Jarred Gallegos, Julie Lutz, Emma Katz, and Barry Edelstein
The assessment of older adults is quite challenging in light of the many age-related physiological and metabolic changes, increased number of chronic diseases with potential psychiatric manifestations, the associated medications and their side effects, and the age-related changes in the presentation of common mental health problems and disorders. A biopsychosocial approach to assessment is particularly important for older adults due to the substantial interplay of biological, psychological, and social factors that collectively produce the clinical presentation faced by clinicians. An appreciation of age-related and non-normative changes in cognitive skills and sensory processes is particularly important both for planning the assessment process and the interpretation of findings. The assessment of older adults is unfortunately plagued by a paucity of age-appropriate assessment instruments, as most instruments have been developed with young adults. This paucity of age-appropriate assessment instruments is an impediment to reliable and valid assessment. Notwithstanding that caveat, comprehensive and valid assessment of older adults can be accomplished through an understanding of the interaction of age-related factors that influence the experience and presentation of psychiatric disorders, and an appreciation of the strengths and weaknesses of the assessment instruments that are used to achieve valid and reliable assessments.
Nicole D. Anderson
Healthy aging is accompanied by decrements in episodic memory and working memory. Significant efforts have therefore been made to augment episodic and working memory in healthy older adults. Two principal approaches toward memory rehabilitation adults are restorative approaches and compensatory approaches. Restorative approaches aim to repair the affected memory processes by repeated, adaptive practice (i.e., the trained task becomes more difficult as participants improve), and have focused on recollection training, associative memory training, object-location memory training, and working memory training. The majority of these restorative approaches have been proved to be efficacious, that is, participants improve on the trained task, and there is considerable evidence for maintenance of training effects weeks or months after the intervention is discontinued. Transfer of restorative training approaches has been more elusive and appears limited to other tasks relying on the same domains or processes. Compensatory approaches to memory strive to bypass the impairment by teaching people mnemonic and lifestyle strategies to bolster memory performance. Specific mnemonic strategy training approaches as well as multimodal compensatory approaches that combine strategy training with counseling about other factors that affect memory (e.g., memory self-efficacy, relaxation, exercise, and cognitive and social engagement) have demonstrated that older adults can learn new mnemonics and implement them to the benefit of memory performance, and can adjust their views and expectations about their memory to better cope with the changes that occur during healthy aging. Future work should focus on identifying the personal characteristics that predict who will benefit from training and on developing objective measures of the impact of memory rehabilitation on older adults’ everyday functioning.
Schema therapy has evolved since the late 1980s as an efficacious and increasingly widely used psychotherapeutic treatment for personality disorders and many other complex disorders that correlate with underlying maladaptive schemas. Only recently, attention among clinical geropsychologists has been growing for the application of schema therapy in older adults. Schema therapy is very feasible for both therapists and older patients. Schema therapy is an integrative psychotherapy, which draws on the cognitive-behavioral, attachment, psychodynamic, and emotion-focused traditions. In this treatment model, early maladaptive schemas are considered core elements of persistent and pervasive psychopathology, including personality disorders. The goal of treatment is to decrease the impact of maladaptive schemas and to replace negative coping responses and maladaptive schema modes with more healthy alternatives so that patients succeed in getting their core emotional needs met. The emerging attention for schema therapy in older adults is in line with the increased attention for personality disorders in later life, and also with the maturing field of psychotherapy for older adults. The first scientific evidence for the feasibility and the effectiveness of schema therapy has recently been shown. Despite these developments, much work is still to be done. The question is whether schema theory, which was developed for adults in young and middle adulthood, equally applies to those in later life. Although the first tests of effectiveness of schema therapy in older adults are encouraging, age-specific adaptations of existing therapy protocols, both for individual and group schema therapy, are wanted. Furthermore, the research that has been conducted so far has focused on the young-old. Especially for the growing and highly complex group of oldest-old patients, the development of feasible and effective schema-based interventions is needed. Integrating age-specific moderators for change, such as wisdom enhancement, attitudes to aging, and integrating the action of positive schemas, deserves recommendation.
Caring for an older adult who needs help or supervision is in many cases associated with mental and physical health issues, especially if the care recipient has dementia, although positive consequences associated with caregiving have also been reported. Several theoretical models have shown the relevance of psychological variables for understanding variations in the stress process associated with caregiving and how interventions may benefit from psychological techniques and procedures.
Since the 1990s it has been witnessed an increment in the number of studies aimed at analyzing caregiver health and developing and testing interventions for decreasing caregiver distress. Several examples of interventions for helping caregivers are considered empirically supported, including interventions for ethnically and culturally diverse caregivers, with psychotherapeutic and psychoeducational interventions showing strong effect sizes. However, efforts are still needed to maintain the results of the interventions in the long term and to make the interventions accessible (e.g., through technological resources) to a large number of caregivers who, because of time-pressure issues associated with caregiving or a lack of support, are not benefiting from them. Making these interventions available in routine healthcare settings would help a large population in need that presents with high levels of psychological suffering.
Gregory A. Hinrichsen
In clinical practice with older adults, depression is a common presenting problem and is usually interwoven with one or more life problems. These problems are often the focus of psychotherapy. Interpersonal Psychotherapy (IPT) is a highly researched and effective treatment for depression in adults and older adults. IPT is time-limited, and as an individual psychotherapy it is usually conducted over 16 sessions. IPT focuses on one or two of four interpersonally relevant problems that may be a cause or consequence of depression. These include: role transitions (life change), interpersonal role disputes (conflict with another person), grief (complicated bereavement), and interpersonal deficits (social isolation and loneliness). The four IPT problem areas reflect issues that are frequently seen in psychotherapy with depressed older people.
Zella Moore, Jamie Leboff, and Kehana Bonagura
Major depressive disorder, dysthymia, and bipolar disorder are very common diagnoses seen among athletes, and they are serious conditions that can be debilitating if not properly addressed. These disorders warrant careful attention because they can adversely affect multiple domains of an athlete’s life, including athletic motivation, performance outcomes, interpersonal well-being, health, and overall daily functioning. Key foci include the prevalence of, clinical characteristics of, causes of, and risk factors for major depressive disorder, persistent depressive disorder/dysthymia, bipolar I disorder, and bipolar II disorder. Sport psychologists should integrate such important information into their overall case conceptualization and decision-making processes to ensure that athletes and performers at risk for, or struggling with, such mental health concerns receive the most effective, efficient, and timely care possible.
Robert A. Neimeyer and Melissa A. Smigelsky
Death and loss are universal human experiences, yet understandings of and attitudes toward expressing grief have shifted across time. The earliest psychological conceptualization of grief pathologized “holding on” to the lost object, a notion that has since been rejected in favor of a conception of continuing bonds that can be adaptive in grief. Similarly, early stage theories of grieving suggested a linear progression toward resolution and acceptance of loss, which has been criticized in favor of approaches that allow for natural regulatory processes of attending to the loss and reengaging with a changed world. In sum, grief is no longer regarded solely as looking back on a past life with the deceased but rather is oriented toward creating and reconstructing a meaningful present and future that accommodate the loss and its impact.
Most people respond adaptively to loss by relying on their internal and social support systems. However, a significant subset of grievers struggles with complicated grief, which is characterized by intense longing for the deceased, causes impairment in various life domains, and extends beyond the period of grieving that is considered normal for the population and culture. Grief therapy is most appropriate and advantageous for grievers who self-identify the need for additional support, and this tends to happen among those who are struggling disproportionately. Complicated grief shares features with other common psychiatric diagnoses (e.g., Major Depressive Disorder and Posttraumatic Stress Disorder), as well as being characterized by distinctive separation distress regarding the deceased. Treatment for complicated grief targets the common symptoms among these disorders as well as the grief-specific manifestations of distress that are concentrated on issues of coping, attachment, meaning, and behavior.
Simona C. Kaplan, Michaela B. Swee, and Richard G. Heimberg
Social anxiety disorder (SAD) is characterized by fear of being negatively evaluated by others in social situations. Multiple psychological interventions have been developed to treat SAD. The most widely studied of these interventions stem from cognitive-behavioral, acceptance-based, interpersonal, and psychodynamic conceptualizations of SAD. In cognitive-behavioral therapy (CBT), patients learn to identify and question maladaptive thoughts and engage in exposures to feared situations to test the accuracy of biased beliefs. Mindfulness and acceptance-based approaches to treating SAD focus on mindful awareness and acceptance of distressing internal experiences (i.e., psychological and physiological symptoms) with the ultimate goal of behavior change and living a meaningful life based on identified values. Interpersonal psychotherapy links SAD to interpersonal problem areas and aims to reduce symptoms by targeting interpersonal difficulties. Psychodynamic psychotherapy for SAD focuses on identifying unresolved conflicts that lead to SAD symptoms, fostering insight and expressiveness, and forming a secure helping alliance.
Generally, CBT is the most well-studied of the psychological treatments for SAD, and research demonstrates greater reductions in social anxiety than pill placebo and waitlist controls. Results from randomized controlled trials (RCTs) suggest that mindfulness—and acceptance-based therapies may be as efficacious as CBT, although the body of research remains small; four of five RCTs comparing these approaches to CBT found no differences. RCTs comparing CBT to IPT suggest that CBT is the more efficacious treatment. Two RCTs comparing CBT to psychodynamic psychotherapy suggest that psychodynamic psychotherapy may have efficacy similar to CBT, but that it takes longer to achieve similar outcomes. RCTs examining CBT and pharmacotherapy suggest that the medications phenelzine and clonazepam are as efficacious as CBT for treating SAD and are faster acting, but that patients receiving these medications may be more likely to relapse after treatment is discontinued than patients who received CBT. Research generally does not indicate added benefit of combining psychotherapy with pharmacotherapy above each monotherapy alone, although this body of research is quite variable. Effectiveness studies indicate that CBT is equally effective in community clinics and controlled research trials, but studies of this nature are lacking for other psychological approaches.
Katy W. Martin-Fernandez and Yossef S. Ben-Porath
Attempts at informal personality assessment can be traced back to our distant ancestors. As the field of Clinical Psychology emerged and developed over time, efforts were made to create reliable and valid measures of personality and psychopathology that could be used in a variety of contexts. There are many assessment instruments available for clinicians to use, with most utilizing either a projective or self-report format. Individual assessment instruments have specific administration, scoring, and interpretive guidelines to aid clinicians in making accurate decisions based on a test taker’s answers. These measures are continuously adapted to reflect the current conceptualization of personality and psychopathology and the latest technology. Additionally, measures are adapted and validated to be used in a variety of settings, with a variety of populations. Personality assessment continues to be a dynamic process that can be utilized to accurately and informatively represent the test taker and aid in clinical decision making and planning.
Stuart Linke and Elizabeth Murray
Alcohol-use disorders are widespread and associated with a greatly increased risk of health-related and societal harms. The majority of harms associated with consumption are experienced by those who drink above recommended guidelines, rather than those who are alcohol dependent. Brief interventions and treatments based on screening questionnaires and feedback have been developed for this group, which are effective tools for reducing consumption in primary care and in other settings. Most people who drink excessively do not receive help to reduce the risks associated with excessive consumption. Digital versions of brief and extended interventions have the potential to reach populations that might derive benefit from them. Digital interventions utilize the same principles as do traditional face-to-face versions, but they have the advantages of availability, confidentiality, flexibility, low marginal costs, and treatment integrity. The evidence for the feasibility, acceptability, costs, and effectiveness of digital interventions is encouraging, and the evidence for effectiveness is particularly strong in studies of student populations. There are, however, a number of unresolved questions. It is not clear which components of interventions are required to maximize effectiveness, whether digital versions are enhanced by the addition of personal contact from a facilitator or a health professional, or how to increase take up of the offer of a digital intervention and reduce attrition from a program. These questions are common to many online behavior-change interventions and there are opportunities for cross-disciplinary learning between psychologists, health professionals, computer scientists, and e-health researchers.