Psychotherapy: An Introduction for a Family Physician
Psychotherapy: An Introduction for a Family Physician
Betty Hum, BSc
As the Canadian population ages, depression, dementia and other mental conditions such as anxiety, alcohol abuse, bereavement, and suicide will become increasingly prevalent.1 Traditionally, it was thought that the elderly were unsuitable candidates for psychotherapy due to the belief that they have an impaired ability for abstraction and new learning.1 Geriatric psychotherapy has gained more attention over the years because medical comorbidities in the elderly can complicate the use of pharmacotherapy.2 Moreover, psychotherapy has the added benefit of providing the elderly with skills to cope with late-life stressors, such as newly acquired disabilities or the loss of a loved one.2
Dr. Michel Silberfeld, a geriatric psychiatrist at the Baycrest Centre for Geriatric Care in Toronto, who has practiced psychoanalysis since 1982, believes that psychotherapy can be very effective in the elderly. However, he suggests that an important factor in its success is the alliance between the patient and the therapist, as some personal matters of deep importance can only be dealt with in the context of a strong attachment, fostered by frequent visits.
Studies in geriatric patients have found most psychotherapeutic modalities to be effective, not only in reducing psychopathology, but also in reducing physical needs, pain, disability, and in improving compliance with medical and psychiatric regimens.2 On average, 63% of patients achieve successful outcomes with systematic psychotherapy compared to 38% of those receiving no treatment or placebo.3
OHIP covers the costs of the psychotherapy sessions, which can be provided by a psychiatrist or a trained primary care physician. Some psychologists also practice psychotherapy and their services may also be covered by other insurance benefits. Most elderly patients with psychiatric problems, however, prefer to be treated by primary care physicians.4,5 Therefore, it is important that these health care professionals become more familiar with psychotherapeutic techniques, and know when it is appropriate to refer a patient to a psychotherapist. There are, unfortunately, very few guidelines available to help a therapist decide which technique, out of several possibilities, would be of most use on a particular patient. This article will review the current indications for the use of psychotherapeutic interventions in the elderly.
What is psychotherapy?
Psychotherapy is the treatment of abnormal behavior or a mental disorder by psychological means, usually, but not exclusively, through patient interaction with a trained therapist. A psychotherapist has expertise in interpreting the past and in supporting the patient through current difficulties, with the goal of improving the patient's sense of well-being, personal and social functioning, and personality integration.6
Indications for Psychotherapy in the Elderly
There are more than 250 different forms of psychotherapy, but we will focus only on those that have been most influential and are supported by research.
Individual Therapies: Standardized
Standardized therapies are focused and time-limited types of psychotherapy that are based on treatment manuals that have been developed with the goal of reducing psychopathology and improving quality of life.2 A meta-analysis of 17 studies, comparing the use of a variety of brief standardized therapies, including cognitive, behavioral, supportive, interpersonal and reminiscence interventions in geriatric depression, showed that all were more efficacious than no treatment.7 Brief introductions to these therapies as well as their primary documented indications in the elderly are provided below.
Behavioral psychotherapy
Behavioral psychotherapy was developed from the learning theory which states that human behaviour is acquired through processes of association, reinforcement and observation.6 This type of therapy involves the use of these very same processes to help the patient unlearn maladaptive behaviour and to maintain or learn more favourable responses.6 Behavioral psychotherapy encompasses many