Techniques
Time Line
Mark years and ages of the person
Ask person to recall important personal events,
e.g., educational events, family events, work,
accomplishments, loves, losses, hopes, regrets,
pleasures
Use important world events as markers

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HEALTH
RELIGION
PETS
FRIENDS
JOBS
EDUCATION
FAMILY
MAJOR LIFE EVENTS
_________________________________
AGES
DATES
WORLD EVENTS
67
Life Review Techniques
Use aids to revive memories
Photo albums, historical picture books, old
letters, diaries, scrap books, mementos, music,
foods, smells, textures

68
Life Review Techniques
Trace clients experience based on a theme
e.g., pets, money, education, religion, family,
love relationships, places of residence
Encourage client to take a pilgrimage to an old
home, neighborhood, workplace, reunion
Family Life Review
Family Tree
Write an autobiography

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70
Knight, 1996
Domains to be considered
Family of origin, significant
developmental issues
Educational experiences
Cohort membership
Sexual history
Love history
Children & adult family life
Work history

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Knight, 1996
Domains to be considered (cont.)
Sense of ethnicity, gender, social class as
influences on life
Body image & changes in body
Religious/spiritual history or life view
Experiences of death
Sense of the future

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Example
Examples
FH, CG Integrative reminiscence
SA Instrumental reminiscence
TA Family unfinished business

73
Questions
What is the first thing you remember in your life? Go back as far as you
can.

Who were the important people in your life when you were a child
(parents, brothers, sisters, friends, people whom you were especially close
to, teachers, people whom you admired, people whom you wanted to be
like)?

What losses did you experience as a child?

When you think about yourself and your life as a teenager, what is the first
thing you can remember about that time?

What were the pleasant things about your adolescence?

What important events occurred in your life when you were a younger
adult?

74
Questions
Tell me about your work. Did you enjoy your work? Did you earn an
adequate living? Did you work hard during those years? Were you
appreciated?

What were some of the main difficulties you experienced during your
adult years? How did you feel when experiencing these difficulties? How
did you cope with them?

What losses have you experienced as an older adult? How did you feel
after those losses? How have you coped?

What have you gained during this period?

On the whole, how would you evaluate your life? What advice would you
give to others?

If you were going to live your life over again, what would you change?
Leave unchanged?
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Life Review Resources
Bender, Bauckman & Norris, 1999. The Therapeutic Purposes
of Reminiscence. Sage Publications.
James Birren & Kathryn Cochran. Telling the Stories of Life
Through Guided Autobiography Groups, Johns Hopkins
Univ. Press.
Birren & Deutchman, 1991. Guiding Autobiography groups for
older adults. Johns Hopkins Univ. Press.
Butler, Robert. 2002. Age, Death, and Life Review. Living With
Grief: Loss in Later Life. Hospice Foundation of America.

76
Life Review &
Reminiscence Resources
B. Haight & B. Haight. 2007. The Handbook of Structured Life
Review. Baltimore MD: Health Professions Press, Inc.
Hargrave and Anderson. 1992. Finishing Well: Aging and
Reparation in the Intergenerational Family.
Brunner/Mazel, Inc. NY, NY.
Knight, Bob G.,McCallum,T.J., Psychotherapy with older adult
families: The contextual, cohort-based maturity/specific
challenge model in Nordhus, Inger Hilde (Ed); VandenBos,
Gary R. (Ed); Berg, Stig (Ed); Fromholt, Pia (Ed).(1998).
Clinical geropsychology. (pp. 313-328). Washington, DC,
APA.
77
Life Review &
Reminiscence Resources
Kunz & Soltys, 2007. Transformational reminiscence: Life
Story work. Springer.
Tristine Rainer. The New Diary: How to Use a Journal for self-
guidance & Expanded creativity. Tarcher/Penguin Group,
1979.
Tristine Rainer. Your life as Story: Writing the New
Autobiography, 1997, Tarcher/Penguin Group.
Linda Spence. 1997. Legacy: A step-by-step guide to writing
personal history. Athens Ohio: Swallow Press/Ohio
University Press.
78
References
Ayers, C. Sorell, J., Thorp, S. & Wetherell, J. (2007).
Evidenced Based Psychological treatments for late life
anxiety, Psychology and Aging, 22(1), 8-17.
Baumann, Steven L. Recovering From Abuse: A Comparison
of Three Paths Nursing Science Quarterly 2007 20: 342-
348.
Fleming, M., Manwell, L., Barry, K., Adams, W. & E.
Stauffacher (1999). Brief physician advice for alcohol
problems in older adults, Journal of Family Practice,
48(5):378-384.
Frazer, D. Christensen, H. & Griffiths, K. (2005). Effectiveness
of treatments for depression in older people, MJA, 182(12),
627-632.
79
References
Healthy Aging Programs
http://www.healthyagingprograms.org/resources/Recom
mended_Programs.pdf
Levkoff, S., Chen, H., Fisher, J. & McIntryre, J. (2006).
Evidenced Based Behavioral Health Practices for Older
Adults. New York, NY: Springer Publishing Co.
Mittelman, M., Ferris, S., Shulman, E., Steinberg, G.
Ambinder, A., Mackell, J. & J. Cohen. (1995). A
Comprehensive Support Program: Effect on Depression
in Spouse-Caregivers of AD Patients. The Gerontologist,
35(6), 792-802.

80
References
Myers, J. & Harper, M. (2004). Evidence based effective
practices with older adults. Journal of Counseling and
Development, Spring, 82, 207-218.
Penninx, B., Messier, S., Rejeski, W. et al. (2001). Physical
exercise and the prevention of disability in activities of
daily living in older persons with osteoarthritis.
Pereles, L., Romonko, L., Murzyn, T., et al. (1996).
Evaluation of a self-medication program. Journal of the
American Geriatrics Society, 44(2):161-165.
Petty, B., Moeller, T. & R. Campbell (1976). Support groups
for elderly persons in the community. The Gerontologist,
16(6), 522-528.
81
References
SAMHSA TAC: Evidence-Based Practices for Preventing
Substance Abuse and Mental Health Problems in Older
Adults
http://www.samhsa.gov/OlderAdultsTAC/EBPLiterature
ReviewFINAL.doc
SAMHSA: Mentally Health Aging; A report on Overcoming
Stigma for Older Americans
http://download.ncadi.samhsa.gov/ken/pdf/SMA05-
3988/aging_stigma.pdf
Schommer, J., Byuers, S., Pape, L., Cable, G., Worley, M.,
Sherrin, T. (2002). Interdisciplinary medication
education in a church environment. American Journal of
Health-System Pharmacy, 59(5):423-428.
82
References
Scogin, F. (2007). Introduction to the special section on evidence
based psychological treatments for older adults, Psychology &
Aging, 22(1), 1-3.
Scogin, F. & Shah, A. (2012). Making Evidence-Based psychological
treatments work with older adults. Wash. DC: APA.
Serrano, Latorre, Gatz & Montanes. (2004). Life Review Using
Autobiographical Retrieval Practice for Older Adults with
Depressive Symptomatology. Psychology & Aging. 19(2). 272-
277.
Toseland, R. (1995). Group work with the elderly and family
caregivers, Springer Publishing co. NY: NY.
Wallace, J., Buchner, D., Grothaus, L. et al. (1998). Implementation
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M301-M306.
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Contact Information
Janet Anderson Yang, Ph.D.
Center for Aging Resources
447 N. El Molino Ave.
Pasadena CA 91101
626-577-8480
[email protected]

84