Psychotherapy With Older Adults Research Paper

It is hoped that these discussions will contribute to improved treatment access for older adults. Facilitating patients’ access to therapy and establishing an effective therapeutic relationship are crucial to all forms of psychotherapy and to all groups of patients. Several factors may combine to undermine the utilization of mental health services by older adults (Gallo, Marino, Ford, & Anthony, 1995; Zivian, Larsen, Gekoski, Hatchette, & Knox, 1994). These include inadequate detection of mental health illness among elderly patients (e.g., due to insufficient geriatric assessment), reluctance on the part of elders to seek mental health care (e.g., because of fear of stigma), and failures to recognize an older adult’s need for psychotherapy by referral sources and mental health professionals (e.g., due to ageism or to poor training).

A recent investigation of attitudes toward mental health services held by older adults is of special relevance in this respect. In this study, Currin, Hayslip, Schneider, and Kooken (1998) found that younger cohorts of older adults held more positive attitudes toward mental health services than did older age cohorts. These data suggest that deficits about knowledge regarding aging and mental health, impediments to financial support of the cost of therapy, barriers to the availability of services, and negative expectations about effectiveness of treatment all decrease among the later born cohorts of older adults. The authors also suggested that younger cohorts expect mental health professionals to be of help and in turn may be more likely to actively seek therapeutic help. Epidemiological trends may mirror this cohort-linked shift in attitudes toward mental health treatment. Koenig, George, and Schneider (1994) argued that the increasing prevalence of mental disorders in successively later born cohorts implies a greater need for mental health services among the older adults of coming decades than in those generations who have been elderly in the past. These shifts clearly have implications for clinical management and implementation of psychological treatment, such as an increased need for mental health professionals skilled in providing mental health services to older adults.

Empirical Support for the Effectiveness of Psychotherapy

The following section reviews the empirical evidence for the effectiveness of psychotherapy with older adults. Standards for evaluation of therapy effectiveness are found in the work of task forces on empirically supported psychological treatments within the American Psychological Association’s (APA’s) Division 12. The task forces have concentrated on treatments for specific psychological problems (Chambless et al., 1998; Task Force on Promotion and Dissemination of Psychological Procedures, 1995). These guidelines have been applied to the literature on psychological interventions with older adults by Gatz and associates (1998). They report that behavioral and environmental interventions for older adults with dementia meet the standards for “well-established, empirically supported” therapy. “Probably efficacious” therapies for the older adult include cognitive behavioral treatment of sleep disorders and psychodynamic, cognitive, and behavioral treatments for clinical depression. For anxiety disorders, the authors conclude that the few treatment studies of psychological interventions conducted to date do not meet these standards, due to lack of a control group and concomitant treatment with anxiolytic drugs. Life review and reminiscence, techniques discussed later in this research paper, are probably efficacious in improvement of depressive symptoms or in producing higher life satisfaction. In the following summary we examine the application of psychological interventions to specific problems faced by older adults, with attention to available empirical literature.

Chronic Illness and Disability

Conducting psychotherapy with emotionally distressed older adults very often means working with older adults who are chronically ill or physically disabled, and who are struggling to adjust to these problems while suffering concurrent depression (Zeiss, Lewinsohn, Rohde, & Seeley, 1996). Estimates of the prevalence of adults over the age of 56 with at least one chronic illness range from 50% to 86% (Boczkowski & Zeichner, 1985; Ham, 1983; National Center for Health Statistics, 1987). Important components of working with this population include learning about chronic illnesses and their psychological impact, control of chronic pain, adherence to medical treatment, rehabilitation strategies, and assessment of behavioral signs of medication reactions.

There has been little study of the effectiveness of psychotherapy with medically ill older adults. However, the few studies completed to date have been encouraging. Arean and Miranda (1996) found cognitive and behavioral approaches effective in relieving symptoms of depression in medically ill outpatients. In another study, Lopez and Mermelstein (1995) found cognitive and behavioral interventions successful in treating depression with inpatients in a hospital geriatric unit. The authors of this study described a treatment program in which patients received 30-min therapy sessions three to four times per week, with an emphasis on increasing pleasant events and cognitive restructuring. Psychological treatment was coordinated with physicians and nurses involved in patient care.

In addition to treating depression in medically ill or disabled elders, psychotherapy can also be used to help manage pain. It has been estimated that 25% to 50% of communitydwelling elderly suffer from chronic pain (Crook, Ridout, & Browne, 1984), with rates of 45% to 80% for elderly who live in nursing homes (Roy & Michael, 1986). Chronic pain is associated with rheumatoid arthritis and delayed healing from injuries. Pain management methods that may be incorporated into psychotherapy sessions include distracting oneself from the pain, reinterpreting pain sensations, using pleasant imagery, using calming self-statements, and increasing daily pleasurable activities (Widner & Zeichner, 1993). Employment of these cognitive and behavioral techniques in therapy may help clients reduce dependence on medication to manage pain. Because chronic pain is associated with depression in older adults (Ferrell, Ferrell, & Osterweil, 1990; Parmalee, Katz, & Lawton, 1991), effective pain management has the potential to reduce risk of depression.

Although medication is frequently indicated to help relieve pain in older adults, outcome studies have shown that cognitive and behavioral techniques are also effective in helping clients manage pain (Cook, 1998). In this study, which included a treatment group of 22 nursing home residents, participants who received cognitive behavioral pain management training reported less pain and less pain-related disability than those in an attention/supportive-control group. Participants were randomized in this study, and were screened to eliminate subjects with serious cognitive impairment. Treatment gains in the cognitive behavioral group were maintained at a 4-month follow-up.

Depression

Depression is prevalent in older adults who are chronically ill (if disability is present) or grieving. However, research findings contradict the stereotype of the older person as frequently depressed, since depression is actually less prevalent in older adults than it is in younger ones: 1% of older adults have a lifetime prevalence of major depression, whereas 6% of younger adults have been diagnosed with a major depressive episode (Robins et al., 1984).

Fortunately, depression in older people appears to respond well to psychological interventions. Gallagher and Thompson (1983) compared cognitive, behavioral, and brief insightoriented therapy with a total of 38 adults over the age of 55.All three groups showed reduction in symptoms of depression, but the cognitive and behavioral groups maintained gains better at follow-up. A similar study with 115 subjects over the age of 60, with the same three treatment conditions and a waiting-list control, found all three treatment approaches superior to the control group, with each mode of psychotherapy equally effective. At follow-up, all three treatment groups maintained gains equally (Thompson, Gallagher, & Breckenridge, 1987; seealso Teri,Curtis,Gallagher-Thompson,&Thompson,1994).Arean et al. (1993) compared group reminiscence therapy, problem-solving therapy,and a waiting-list control. Both groups showed reduction in depressive symptoms in comparison to the control, although the problem-solving group showed greater improvement, a difference that was maintained at a 3-month follow-up. In a recent study that examined the effectiveness of interpersonal psychotherapy for maintenance following treatment of recurrent major depression with antidepressants, Reynolds et al. (1999) found that both interpersonal therapy and nortriptyline were superior to a placebo in preventing relapse, and that combining both treatment methods was superior to either one in isolation.

Anxiety

Although prevalence rates have varied among studies, results from epidemiological investigations indicate that symptoms of anxiety, as well as recognized anxiety disorders, constitute a significant problem among older adults (Blazer, George, & Hughes, 1991; Robins & Regier, 1991). As with depression, anxiety frequently occurs in association with physical illness and disability in late life (Fisher & Noll, 1996).

The few intervention studies conducted to date suggest that behavioral interventions for anxiety symptoms are promising. Progressive muscle-relaxation training appears to be effective in reducing levels of anxiety as well as self-reported psychiatric symptoms among community-dwelling samples of older adults. Rankin, Gilner, Gfeller, and Katz (1993) found that one session of relaxation training significantly reduced trait anxiety according to a modified version of the Spielberger StateTrait Anxiety Inventory. Yesavage (1984) found that older adults were less anxious than a control group after 3 weeks of progressive muscle-relaxation training. Scogin, Rickard, Keith, Wilson, and McElreath (1992) investigated the effects of relaxation on a group ofolder adults with high self-reported anxiety. They found that progressive muscle-relaxation and imaginal relaxation techniques were equally effective in increasing relaxation level and in reducing anxiety and psychiatric symptoms. In this study, imaginal relaxation entailed participants’ visualizing the tensing and releasing of each muscle group, rather than actually doing so. These gains were maintained at follow-up 1 month after training. A follow-up studyconductedontheparticipants1yearlaterfoundthatboth treatment groups showed continued improvement in relaxation levels, with gains maintained on measures of anxiety and psychiatric symptoms (Rickard, Scogin, & Keith, 1994). This report did not indicate how often participants continued to use relaxation techniques in the intervening year. However, other studies have suggested that continued practice of relaxation techniques is necessary to maintain anxiety symptom reduction (De Berry, 1982; De Berry, Davis, & Reinhard, 1988).

The positive effects of relaxation training appear to be quite broad. De Berry (1981–82) found that a group of anxious widows reported less anxiety, less muscle tension, better sleep, and fewer headaches following 10 weeks of combined progressive muscle relaxation and guided visual imagery. Reduction in anxiety was maintained at follow-up 10 weeks later, although the study did not make clear whether the other improvements were maintained. Relaxation has also been useful in reducing anxiety and breathing problems in older medical patients (Gift, Moore, & Soeken, 1992). In the context of group psychotherapy, relaxation training may also reduce symptoms of generalized anxiety disorder (Wetherell, personal communication, June 19, 2000).

Alcohol Problems

Although rates of alcohol abuse and dependence are lower for older adults than for younger ones, drinking remains a serious problem among the elderly. Aside from the psychological and social problems accompanying addiction, alcohol-related health risks to older adults include adverse interactions with medications, liver damage, increased risk of falling, and negative effects on cognitive functioning (see Bucholz, Sheline, & Helzer, 1995, for review). Bienenfeld (1987) found that elderly alcoholics were at 5 times greater risk for suicide than non-alcoholic elderly.

Empirical studies suggest that psychotherapy can be useful in treating older alcoholics. In a review of published outcome studies of psychological interventions, Schonfeld and Dupree (1995) found the empirical evidence for the effectiveness of cognitive and behavioral interventions superior to that of 12-step and social support treatment models. However, not all of the studies they review that support cognitive and behavioral treatment were controlled (e.g., Dupree, Broskowski, & Schonfeld, 1984). In one study that did include a control group, Kashner, Rodell, Ogden, Guggenheim, and Karson (1992) compared subjects randomly assigned to a mixed-age confrontational treatment group to those in an age-specific group treatment for older adults, called OlderAdult Rehabilitation (OAR). Therapy for this group included a reminiscence component. Seventy-two male participants completed OAR treatment. Participants in OAR were more than twice as likely to maintain abstinence at a 1-year follow-up. In another study that also addressed the long-term impact of intervention, Carstensen, Rychtarik, and Prue (1985) found that a behavioral treatment program for older males was successful in maintaining treatment gains at a 2-year follow-up. In conjunction with a cognitive behavioral treatment approach, these studies suggest that older adults benefit both from being in a group setting with other older alcoholics and from a less confrontational style on the part of group leaders.

Recent studies of intervention for alcohol problems have focused on brief interventions. These interventions include psychoeducational sessions for at-risk drinkers, in which information regarding the risk of excessive alcohol use is offered. Blow and Berry (2000) found that a single-session intervention was useful in decreasing the amount of alcohol consumed by older adults. It seems likely that this strategy may be usefully incorporated into more formal therapy, when the therapist has recognized a possible alcohol problem.

Sleep Disorders

Insomnia is a frequent problem for older adults, and may interfere significantly with day-to-day functioning. Between 12% and 25% of adults over the age of 65 complain of chronic sleep difficulties (Ford & Kamerow, 1989). In sleepmaintenance insomnia, the individual may awaken in the middle of the night and be unable to get back to sleep. He or she may then take naps during the day in order to make up the sleep time lost, resulting in greater and greater time spent in bed in order to receive a normal amount of sleep.

Although insomnia is sometimes thought of as a medical problem or an inevitable result of aging, studies have found that psychological interventions can be very effective in treating this disorder. Zeiss and Steffen (1996) have recommended a combination of education, sleep restrictions, and stimuluscontrol interventions in treating sleep-maintenance insomnia in older adults. In sleep education, the client is taught about the effects of alcohol, caffeine, nicotine, exercise, sleeping aids, and nutrition on sleep, as well as about age-related changes in sleep. The latter information can help reduce unrealistic expectations regarding sleep time because the client may be relieved to know that older people generally sleep less than younger ones.

This approach has been found effective in controlledoutcome studies, with gains maintained up to 1 year following treatment (Morin, Kowatch, Barry, &Walton, 1993).The outcome study conducted by Morin and his colleagues found that treatment was effective in reducing sleep latency (difficulty falling asleep), waking after sleep onset, and early morning waking; for each of these problems, sleep efficiency was increased. In another outcome study, Morin, Colecchi, Stone, Sood, and Brink (1999) found that combined pharmacotherapy and cognitive behavioral therapy was most effective in treating insomnia in a sample of older adults. However, cognitive behavioral treatment was more effective in treating insomnia than pharmacotherapy alone. Treatment gains were better maintained at follow-up by those study participants who had received cognitive behavioral therapy.

The effectiveness of treating insomnia with cognitive and behavioral methods represents an important advance, given the high prevalence of insomnia and the negative side effects of sedative-hypnotic medications in older adults. These include cognitive impairment, increased risk of falls, and the fact that most medications lose their effectiveness over time (Morin & Kwentus, 1988).

Given the growing empirical evidence for the efficacy of a number of psychological interventions with a wide variety of problems faced by older adults, as described in the previous section, and positive clinical experiences reported over a period of 80 years or more (Knight et al., 1992), the stage is set for an exploration of integration issues in psychotherapy with older adults. Four strands of psychotherapy integration will be pursued in the following sections: common factors in psychotherapy; Knight’s contextual, cohort-based, maturity, specific-challenge (CCMSC) model as a transtheoretical framework for therapy with older adults; the CCMSC model as a guideline for prescriptive eclecticism; and theoretical integration as exemplified by the Bergen model.

Common Factors in Psychotherapy with the Older Adult

Probably most closely identified with the work of Jerome Frank, especially his classic book Persuasion and Healing (1961), an early and consistent theme of psychotherapy integration has been the concept that there are common factors in change processes that are effective ingredients in psychotherapy and that likely cut across theoretical systems. Frank (1982) has described potential common factors as including an intense and confiding relationship with the therapist that inspires hope, a healing setting, a rationale that explains the person’s difficulties and provides methods for change or relief, and a set of prescribed treatments.

Knight (1996a) noted that older adults seem especially responsive to simply being listened to, and speculated that this may be a somewhat unusual experience for many older adults experiencing psychological problems. To the extent that societal attitudes about aging and about older adults tend to be negative in tone and pessimistic in expectations (e.g., Butler, 1975), a relationship that provides support and hope is likely to have a powerful impact on older adults. Although the psychotherapeutic relationship is more explicitly discussed in psychodynamic and humanistic approaches to therapy, Castonguay (1997) cites evidence for its salience and importance in behavioral approaches as well. In fact, Bruninck and Schroeder (as cited in Castonguay, 1997) found evidence that behavioral therapists can be more supportive than psychodynamic and Gestalt therapists.

In one of the few empirical studies of the effects of the therapeutic relationship in therapy with older adults, Marmar, Gaston, Gallagher, and Thompson (1989) found independence of therapist and client ratings of the alliance, and a stronger association of alliance with outcome in cognitive therapy. In a different article, the same group reported a stronger correlation of patient defensiveness with patient commitment to treatment in cognitive therapy than in psychodynamic therapy (Gaston, Marmar, Thompson, & Gallagher, 1988). The researchers speculated that cognitive therapy requires a stronger commitment from the patient and that cognitive therapists may not handle defensiveness well. These findings are reminiscent of work by Beutler and colleagues (e.g., 1991) finding that cognitive therapy works better with younger adults who have externalizing coping styles and are low on reactance. Further research is needed on the importance of the therapeutic relationship in therapy with older adults, and on the need to match therapy to the characteristics of older adults that may influence therapy effectiveness.

In a somewhat similar manner, the provision of a rationale for the problem and a potential way to achieve relief may have a great effect on older adults. Older adults seem less likely than younger ones (at least in current and recent cohorts) to identify problems as psychological in nature (Lasoki &Thelen, 1987). The identification of a set of symptoms, perceived as unrelated and possibly physical in origin, as due to depression may in itself be a relief for an older client. The rationale for the problem and the description of a potential treatment also serve to correct the likely attribution of the problem to aging processes, which are assumed to be irreversible (Knight & Satre, 1999). These common aspects of therapy are likely to be even more effective with older clients than with younger ones, given their presumed lack of experience in conceptualizing problems in psychological terms and the pessimism likely to be associated with aging-based attributions.

This brief exploration of common factors in psychotherapy points to the importance of further exploration of this area of potential commonalities across therapy systems used with older adults, so far generally neglected in research and scholarship on therapy with the elderly. The salience of the therapeutic relationship and of the provision of a rationale for the psychological problem and its treatment may be of particular benefit to older clients. Other potential common factors with some empirical support in research with younger adults include self-efficacy and corrective emotional experience (Weinberger, 1993) and should be further explored with older persons as well. As with younger adults, it appears that there are powerful basic elements to psychotherapy with older adults that may play a central role in treatment. In the next section, we turn to the CCMSC model and its potential role as a transtheoretical framework and as a guide for prescriptive therapy with older adults.

The CCMSC Modelas a Type of Transtheoretical Framework

Another type of approach to psychotherapy integration is to construct an overarching framework that can organize differing theoretical approaches and inform their application to different types of clients, to different types of problems, or to different ways of approaching problems. Rather than reducing apparently different therapies to a set of common factors (as discussed previously) or trying to achieve a theoretical integration (as will be discussed later), the transtheoretical approach organizes the differing theories within an overarching framework. In discussing integration with younger adult clients, Prochaska (1984) is a major proponent of this effort. For older adults, the proposed framework of therapy is based on key research findings from life span developmental psychology and social gerontology. Knight (1996a) proposed a contextual, cohort-based, maturity, specific-challenge (CCMSC) model as a way of addressing the questions of whether and how psychotherapy needs to be adapted for work with older adults. Briefly, the model proposes that differences could be due to the following factors:

1. Social contextual factors, or the ways in which older adults are segregated within social contexts such as nursing homes, medical settings, and age-segregated living environments and are treated differently by both formal laws and regulations (e.g., Medicare, the Older Americans Act) and by informal social norms and attitudes (ageism, age stereotypes of all kinds).
2. Cohort effects, or differences that arise from being born into a specific set of social historical circumstances that influence the length and nature of educational experience, social values, normative life experiences, and so forth (focusing, e.g., on differences among generations of the Jazz Age, the Depression era, World War II, and the baby boom as older adult cohorts).
3. Maturational effects, or the changes that occur during adult development and aging (life span psychology would suggest that these can involve improvement and stability as well as decline).
4. Specific challenges of later life, chronic illness, disability, grief, and caregiving. Not unique to later life but stochastically more common, these issues require specific knowledge and skills that therapists who primarily work with older populations may need to acquire.

In general, Knight (1996a) argued that differences in therapy with older adults, when they occur, are more often due to contextual influences, cohort differences, or the nature of the specific challenges than to maturational changes.

Over the past several years, Knight and his colleagues have applied the CCMSC model to a variety of specific therapy systems to explore issues related to therapy with older adults. In a discussion of CCMSC and psychodynamic therapy, Knight (1996b) argued that the CCMSC model can assist developmental views of adulthood and aging within the psychodynamic model by extending them into later life in a way that draws upon research in gerontology and life span developmental psychology and the writings of those with specific clinical expertise in work with older adults. He argued that this knowledge base provides a more optimistic view than is found in much psychodynamic writing about later life. Grief work, psychodynamic work on illness-related issues, and the importance of transference and countertransference issues were all seen as strengths of the psychodynamic approach.

On the other hand, the CCMSC model calls attention to social-context effects and cohort effects in ways that are often neglected in noncontextual intrapsychic theorizing. Knight argued, for example, that retirement is better conceptualized as a social role than as a developmental stage. As a social role, the psychological effects of retirement are expected to vary by occupation, social class, and gender and can be expected to change over time. The individual’s task is changed from adjusting to a developmental stage of loss of work to creating a meaningful, optimal role as a retired person. Therapy within residential care is unlinked from the developmental-stage framework and is seen as specific to the setting and to the illnesses that cause people to live there. Different cohorts (e.g., Depression-era vs. baby boom cohorts) differ in diagnostic profiles, common character disorders, and typical childhood experiences.

Knight and Fox (1999) discussed the relationship of the CCMSC model to behavior therapy approaches. Behavior therapists have argued that their approaches may be more acceptable to older clients who have grown up in less psychologically minded eras and want relatively quick, practical solutions to problems. The CCMSC model would see this as a cohort effect, and one that would be expected to change as the baby boomers become older adults. Knight and Fox reviewed evidence that learning may take longer with older adults and that classical conditioning may reach a lower asymptote than in younger adults. Operant conditioning appears to be relatively well preserved in older adults, including those with psychosis and with dementia. The behavioral approach has been used a great deal with older adults in nursing homes and in other institutional settings and is well suited to analyzing and changing the contextual settings in which older adults are sometimes located as a way of resolving their problems.

Knight and Satre (1999) discussed cognitive behavioral approaches as related to the CCMSC model. Maturation was argued to affect cognitive behavioral therapy (CBT) by suggesting a slower pace and possibly simpler presentation of some concepts, and by providing a push toward higher levels of abstraction (i.e., working on schemas more frequently than on automatic thoughts). Cohort effects were seen as influencing many proposed changes in assessment and in therapy with older adults, in that changes in the presentation of questions or of therapy materials may be due to lower educational levels in earlier born cohorts and to their differing life experiences, rather than to effects of aging as a developmental process. The importance of understanding older adults’social context as they perceive it and changing these perceptions was seen as critical in CBT work with older clients. Finally, the literature on psychological interventions with older adults was reviewed as organized around the treatment of specific challenges in later life (e.g., coping with disability, pain management, sleeping disorders, caregiving issues).

Knight and McCallum (1998) applied the CCMSC model to family systems approaches to therapy. The maturity component of the model called attention to the question of what defines a family as an aged family. That is, virtually all families contain aged members; so how is it that some families define themselves or come to be seen by the therapist as having specific aging issues? The cohort effects part of the model calls attention to the misunderstandings and values conflicts that arise within families in part because families are composed of persons from a variety of cohorts with differing social-historical contexts for their own maturation. The special contexts in which older family members may be living can be difficult for younger family members to comprehend and negotiate, precisely because they are different from the contexts with which younger family members are familiar. As in other models, much of what makes family therapy with “older families” different (and likely often answers the question of why we think of them as older families) has to do with the specific challenges faced in later life by some older family members.

This overview of the CCMSC’s application to four types of psychotherapy systems illustrates several points about this framework for thinking about psychotherapy with older adults. The framework is transtheoretical in the sense that it can be applied to all of these theoretical approaches to inform their use with older adults. In doing so, it often raises questions and issues not typically addressed by the individual systems. In part, this comes from the nature and history of the CCMSC, which is rooted in life span developmental psychology and social gerontology. Each of these is, in turn, influenced in varying degrees by the need to integrate physiology of aging, psychology of aging, sociology of aging, and social policy about the aged when addressing older adults and the problems they face. Older adults often have multiple problems from more than one of the domains of medicine, psychology, and social issues, domains that have typically been kept separate when addressing the problems of younger adults. This separation, quite possibly not a great idea for younger adults but workable to the extent that younger adults often have a principal problem falling in only one of these domains, is neither defensible nor practicable with older adults who commonly have multiple problems in multiple domains.

As seen in this section, the CCMSC model can guide the discussion of whether various theories of psychotherapy need modification when used with older adults. In the next section, we turn to the question of whether specific problems frequently faced by older adults call for the use of different therapy theories and techniques. In integrative therapy, matching therapies to problems is called prescriptive eclecticism.

The CCMSC Modelas a Framework for Prescriptive Eclecticism

The proponents of prescriptive psychotherapy, primarily Beutler and his colleagues (e.g., Beutler & Hodgson, 1993) have positioned themselves within the technical eclecticism approachtopsychotherapyintegration.Thisapproachfocuses on techniques rather than theoretical systems and advocates that selection be based on what is empirically known to work with specific problems, specific types of clients, and so forth. As Gold (1996) noted, the methods and the recommendations stemming from this approach can be quite similar to those of the transtheoretical approach. The principal difference would be that the selection of techniques would be guided by empirical findings, rather than by conceptual guidelines. Technical eclecticism can also be viewed as a consequence of therapeutic experience, to the extent that therapist behavior is shaped by the reinforcement of seeing clients improve; observers have often noted that the techniques of experienced therapists from different schools of thought are more similar than different (e.g., Jacobson, 1999; note that Jacobson was not an integrationist, however).

Some reflection on the history of psychotherapy with older adults reveals an apparent tendency for experience with older clients to pull the therapist somewhat out of model. From at least the middle of the twentieth century, psychodynamically oriented therapists have written about needing to be more active, more goal-directed, and more practical with older clients (see Rechtschaffen, 1959, for an early review). More recently, Nordhus, Nielsen, and Kvale (1998) wrote about the use of a psychodynamic theory with older adults, while drawing extensively upon the writing of CBT therapists who work with the elderly. In the other direction, life review is at times included or incorporated into discussions of CBT (e.g., Gallagher-Thompson & Thompson, 1996), even though its conceptual roots and the nature of its practice are much more similar to psychodynamic therapy. Knight and Satre (1999) noted that the natural tendency of older adults to reminisce, noted by Butler (1963) in a classic article, may pull CBT practitioners toward this more abstract and lifehistorical level of analysis. The problems of later life, and possibly the nature of older clients themselves, would appear to exert a certain pull toward eclectic use of techniques.

The CCMSC framework suggests that there may be a degree of pragmatic prescriptive psychotherapy being practiced witholderadults.Aswithotherapplicationsofthisframework, the prescription is not based so much on maturation as on other domains included in the framework. For example, consideration of context effects can call attention to the extensive use of behavioral techniques within medical and nursing home settings. This focus on behavioral technology is no doubt determined in part by the nature of the residents’ problems, and so could be placed under specific challenges as well. The great majority of nursing home residents have dementia or chronic medical disorders, or both. These disorders seem especially amenable to behavioral intervention (Fisher & Carstensen, 1990; Gatz et al., 1998). In addition, however, the nursing home environment itself often needs behavioral analysis and intervention (Spayd & Smyer, 1996), and evidence suggests that behavioral interventions are needed to set up contingency systems that reward staff for using behavioral interventions with the residents (Stevens et al., 1998). Older adults are often heavily involved in medical contexts and tend to bring psychological problems to medical offices. Adaptations for behaviorally oriented consultations in doctors’ offices, clinics, and hospitals are also likely to be needed (Haley, 1996).

Cohort effects are most likely to affect the selection of psychological interventions by their effect on the prevalence of psychological disorders, the educational levels of clients, and the typical psychological-mindedness of clients. Depression seems to vary by cohort, and it can be predicted that the prevalence of depression among older adults in later born cohorts (e.g., the baby boomers, now poised on the brink of older-adult status) will be higher than in the past (Koenig et al., 1994). Suicide rates are also higher in later born cohorts (McIntosh, Santos, Hubbard, & Overholser, 1994). Knight (1996b) speculated that some apparent age differences in character disorders may be cohort based rather than the results of maturation. Educational levels have increased in consecutive cohorts through the twentieth century. Changes in psychotherapy approaches that have been responsive to lower educational levels and lower prior exposure to psychological thinking should become unnecessary in the next decade or so.

Maturational changes as we age are thought to have relatively little effect on determining the type of technique that can be used with older adults (Knight, 1996a). However, therapists from a number of systems have recognized a need to talk more slowly, to present ideas one at a time, and to be prepared to accommodate changes in sight, hearing, and mobility that are common with aging.

The specific challenges of late life may themselves pull for certain prescriptive practices when one is selecting techniques for use with older clients. Much work with chronic illness and disability with any age of client draws heavily upon CBT techniques (Knight & Satre, 1999). Griefwork, in contrast, seems to pull for a more life-review or psychodynamic focus on emotions and on the meaning of life with and without the deceased. It must be noted, however, that there is scant evidence on the effectiveness of grief work. Knight and McCallum (1998) noted that family caregiving issues would seem to call for the use of family systems approaches; however, most of what has been done with caregivers uses CBT techniques with the individual caregiver, with rather modest results (Gatz et al., 1998; Knight, Lutzky, & Macofsky-Urban, 1993).

Life review and reminiscence in therapy with older adults may take a variety of forms. As noted previously, older patients often tend to reminisce in therapy, particularly when dealing with grief. In this way, life review helps to integrate the patient’s current distress into the context of his or her entire life, which may serve as a useful tool in coping with present suffering. Life review has also been advocated as a more formalized tool in both individual and group psychotherapy for older adults. In guided life review, the patient explores his or her experiences and values in key areas, such as relationships, work, and spirituality, as a way of understanding these experiences and identifying goals for personal growth (Birren & Deutchman, 1991).

Although prescriptive eclecticism suggests a pragmatic use of techniques developed in different theoretical contexts, theoretical integration would provide a conceptual basis for drawing upon differing theoretical systems when working with older adults. To date, there has been little work on psychotherapy with older adults that crosses traditional theoretical boundaries. In the next section, the Bergen model is presented as an example of this type of integration.

The Bergen Integrative Psychodynamic Model

The Bergen integrative psychodynamic model has its roots in life span developmental psychology. Within the framework of psychotherapy following psychodynamic principles, Erikson’s (1959, 1982) psychosocial developmental theory is the only one containing a specific focus on aging, and thus, a theoretical basis for an age-specific therapeutic approach. He was the first to describe the developmental tasks of later life and relate them to the psychotherapy endeavor, and based on this perspective, the life-review intervention strategy was described (Butler, 1963). From the early formulations by Butler (1963), several modifications of the basic life-review format have been elaborated; central among these more recent approaches is the development of autobiography (Birren & Deutchman, 1991). The common principle in all these approaches, and basic in classical psychoanalytic approaches, is to prompt early recollections, and thus facilitate the process of gaining an integrated perspective on one’s life. Different authors may vary in their emphasis on the universality of the life-review process, but the process is more often than not described in normative terms—that is, as a process that is normal and particularly beneficial for older adults (see Nordhus & Nielsen, 1999).

More recently, therapists adhering to basic psychodynamic principles have changed from the traditional normative stance as we know it from classical ego psychology formulations (e.g., Silberschatz & Curtis, 1991).Amore time-limited treatment course is increasingly being used, with goals formulated in terms of the presence of pathogenic beliefs (e.g., Curtis & Silberschatz, 1997) or of maladaptive interpersonal patterns (e.g., Levenson & Strupp, 1997). A basic observation that engendered concepts such as transference and resistance to change is that people tend to repeat their typical relationship patterns—even when such patterns are associated with distress. Thus, the repetition of early relationship patterns was traditionally conceived of as a means of meeting one’s infantile security and attachment needs.

A contemporary life span–psychodynamic understanding would maintain that security and attachment are lifelong needs that continue to exert their influence throughout adulthood and into later life, rather than aims that ought to be relinquished in adulthood. Attachment theory introduces a general motivational factor for the repetition of interactional patterns as a way of rendering the world predictable and manageable (Bretherton, 1987). What needs to be modified in therapy is the maladaptive way in which one goes about meeting these needs in order to stop repeating early dysfunctional relationship patterns. Essentially, this is a learning perspective, in which the individual learns mental representations that are generally resistant to change and that have a strong effect on later relationship patterns. Generally, this perspective allows for a greater flexibility in therapy, in that it allows a focus either on the past or on the here and now.Also, it provides the possibility of using behavioral and cognitive techniques to optimize the therapeutic process (Nordhus et al., 1998). The clinical focus on problems that originate with beliefs, relationship behaviors, and the perception of relationships invites the use of cognitive behavioral and interpersonal intervention strategies.

Modifications suggested when working with older patients focus primarily on the relationship between the therapist and the patient. The therapist may often be encouraged to take a more active stance than typically seen with younger individuals and may need to educate the client about the nature of the psychotherapy endeavor. With regard to the process of therapy, the therapist may need to be more flexible in setting the duration and frequency of sessions, as well as in the interactions with family or other professionals being involved with the patient (Knight, 1996a). This flexibility primarily relates to the specific challenges that the patient faces (e.g., recently bereaved), and not to the therapeutic potential of older patients.

The Value of Case Formulation

Psychotherapy literature on aging generally tends to be well described clinically but not necessarily supported by extensive empirical research findings (Gallagher-Thompson & Thompson, 1995). The need to further develop empirically validated therapeutic approaches toward older adults is indisputable. For one thing, evaluation of the individual case in clinical descriptions of older patients has to a large extent relied on anecdotal methods in the absence of more informative and specific coding procedures. Although the study of individual cases has been a fundamental source of data in the clinical literature in general, there are long-recognized difficulties in using data so derived for hypothesis testing or for verification of clinical constructs. The critical task is to identify and operationalize clinical constructs in a way that permits continuous assessment and evaluation. One way to do this is to formalize the case study method by focusing on specific therapist-patient interactions and demonstrate how they develop through the course of therapy.

A case formulation is tailored to the specific individual’s life circumstances, needs, thought patterns, and so on. The therapist must, nevertheless, rely upon general clinical knowledge, including knowledge about older adults, as well as experiences from working with other individuals, including supervised experience working with older adults. The repetitive, dysfunctional interaction construct is rooted in general and familiar theoretical language (e.g., attachment theory and transference). Staying close to the descriptive data, however, provides us with an empirical underpinning for aspects of these concepts as these unfold in each individual case. This may in turn counteract a tendency to overgeneralize about persons with whom we have little knowledge or experience. For example, therapists without appropriate knowledge and experience may stereotype clients’ psychological needs in terms of age.

The Cyclical Maladaptive Pattern

The Bergen model was developed in the context of a clinical training program conducting individual psychotherapy with older adults in the outpatient clinic in the Department of Clinical Psychology at the University of Bergen in Norway, and is described in detail elsewhere (e.g., Nordhus & Nielsen, 1999; Nordhus et al., 1998).At a general level, the Bergen approach can be classified as integrative psychodynamic (Wachtel, 1993, 1997), and utilizes a specific format of case formulation: the cyclical maladaptive pattern (CMP; Levenson & Strupp, 1997; Strupp & Binder, 1984). The integrative psychodynamic label implies that various therapeutic techniques and interventions may be productively combined within the same, psychodynamically informed, course of treatment. This type of theoretical integration may also be described as assimilative integration of psychotherapeutic theory and technique (e.g., Messer, 2001).

A basic assumption of the Bergen model is that psychopathology can be described in terms of vicious cycles or maladaptive interpersonal functioning in the patient’s interaction with others. In the patient’s attempt to satisfy basic needs or to establish and maintain satisfying relationships, he or she typically acts in ways that unintentionally elicit repetitions of negative experiences or traumas. Erikson’s shift to a life span developmental model argued that these negative experiences could have occurred in adulthood and are not limited to childhood events. In older clients, it is as likely that presenting problems will have had their origin in adulthood.

The persistence of these vicious interpersonal cycles results from an interplay among the patient’s characteristic coping styles, inaccurate and maladaptive beliefs about herself or himself and others (Weiss & Sampson, 1986), and the inadvertent reinforcement provided by the responses of others. These maladaptive circles involve inflexible and selfperpetuating behaviors, and in turn negative self-appraisals by the patients leave them vulnerable to various feelings of psychological distress and observable symptoms. In different words, much of this description would be consistent with cognitive behavioral or interpersonal theories of therapy

Adhering to basic psychodynamic concepts such as unconscious motivation, conflict, defense, and so forth, the integrative model implies cyclical processes by which internal states and external events each continually recreate the conditions for the recurrence of the other (Wachtel, 1994). Internal processes such as wishes, fantasies, and motives are as likely to result from as to cause a patient’s behavior. Acentral element in the model, therefore, is that causality is circular rather than linear. This implies that the traditional question of What comes first, insight or behavioral change? no longer is meaningful. Nor is insight conceived of as the final result, or an end product. Most insights are partial insights, and positive change typically develops gradually and may imply recurrent or intermittent brief therapy encounters (Cummings, 1986; Levenson & Strupp, 1997). In this way, while the theory of problem etiology is psychodynamic, the change processes might be seen as cognitive behavioral or interpersonal as well as psychodynamic.

A typical therapeutic challenge ensuing from this way of reasoning is to help the patient interrupt cyclical maladaptive patterns by learning new ways of integrating interpersonal experience, and to adopt more flexible and adaptive ways of relating. This new learning might most profitably start within the relatively safe and confiding climate of the consulting room. The psychotherapeutic process, therefore, is viewed as a set of collaborative interpersonal transactions, and the relationship between patient and therapist is used as a vehicle for bringing about change (Binder & Strupp, 1991). Because of the patient’s unwitting tendency to cast the therapist into the roles of significant others and to enact with the therapist maladaptive behavior rooted in earlier conflicts, this process holds a fundamental therapeutic potential for new and experientially based learning. Evoking therapeutic change, however, requires that the therapist actively identify and attend to the repetitive, cyclical maladaptive patterns that unfold within the therapeutic encounter (the transference). The patient’s past may be helpful to understanding the origin and development of a particular maladaptive pattern, and to help place a particular transference enactment between the therapist and patient into a broader perspective. However, focusing on the self-perpetuating behaviors in the patient’s present life may be more strategically useful than focusing on the original or initiating causes (Nordhus et al., 1998). Thus, this perspective does not rule out a life span developmental framework, but it is a question of therapeutic choice whether the unique developmental story should be the focus. Therefore, the therapeutic focus may vary, balancing past history and present needs.

The pursuit of insight into the distant past as a critical agent of change may be overvalued, often at the neglect of focusing on interpersonal exchange that takes place in the therapeutic transaction. The classical ideas of Alexander and French (1946) served as an impetus for the development of contemporary short-term psychodynamic psychotherapies by questioning the traditional analytic assumption that depth and enduring change were proportionate to the prolonged reconstruction of childhood conflictual experiences. Erikson’s (1982) life span approach moved theoretical attention away from the exclusive focus on childhood conflict to include those arising during adult developmental stages. Alexander and French (1946) asserted that substantial change may result from new corrective emotional experiences provided by the very interaction between patient and therapist in the here and now of the transference. In our own model, we have found the corrective emotional experience to be a very useful clinical concept also in terms of keeping the therapist on target and close to clinical phenomena as opposed to getting caught up in defeatist ageist stereotypes. The CMP is a way of organizing interpersonal information as it unfolds in the therapeutic encounter and is briefly illustrated in the following vignette.

Case Illustration

Mr. A., a 76-year-old retired businessman, presented his problems as lack of confidence and strong feelings of worthlessness. He described himself as one who tended to feel uncomfortable when expressing irritation and anger, which were often followed by negative feelings and depression. In his retirement years he had more or less withdrawn from social life except for relatively frequent contact with his two grown children and their families. He lived with his 74-yearold wife, whom he described as a considerate woman, but he communicated openly that he wanted to be more cared for by his wife and sometimes felt rejected by her. Mr. A. was a kind, introspective, sensitive man who nevertheless had difficulty interacting comfortably with people. His father died when Mr. A. was 17 years old, and it appeared that his mother had a history of recurrent periods of depression during his adolescent years. At intake, the patient met the criteria for major depressive disorder.

In terms of a developmental diagnosis, it seemed reasonable to focus on how the patient’s past behavior persisted in his current relationships, and how it colored the therapeutic connection. The historical information provided a context for understanding the vulnerability of the patient that was unfolding in the therapeutic setting. It seemed likely that his mother’s depression and the early loss of his father, at the time when he was entering manhood, helped to form relationship patterns that were still causing problems in late life. He developed negative expectancies and a conditioned depressive response to situations that required assertiveness and an explicit voicing of his needs. In terms of a CMP, however, it is what goes on in the therapeutic interaction in the here and now that serves as central descriptive clinical data (Strupp & Binder, 1984).That is, rather than focusing on reviewing the history of relationships with mother and father, the therapeutic focus was the relationship with the therapist and with the wife.

In the following excerpt, the therapist’s initial formulation of a CMP is presented. The CMP is composed of four categories that were used to organize the interpersonal information about the client. It was formulated by the end of the third session, including the reenactment experienced in the therapeutic setting by the therapist.

Acts of the Self

Mr. A. presented as a person who was conflicted about his relational wishes. On the one hand, he wanted to be closer to people, especially to his wife, but he was frightened that he would be rejected. He wished to express his irritation and anger when feeling rejected, but would frequently be passive or self-punitive rather than appropriately assertive. (“I observe that my wife is helping others rather than me. If I say something about it, we always end up quarreling. The best thing to do is to say nothing at all.”)

Expectations of Others’ Reactions

Mr. A.’s experiences with others left him with somewhat negative views of what he could expect to happen in relationships (which was not altogether unrealistic, given his experiences). He validated his general expression of being ignored by saying that “If I tell my family, and especially my wife, that I am depressed, the risk of being asked to count my blessings and pull myself together is too high.”

Acts of Others Toward the Self

Mr. A.’s feelings of being left outside his family were explicitly communicated. He expected that others perceived him as too weak to be heard in things that mattered (“I have always tried to solve conflicts by being diplomatic, something that is not considered to be a positive characteristic”).

Acts of the Self Toward the Self

By withdrawing and by refraining from voicing his problems and complaints, Mr. A. thought that he would appear less troublesome and more acceptable to his family. He acknowledged his own vulnerability and was constantly blaming himself for not being able to interact in a more assertive way. After the first session, he was blaming himself for not showing any progress in therapy, and “for not bringing good news to the therapist.”

Therapist’s Reaction to Client

Based on the previous formulation, the therapist prepared herself for identifying recurrent themes that in one way or another were related to Mr. A.’s cyclical maladaptive patterns. Central to this approach was the therapist’s own experience of frustration resulting in a feeling of not knowing how to help the patient. By communicating his needs for help in a self-blaming manner, the patient contributed to the therapist’s growing feeling of not being able to help the patient. In this way, Mr. A. verified his own assumption of being weak and a hopeless case. An important element of this approach is that the therapist’s sense of impotence was analyzed in a client-specific manner rather than being accepted as being due to the client’s age and limited potential for change due to being old.

The central question for planning intervention was to focus on what kinds of new experiences and understanding (or corrective emotional experience) will support Mr. A. in identifying and communicating his own need in a more direct way. This would imply encouraging behaviors that signify a new manner of acting toward the therapist.

The therapist assumed that the type of new experience that might facilitate change in Mr. A.’s maladaptive interpersonal style would be the following:

1. A.’s experience of the therapist as one who accepted him as a person with a legitimate need for help (communicated by the therapist in a safe and supportive climate), and
2. A.’s experience of himself as a person who asks for help in an explicit and nondefensive way (e.g., using assertiveness training or role play).

In subsequent sessions, the therapist maintained a persistent focus on the interactive style of the patient. Whenever the patient demonstrated self-reproach and mistrustful expectations toward others’ ability to help him, the therapist confronted him with direct questions such as “How can I know how to help you, when you keep telling me that you do not expect anyone to be able to help you?” Questions like these were followed by the therapist’s confirming that she observed his pain and discomfort and by encouraging him to verbalize what he ideally would expect from therapy.

By confronting the patient with the vague and passive way he presented his needs, the therapist was able to have Mr.A. experience the confusion that his communicative style created. By taking part in the patient’s mode of relatedness instead of focusing primarily on symptoms or past developmental history, the therapist was working at the core of the therapeutic process, in the here-and-now transaction (Levenson, 1995). In order to stay in that transaction, the therapist utilized assertiveness training and role playing, and eventually a joint focus on parallel interaction problems outside of therapy was established. These interventions, while chosen within a psychodynamic framework, are fairly commonly used cognitive behavioral techniques. In the following videotaped sessions, Mr. A. appeared to be more engaged and spontaneous in the therapeutic exchange. He gradually realized (somewhat reluctantly) his own responsibility in producing positive change in his relation with his wife.

Summary of the Bergen Model

According to the Bergen model, the cyclical and integrative psychodynamic perspective is a sound foundation for developing competencies in clinical practice with older adults (Nordhus & Nielsen, 1999). Within the framework of brief psychodynamic therapy, it incorporates current developments in interpersonal, object relations as well as cognitive behavioral approaches. Yet to what extent is chronological age an informative variable for therapeutic work, let alone a matter of therapeutic adaptation? Generally, the therapist is challenged to understand how much emphasis to place on the individual’s being old, and how much to place on his or her being a patient. Therapeutic work with older adults requires an understanding of both psychotherapy and aging, as well as how to use each understanding in the service of the other (Kivnick & Kavka, 1999).

First, working within an outpatient clinic like the one in Bergen necessitates that we do not offer psychotherapeutic services to patients with severe cognitive and psychotic symptoms. On the other hand, the majority of our patients aged 60 years and older report moderate to severe medical problems. This means that we typically have a communitydwelling older patient with medical problems, who is either self-referred or referred by a family physician, other medical units, or a family member. He or she may enter therapy with various forms of depression, anxiety, somatoform disorders, or minor to moderate adjustment disorders. Medical problems and medication use often imply that we coordinate our strategies with medical care, but these seldom negatively interfere with the therapeutic course.

Second, patients often seek therapeutic help in the clinic, because they are enmeshed in an unsatisfying relationship or are suffering from symptoms and dysphoric feelings that appear to be linked to troubled relationships. Recent empirical findings indicate that conflicts in current, close relationships are commonly presented complaints of older patients (e.g., Miller & Silberman, 1996). Such facts serve as important corrections to the traditional one-sided perception of the normative needs of the older patient, which would have the therapist focus on reconciling the patient to the life that has already passed. In the Bergen model, with an interactional and mastery-oriented approach to therapy, we emphasize the cooperative working relationship between therapist and patient. By focusing on the patient’s present reality, current life situation, and interpersonal relationships, the therapist becomes an active participant in the therapeutic exchange.

Third, with regard to the process of therapy, our experience is that the therapist may need to be more flexible in setting the duration and the frequency of sessions, compared to therapeuticworkwithyoungeradults.Undercertaincircumstances,for instance with a patient under great stress, the therapist might find it appropriate to offer direct advice. Generally, we adhere to setting a time limit, also aiming at reinforcing the patient’s confidence in his or her ability to resolve the current complaint. Nearly two thirds of the therapies last fewer than 20 sessions, but the older patients tend to have their sessions given at a more flexible schedule with more sparsely distributed sessions (e.g., every 2nd week). The most common reason for this is that concomitant physical decline and illness is making them less mobile, although it is also true that our patients (especially those aged 80 years and older) may expect that psychologists are like their primary physicians, implying fewer scheduled sessions. In conclusion, then, it seems that reasons for adaptations in therapy with older adults are primarily due to medical and contextual factors rather than limitations in the psychological potential for change. The cyclical maladaptive patterns format seems valuable for the therapeutic endeavor itself as well as for supervising psychotherapy training. In terms of contributing to the geropsychology field, specific case formulations, like the CMP, keep the therapist focused on a remediable problem rather than forming abstract and vague formulations, including age stereotypes. In addition, these formulations keep the therapist close to ongoing observable clinical data and encourage the use of active, present-oriented intervention techniques.

Summary and Conclusions

In this review of psychotherapy with older adults, we have examined the literature within a framework of integrative approaches to psychotherapy. As with younger adults, outcome studies with an older adult population have largely been done within a cognitive behavioral theoretical framework, but there is evidence for the effectiveness of other therapies as well. First considering a common factors approach to integrative psychotherapy, there is some reason to believe that older adults may be especially responsive to the common relational elements of psychotherapy and to the hope imparted by the identification of a problem as a psychological disorder that can be treated. In a second type of integrative model, Knight’s CCMSC model can be seen as a type of transtheoretical framework for thinking about the need to adapt therapy for working with older clients. Psychotherapy with older adults, driven by the interdisciplinary nature of gerontology and by the fact that older clients typically have problems from multiple domains, has always been integrative in the sense of crossing disciplinary lines to create a knowledge base for understanding aging and older clients, but has not been integrative in drawing on differing therapy theories. Third, the CCMSC model can also be seen as guiding a kind of prescriptive eclecticism with regard to the specific challenges of later life: CBTs for coping with the effects of functional disability and chronic illness, active listening and life review with grief, and family-oriented interventions with caregiving. Finally, the Bergen model is offered as a first example of theoretical integration or assimilative integration in work with older clients: a model that is rooted in psychodynamic theory and uses many concepts and techniques from cognitive behavioral work with older adults.

Clearly there is much more work to be done to develop a truly integrative psychotherapy with older adults. Research in clinical geropsychology could be planned to investigate the role of common factors in therapy with older adults and could explore prescriptive approaches to matching therapies to presenting problems. Theoretical integration or assimilative integration could be used to reconcile the use of techniques by therapists whose theories do not easily support them: the commonly cited idea that psychodynamic therapists have to be more active and problem focused with older clients or that cognitive behavioral therapists engage in some degree of reminiscence or life review with older clients. Within integrative therapy, a focus on older clients and on life span developmental ideas could expand the integrative discussion into the consideration of lifelong development, the role of societal context, and the constantly shifting historical context in which psychological development unfolds. At present, integrative therapy, like much of psychology, risks being a de facto specialty concerning young adults (and sometimes including children and adolescents).

The ideas covered in this research paper can be seen as pioneering steps toward this goal. Bringing clinical geropsychology into the dialogue about integrative psychotherapy could advance theory and research about the nature of psychotherapy with older adults and also enrich thinking about therapy with adults by introducing a life span perspective into the ongoing debate about integrative psychotherapy.

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