by Ellen Colangelo, Ph.D., President of the San Diego Psychological Association
This is an exciting time as we launch the online edition of The San Diego Psychologist. Our new editor, Gauri Savla, has researched and designed the most user friendly way to publish the newsletter. You may agree that she has managed to retain the attractiveness and journalistic quality that we have enjoyed over the years in the hard copy versions.
Historically, each editor has brought his or her own unique style and flavor to The San Diego Psychologist. This is what keeps it vibrant and alive and motivates us to want to read it.
Gauri’s intent as editor is to have a theme to each edition; She has selected Aging for the current, Spring/Summer 2016 issue. As the boomers move into the final quarter of their lives, we begin to see more and more of the Medicare crowd in our practices, struggling with the gradual decline of strength and flexibility, minor to major cognitive decline, financial concerns, loss, and spiritual challenges that come with the existential awareness of life as impermanent. As one who is in this generation of Elders, I look forward to reading this maiden, online edition of The San Diego Psychologist.
Congratulations, Gauri, on a job well done. Special thanks to our previous editors, especially Karen Fox, our outgoing editor, who continued the strong tradition of quality that is the foundation of this publication.
by Brenda Johnson, Ph.D.
SDPA has been fortunate to have had many exceptionally talented Newsletter editors over its years. As this first online edition of The San Diego Psychologist launches, I am pleased and honored to introduce you to our newest editor, Gauri Savla. I have known Gauri for almost 13 years; I was among her first clinical practicum supervisors, and am now proud to call her my colleague and friend.
Gauri brings so much to the SDPA; Her academic achievements are significant. After graduating at the top of her class in her Clinical Psychology Master’s program at the University of Mumbai, India she attended the San Diego State University/University of California, San Diego Joint Doctoral Program, graduating with a second Master’s degree in 2006 and a Ph.D. in 2009. She went on to earn a National Research Service Award Postdoctoral Fellowship in Geriatric Psychiatry for her postgraduate studies at the UCSD Department of Psychiatry.
So far in her young career, Gauri has authored over 20 peer-reviewed papers and 10 invited book chapters. She has served as a reviewer for several journals, including the American Journal of Geriatric Psychiatry and the British Journal of Psychiatry, and she has presented at numerous professional conferences. As a clinician, she has had years of experience providing individual and group psychotherapy in both outpatient and inpatient settings, and conducting neuropsychological assessments at UCSD Outpatient Psychiatry Services, VA Healthcare System San Diego, and the Langley Porter Psychiatric Institute at UC San Francisco, among others.
Gauri’s primary professional focus and passion is working with seniors and their families. In 2014, she opened her private practice in Encinitas, specializing in geriatric psychology.
In 2005, as an SDPA student member, Gauri presented a workshop to our members on ways to improve power point presentations. Her task was challenging because the attendees’ computer skills varied wildly from “How do I turn on this laptop?” to “How do I add movie clips?” I recall Gauri clearly, concisely and very patiently taking each of us step-by-step through that process. She made the class a lot of fun and everyone left better informed.
Under her editorship, the San Diego Psychologist will enjoy the same professional focus and technical expertise Gauri brought to that workshop. She will welcome your contributions.
Dr. Johnson is a Past President and Fellow of the SDPA and a clinical psychologist in private practice.
by Wendy Tayer, Ph.D.
Years of clinical experience have taught me that people enter psychotherapy feeling disempowered in some way. This characterization is especially true for seniors. They seek or are referred for mental health treatment for a variety of reasons, including depression, anxiety, grief, and disability. Often, those seeking therapy are isolated, widowed, struggling with caregiving burdens or feel disconnected from their community after retirement. This population is aging in a rapidly changing world of technology, mass communication, busy distracted family members and a society that does not revere aging. These circumstances create numerous challenges in addition to the expected declines in functioning due to aging.
Our elder population is growing; according to the APA Office on Aging (2011), people over 65 years old are the fastest growing segment of our population and and will comprise 20% of our nation’s population by 2020. They are grossly underserved in the arena of mental health, so much so that the APA advertises this specialty, established in 2010, as one of the chief areas for job growth in clinical and research psychology. The APA materials explain the demographics and needs of the population but they don’t convey the experience of working with seniors.
They are grossly underserved in the arena of mental health, so much so that the APA advertises this specialty, established in 2010, as one of the chief areas for job growth in clinical and research psychology.
I believe that in order to draw more psychology students and newly licensed psychologists into the field of geropsychology, it is helpful to share my experience in working with seniors for 10+ years. I have done so with my supervision students in informal ways over the years with positive results. This article is intended to be a qualitative reporting of my many rewarding years of working with seniors. Research findings are interspersed to support and validate my experience.
Americans tend not to welcome aging or revere our seniors; in fact, we worship youth and often go to great lengths to prolong the appearance of youth, evidenced in our media. But aren’t aging and the passage of time the most fundamental aspects of our life on this planet? These are some of the topics that I explore with seniors. Whether it is the retired physician in chronic pain or the lonely, frustrated widow or the man who cannot bear the thought of his wife dying – we find ways to explore their dissatisfactions, fears, memories and strengths in order to find points of connection and enrich their lives.
Americans tend not to welcome aging or revere our seniors; in fact, we worship youth and often go to great lengths to prolong the appearance of youth…
This population is characterized by rich, complex personal histories of coping, family life and personal struggles in addition to the challenges of facing personal and familial morbidity and mortality. (American Psychologist, 2014). And, they come into therapy ready to engage in “life review” work or reminiscence therapy, both of which are strategies for reviewing old memories and mementos while seeking connections, meanings, and summing up one’s life in search of resolution. This work is often profound for seniors, and the literature documents its efficacy in treating depression and enhancing well-being among cognitively intact seniors (Oxford Handbook of Clinical Geropsychology, 2014). My role is typically characterized by offering reality testing, socialization, and support to seniors who often feel disenfranchised. Frequently they tell me that I am the only or one of the few people in their lives who sits and listens to their struggles, offers empathy, unconditional acceptance and steps toward resolution. Often they describe their families as resentful, impatient, intolerant or just too busy to listen and attend to their needs, or include them socially.
Their generation understands personal responsibility and commitment; they show up for therapy, are goal-directed, do the work and tend to be more satisfied with psychotherapy than younger adults
Seniors today are a product of their experience and a 20th century worldview. We engage in much verbal unraveling of experience and personal stories to help them heal or uncover new ways to understand and carry their life story. We also discuss ways to adapt to the 21st century. They are digital “newbies,” which I consider to be one of their strengths, as they understand the value of interpersonal connection; this appreciation for connection also yields a more positive result from our therapeutic relationship. Their generation understands personal responsibility and commitment; they show up for therapy, are goal-directed, do the work and tend to be more satisfied with psychotherapy than younger adults (New York Times, 2013). However, elders vary in their technological skill level. I spend many sessions offering tutorials in smart phone or PC utilization in order to foster more independence. Recent research findings indicate that utilization of technology is cognitively and emotionally beneficial to seniors (Oxford University Press USA, 2014).
The therapeutic alliance is a critical element with seniors. I have not encountered much data on this topic but can speak from years of experience. Seniors are unique in that they can be isolated and a third of them use some kind of device to help them ambulate (Purdue University, 2010). Thus, psychotherapy with them requires us to rethink the traditional rules of psychotherapy. For example, in most clinical settings, we typically would not touch our patients. However, seniors can have limited opportunities for socialization and human connectivity, especially affection or touch, this point commonly referenced on nursing home and caregiving websites. Thus, it is not unusual for female seniors to ask for a hug or for me to offer a reassuring pat, these gestures serving as vehicles for building and maintaining an emotional connection. Often, seniors come to my office with wheelchairs, walkers, canes and leg braces. They often need assistance and express gratitude for the acknowledgement of their “helping” device.
Seniors face the challenges of permanent life changes that threaten their autonomy. In my experience, one of the most prominent concerns is the loss of function, independence and ability to be self-sufficient. Surrendering one’s driver’s license and moving an elder out of his or her home into an assisted living facility are probably the most emotionally charged losses for seniors. Other common themes are cognitive and sensory decline, death and dying, and grief about ill and deceased loved ones, including pets (APA Office on Aging, 2011). These patients often have outlived their peers and feel disconnected and alone. And they are at various stages of aging and retirement. Some are adjusting to retirement after a long purposeful, satisfying career. Others are trying to renew themselves and establish new avenues of expression or contribution to their community.
According to the APA and other literature, the interventions that we use with other populations are applicable to seniors (American Psychologist, 2014). However, they are adapted to meet the needs of our aging population. For example, we may spend more time on review of life events and memories than with younger people. And we may slow down the process of teaching them a new coping skill. I apply an array of evidence-based strategies such as journaling, CBT, humor therapy, mindfulness, ACT, and supportive psychotherapy. A mix of these strategies along with an acknowledgement and exploration of their existential issues, especially morbidity and mortality, is very effective with elders (American Psychologist, 2014).
The influx of new information about our brains offer tremendous hope for easing the aging process and offering more fluid, flexible interventions for optimizing the aging brain.
I especially enjoy sharing the most recent advances in neuroscience with seniors. We have evidence that acquisition of new information enhances cognitive functioning (Psychological Science, 2014) and that the brain is neuroplastic across the lifespan. (SharpBrains.com, 2016) The influx of new information about our brains offers tremendous hope for easing the aging process and offering more fluid, flexible interventions for optimizing the aging brain. For example, we know that starting exercise regimens as a senior can improve memory processes and quality of life (University of Montreal, 2012). These are just a few of the recent research findings on this exciting topic.
Related to providing psychoeducation to seniors, I have developed a modest session goal over the years, which usually is well-received. I aim to offer my patients one suggestion or piece of information to take away and mull over until the next session. It focuses us on the experiential and relational elements in therapy. In this vein, I make it a point to capitalize on their strengths and emphasize a mindful, accepting approach. I enjoy humor and share laughter with seniors in session if they are amenable to it, thus incorporating a bona fide mood booster for all parties involved.
They teach me valuable lessons every week for which I am eternally grateful. These therapeutic relationships are mutually emotionally beneficial.
I learned how to work with seniors on the job, sitting with my patients, attending geropsychology seminars, reading the literature and consulting with colleagues. There is a great deal of information about gerontology that this article space does not allow, including the role of medications and substances, cognitive decline, assessment, caregiving, and potential financial and physical abuse. My aim was to touch on some key experiential themes that resonate with me as a clinician. I am constantly learning more about this multifaceted, largely unappreciated population group. They teach me valuable lessons every week for which I am eternally grateful. These therapeutic relationships are mutually emotionally beneficial. My newest tidbit for sharing is Dr. Amy Cuddy’s power pose after listening to her speak recently. A Harvard Business School social psychologist, her research focus is the universal role and potential of nonverbal behavior to empower us, and her TED talk is the second most watched TED talk on the web. I also recommend her book entitled “Presence.” This intervention is an especially enlivening and well-received addition to our sessions.
If you are interested in a career or specialization in geropsychology, acquaint yourself with the literature and online resources such as APA and The Gerontological Society of America. Attend conferences, find a mentor, spend time with seniors and read both fiction and non-fiction about aging and seniors (some suggestions below).
- Albom, Mitch. (1997) Tuesdays With Morrie. Doubleday
- Bachman, Fredrik. (2014) A Man Called Ove: A Novel. Simon and Shuster
- Brizendine, Louann (2007) The Female Brain. Harmony Books
- Brizendine, Louann (2010) The Male Brain. Harmony Books
- Cuddy, Amy (2015) Presence: Bringing Your Boldest Self to Your Biggest Challenge.
- Little, Brown, and Company
- Didion, Joan. (2011) Blue Nights. Alfred A.Knopf
- Ephron, Nora. (2008) I Hate my Neck and Other Thoughts About Being a Woman. Vintage Books
- Gawande, Atul. (2014) Being Mortal. Metropolitan Books
- Strout, Elizabeth. (2008) Olive Kitteridge. Random House
- American Psychological Association. (2014, January) Guidelines for Psychological Practice With Older Adults. American Psychologist. 69(1), 34-65. DOI:10.1037/a0035063
- APA Office on Aging Resource Guides, 2009-2013, American Psychological Association, Retrieved from http://www.apa.org/pi/aging
- The Gerontological Society of America. (2014, April 17) Internet use may cut retirees’ depression. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2014/04/140417124706.htm
- Ellin, A. (2013, April 22) How Therapy Can Help In the Golden Years. The New York Times, Retrieved from http://www.nytimes.com
- University of Montreal. (2012, September 6) Even the very elderly and frail can benefit from exercise. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2012/09/120906182008.htm
- Michelon, P. (2008) Brain Plasticity: How Learning Changes Your Brain. Retrieved from http://www.sharpbrains.com.
- Pachana, N.A., and Laidlaw, K., eds. (2014) The Oxford Handbook of Clinical Geropsychology: Bahr, S.S., Reminiscence Therapy, A Review. Oxford University Press, pp. 675-690 DOI: 10.1093/Oxfordhb/9780199663170.13.018
- Park, D.C. et al. (2014). The Impact of Sustained Engagement on Cognitive Function in Older Adults: The Synapse Project. Psychological Science. 25(1), 103-112. Retrieved from http://www.psychologicalscience.org
- Purdue University. (2010, July 29) Weight issues move up need for walkers, canes, other devices. Science Daily. Retrieved from http://www.sciencedaily.com/releases/2010/07/100728121331.htm
- Oxford University Press USA. (2014, August 12). Digital literacy reduces cognitive decline in older adults, experts find. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2014/08/14081216709.htm
Dr. Wendy Tayer has been a clinical instructor in the UCSD psychiatry department since 2001. She practices psychotherapy and is a clinical supervisor specializing in gerontology, behavioral medicine and student health.
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by Hugh Pates, Ph.D.
I have had the opportunity to treat geriatric patients in skilled nursing facilities (SNF) for the past 15 years of my 40-plus career as a practicing clinical psychologist. In the course of my experience, I have encountered ethical dilemmas that have led me to make subtle and significant changes in my practice of therapy with this group of patients.
My goal in writing this article is to highlight some of the common considerations in working with patients in SNFs, and my suggestions for how to address them.
As any practicing clinician knows, confidentiality is the cornerstone of the therapeutic relationship, and is strictly maintained (with the usual legal limitations) in general clinical practice at all times. The SNF, however, is powered by a team of professionals, all of whom play vital roles in a patient’s care. Confidentiality, in such settings, are between the patient (and his or her family) and a team of healthcare professionals, rather than a single therapist.
Confidentiality, in such settings, are between the patient (and his or her family) and a team of healthcare professionals, rather than a single therapist.
Before any discussion about confidentiality is broached, I like to gauge whether the patient has the competence for talk therapy, often with the aid of a Mini Mental Status Exam (MMSE). I then ask the patient to sign a waiver of confidentiality to allow me to communicate with medical personnel associated with the patient’s care and “others” as needed. “Others” generally include appropriate family members and/or conservators. Consultations of this nature are necessary in order to improve the medical care of the patient, and to also help family members understand what is going on with their loved one and assuage any fears or doubts they may have.
The most striking difference in keeping records of therapy sessions (in the form of progress notes) when working with patients in SNFs is that any professional involved in their care has access to them. This makes a team approach to a patient’s care seamless. Both these practices are clearly different among therapy patients in SNFs than those in a typical, outpatient/community practice.
Suitability for Talk Therapy
Sensory impairment (particularly hearing) or cognitive impairment pose challenges for talk therapy, therefore, an evaluation of a patient’s ability to participate in and profit from talk therapy is essential. These challenges tend to be present more frequently among seniors at SNFs.
When I began my work in SNFs, I was concerned about the ethics of working with someone who may not benefit from therapy; as it turned out, I witnessed substantial improvements in the quality of life among numerous patients in a skilled and supportive therapeutic milieu.
The initial diagnostic interview is the ideal way to evaluate the manner in which a person is able to articulate their thoughts and goals, and recall personal historical information. This is also a good opportunity to determine the extent of hearing impairment, if any, and the modifications necessary to render talk therapy and appropriate mode of treatment. Additionally, a cognitive screen such as the MMSE is a quick and effective way to assess a patient’s basic cognitive skills, attention and orientation, and short term recall and recognition. I have found that an MMSE of 18 (out of a possible 30 points) is the minimum score required to proceed with therapy.
Gift exchanges, particularly accepting gifts from patients has always remained a gray area in the therapeutic relationship. However, among older patients in SNFs, distributing small gifts can serve to strengthen and enhance therapeutic alliance. Candy (when appropriate), other edibles, or flowers are usually the types of gifts that are appreciated and tend to facilitate swift positive changes in behavior patterns that in turn, can improve mood (e..g, reduced expression of anger, willingness to participate in activities, more cooperation with caregivers).
Touch, like gift exchanges, fall into that controversial, gray area in general clinical practice. However, physical touch (patting someone on the shoulder, holding a hand, or a hug) among geriatric patients, in both outpatient and inpatient (e..g, SNF) settings can be a powerful way to build the therapeutic relationship. Older adults respond more positively to interventions when they see their therapists as caring and concerned about their well-being, and gentle, caring touch when they are experiencing an emotional moment, or at the conclusion of the session goes a long way in maintaining rapport.
…physical touch (patting someone on the shoulder, holding a hand, or a hug) among geriatric patients, in both outpatient and inpatient (e..g, SNF) settings can be a powerful way to build the therapeutic relationship.
I have consistently found that revealing details from my own life with geriatric patients has a hugely beneficial effect in moving therapy forward. Patients tend to become more energized, alert, and involved when they see therapists as people they can have a connection with; I share tidbits from my own life, such as escapades with my grandchildren or my interest in various athletic activities. I direct my own experiences to those they have had in the past or are currently experiencing, in order to engage them in dialogue about goals for the session at hand.
Patients tend to become more energized, alert, and involved when they see therapists as people they can have a connection with…
These are but a few ways in which my ethical practices differ from those pertaining to other populations I see in my practice. They are modified in the manner described in this article to engage a group of patients traditionally not open to therapy, and to enhance the effectiveness of existing, evidence-based interventions. My hope is that science catches up with the practice of therapy with geriatric older patients, a rapidly growing demographic that is underserved and less understood than any other age group of therapy patients.
Hugh Pates Ph. D. has been a senior Therapist with the Co- Health Organization for over 15 years. This group contracts with Skilled Nursing Facilities to provide their Behavioral Health Services to Geriatric patients. Dr. Pates is currently a member of the Board of the San Diego Psychological Association.
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by Jennifer Chappell Marsh, LMFT
John and Sarah are in their mid 60s and have been married for more than 40 years. They raised three children together, navigated periods of unemployment, the death of their parents, retirement and countless stressors over the course of their marriage. They have come to couples therapy because post-retirement life uncovered the gulf of emotional and physical distance between them. They calmly and matter-of-factly describe the lack of intimacy in their relationship. Sarah says she feels lonely and wants to feel more “together.” John agrees, describes their relationship as “roommates.”
As more and more older couples find their way to counseling, it is promising that older clients generally have a higher satisfaction rate in therapy than younger clients.
John and Sarah present the typical issues for older couples that I see in my couples therapy practice. The overall number of older couples seeking therapy is growing. According to the American Psychological Association (APA), “People 65 years old and older are the fastest growing segment of the U.S. population. By 2030, older adults will account for 20 percent of our nation’s people, up from 13 percent in 2008.” As more and more older couples find their way to counseling, it is promising that older clients generally have a higher satisfaction rate in therapy than younger clients. For these couples, time is precious and they have well defined goals leading them to take couples therapy as a serious investment (Ellin, 2013).
EFT helps couples to understand how their their attachment longings (to rely and depend on, and connect with their partner) influence emotional states and behavioral reactivity…
I have found couples therapy, and specifically Emotionally Focused Therapy (EFT), to be highly effective with older couples. Based in attachment theory, EFT was developed by Drs. Sue Johnson and Les Greenberg to address the way couples get stuck in a negative interactional dance, reinforcing emotional disconnection. EFT helps couples to understand how their their attachment longings (to rely and depend on, and connect with their partner) influence emotional states and behavioral reactivity; As couples age, their attachment needs become more apparent and there is an increased need for each partner to have the other’s support. Studies suggest that given the increased potential for separation, attachment issues are particularly relevant in older adult relationships, especially given the loss and vulnerability associated with aging (Bradley & Cafferty, 2010).
…given the increased potential for separation, attachment issues are particularly relevant in older adult relationships, especially given the loss and vulnerability associated with aging.
Sarah reports that her memory is fading. John says his hearing is declining. John jokes: “She needs me to remind her of what she’s looking for in her purse and then yell to me when she’s found it.” In times of distress and vulnerability, we look to our partner as our “safe haven”. We need to know our partner will be there for us, is responsive to our needs and is emotionally engaged. “As individuals age, many elements of their life that had been constant, begin to change. For many, their support systems (in the form of spouses or friends) begin to disappear. It also becomes harder to remain completely independent, a particularly hard thing for individuals to accept.” (Peluso, Watts, & Parsons 2012).
Furthermore, we know that older couples are in an ever increasing state of vulnerability. “As their non-familial network diminishes with age, family relationships (in particular, the martial relationship) become extremely important sources of emotional support to the elderly.” (Canadian Medical Association Journal, 1984). For some couples, like Sarah and John described above, this increased dependance highlights a missing connection in their relationship.
Where primary attachment figures are involved, individuals have strong emotional and behavioral reactions to disconnection. “While individuals may attempt to cope with this vulnerability by using a variety of strategies, two of the more common approaches involve constellations of feelings, thoughts and behaviors related to anxiety (e.g., protesting, clinging, demanding, criticizing, dependency) to avoidance (e.g., withdrawal, affective “cutting off”).” (Bradley & Palmer, 2003). These individual attachment systems are likely to be activated in times of distress related to vulnerability, separation and loss. Such strategies, when used to cope with disconnection, create negative interactional patterns between partners.
Older couples may also have relatively long histories of marital distress, conflict withdrawal, disengagement, or feelings of resignation to the status quo in one or both partners.
In older couples, the more common “protest/withdrawal” dance turns into a mutual withdrawal. Attempts to connect fall short over the years. Older couples may also have relatively long histories of marital distress, conflict withdrawal, disengagement, or feelings of resignation to the status quo in one or both partners. (Canadian Medical Association Journal, 1984) So instead of hurling angry criticisms at John, Sarah sighs and says, “I used to get upset when he’d shut down but I guess I’m just used to it now. I’ve known for a long time that he doesn’t really care.” John responds, “I want Sarah to be happy. I have just become numb over the years because there’s nothing I can do.” This pattern of mutual disengagement is more common in older adults; Years of failed attempts at connection leave both parties hopeless about gaining closeness (Bradley & Palmer, 2003).
Older people will use strategies to avoid the experience of negative emotions and, in turn, older couples’ interactions are less volatile than their younger counterparts. Couples may “leave well enough alone” by staying in affectively neutral interactive sequences and avoiding escalation to negative affect. In order to avoid high conflict older couples who are unhappy in their relationship are less likely to engage in negative start-up responses to potential discord (Carstensen, Gottman, & Levenson, 1995). A mutual withdrawal is effective at keeping the peace but also maintains distance between couples.
The therapist who employs EFT in their practice supports and guides both partners with directly expressing their attachment needs and fears. Thus, each partner learns to risk engaging with their vulnerability.
Emotionally Focused Couples Therapy helps to close the gap that forms from mutual withdrawal. Dankoski (2001) points out that EFT is particularly useful for treating couples whose distress is related to major life events. Without a secure base, older adults experience higher levels of distress. The therapist who employs EFT in their practice supports and guides both partners with directly expressing their attachment needs and fears. Thus, each partner learns to risk engaging with their vulnerability.
Let’s return to the case of Sarah and John. Sarah finds she is able to open up about her fears of abandonment and rejection. John learns to discuss feelings of helplessness, particularly at meeting Sarah’s needs. Through EFT, the therapist explores interactional cycles, allowing the couple to reconnect with disowned needs, and gain a new experience of connection and attainment (Johnson & Greenberg, 1988). John comes to understand that Susan’s past criticisms come from her feelings of abandonment. Similarly, Sarah gains the insight that John’s withdrawal is his shield against feelings of helplessness, and of failing her. Through EFT sessions, John and Sarah each gain a greater sense of emotional connection and relational security.
Changing the withdrawal/withdrawal dynamic requires helping older couples to acknowledge their need and desire for closeness. Like narrative-based approaches to psychotherapy, the skilled used of EFT encourages therapists and clients to examine and actively construe their “life stories” in subjective, personal terms. EFT can indeed offer older couples a chance to rewrite the ending to their shared life story.
American Psychological Association. What Mental Health Providers Should Know About Working With Older Adults. retrieved 03/20/2016.http://www.apa.org/pi/aging/resources/guides/practitioners-should-know.aspx
J. Michael Bradley & Thomas P. Cafferty. Attachment among older adults: Current issues and directions for future research.(pages 200-221)Published online: 07 Oct 2010
Bradley, M. and Palmer, G. (2003). Guilford Press. Edited by Susan M. Johnson, Valerie E. Whiffen. Attachment in Later Life – Implications for Intervention with Older Adults. Attachment Processes in Couple and Family Therapy (pp. 281-296)
Carstensen, L., Gottman, J., & Levenson, R. (1995). Emotional behavior in long-term marriage.
Psychology and Aging, 10, 140-149.
Dankowski, M. E. (2001). Pulling on the heart strings: An emotionally focused approach to family life cycle transitions. Journal of Marital and Family Therapy, 27(2), 177-187.
Ellin, Abby (2013). How Therapy Can Help in the Golden Years. New York Times. Published online: http://well.blogs.nytimes.com/2013/04/22/how-therapy-can-help-in-the-golden-years/?_r=1
Leslie S. Greenberg, Susan M. Johnson (1988). Emotionally Focused Therapy for Couples.
Paul R. Peluso, Richard E. Watts, Mindy Parsons (2012). Changing Aging, Changing Family Therapy: Practicing With 21st Century Realities. Taylor & Francis, Apr 27, 2012.
Marital therapy for the elderly. Canadian Medical Association Journal. Vol. 130, June 15, 1984.
Jennifer Chappell Marsh, owner of Chappell Therapy is a Licensed Marriage and Family Therapist. She has a full-time private practice in San Diego focusing primarily on couples therapy. Jennifer draws on strength-based and evidence-based approaches, namely Emotionally Focused Therapy (EFT) to help her clients build and maintain happy, healthy relationships.
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by Sarah Nunnink, Ph.D.
Yet, most older couples (whether gay or straight) report a sexual pulse that, while declining in terms of frequency and intensity, is certainly palpable.
Older adults are often dealing with major transitional and generational/contextual issues that affect their marital dynamic that can cross over into the bedroom as well.
- Prejudicial stereotypes of older people as asexual, sickly, irrelevant and unimportant
- Retirement from employment in one or both partners, resulting in a loss of social status, identity, power and self-worth
- Physical illness in one or both partners, leading to an increased need for dependency on loved ones/partner;
- The direct or indirect (e.g., medication-related) effects of physical illness on sexual functioning
- Generational social conditioning of men (especially older men) to be emotionally “strong,” avoid expressions of vulnerability and be “emotionally independent” or self-sufficient
- Significant loneliness in older age, and sense of disconnection coupled with a deep human longing for physical contact/touch
- Death of a partner and the need to develop new relationships, as well as the possibility of “blended” families with multiple marriages across the lifetime
- Changes to physical appearance, body, hormones, and sexual physiology that accompany aging or illness, including 1) menopause, lower vaginal elasticity and arousal, greater possibility of dyspareunia for women, 2) declining testosterone levels, erectile difficulties or decreased penile sensitivity for men, and 3) lower desire or frequency of sex for the majority of older individuals. Vasoactive agents (e.g., sildenafil) are often offered as a first line treatment for men and estrogen cream or supplement may help for women – however, given the contextual issues surrounding sex and the senior couple, even if the “mechanics” of sex improve, often the sexual satisfaction may not
Despite these challenges, older couples also have significant strengths:
The longer term pair-bonds of older couples, some of whom have been together for decades and have a shared history
Greater emotional intimacy and the capacity to truly see and be seen by our partners, resulting in the potential of optimal sexuality, and the possibility of intimacy-driven sexual behavior as opposed to strictly mechanistic and performance-based sex
Sex is one of the most sensitive barometers of the general functioning of a relationship; it often serves as the “red flag” that the relationship is in trouble (or has been for quite some time). Historically, the field of couples therapy has often underemphasized the role of sex, whereas the sexual health field originally focused on the mechanisms or “medicalization” of sex, missing the larger contextual framework in which sexual problems arose. Recently, there has been a welcome converging of the fields, and the work of Sue Johnson, Ed.D. using an Emotion Focused (EFT) and Sex Therapy integrated model, is particularly promising.
From an EFT framework, the sexual system is one of the three primary ingredients in the formation of adult romantic bonds, resting between the attachment and caregiving systems. Sex often facilitates the development of the attachment bond between partners, though its significance wanes in later stages of the relationship (Johnson & Zuccarini, 2011). In EFT, a securely attached bond that is defined by emotional accessibility and responsiveness allows integration of all three systems. In an insecurely attached bond, it is common to see couples presenting with sexual complaints, which might include an anxious approach for sex or, alternatively, an avoidant deactivation within the sexual dynamic. In other words, in a distressed couple, one partner might anxiously pursue sex as an attempt at attachment soothing (reassurances of attractiveness, desirability, confirmation of their importance to their partner in order to “calm” fears of abandonment). Conversely, an avoidant partner might present by minimizing internal emotions, sexual cues and needs in order to soothe attachment fears of rejection by partner (avoid sex altogether, focus on the “performance” or mechanics of sex without allowing emotional engagement). Importantly, these dynamics of pursuit and withdrawal, while clearly apparent in the realm of sexuality and the “presenting problem”, are also typically more broadly seen within the couple’s general relational style with self and other. From an EFT perspective, it is necessary to address such a negative “cycle” both within and outside of the context of the bedroom. Either of the insecure styles of engagement listed above (approach/avoid) often lead couples down a troubling path that includes a general restriction in the possible healthy or optimal ways sex could function in their relationship. In such distressed and insecure bonds, sex can be described as non-pleasurable, pressured, dry and mechanical, task-oriented, constricted, rigid, “stale,” “lonely”, burdensome and one-dimensional.
For senior couples, some of the very issues that are contextually relevant to this population might readily “bleed” into bedroom. For example, consider the male partner (in a gay or straight couple) who has grown-up with gender-stereotypical messages of emotional restriction. He is told to “buck up and be strong…boys don’t cry,” influencing a lifelong stance of unhealthy independence and self-reliance. As this individual ages, imagine the difficulties that might arise when physical illness sets in, he requires a greater degree of reliance and “leaning into” his partner for assistance with tasks of living, all the while experiencing significant internal conflict with this human dependency need, his sexual potency (as a result of general aging/illness AND psychogenic dependency issues) declines and he is operating under the implicit emotional messages from a lifetime of social emotional learning that says “don’t reach out” and “don’t show weakness.” It would not be uncommon in such a scenario for the male partner to present alone in “secret” to his primary care doctor with a request for “Viagra.” Yet providing such a prescription may or may not improve the “mechanics” of sex in terms of “performance’, and often results in continued complaints of low desire or low satisfaction with sex for one or both partners.
The beauty of the EFT model of integrated sex/couples therapy is that the “emotional truth,” meaning and relevance of the “presenting sexual problem” is seen within the larger view of the attachment bond.
This allows for sex to function as just one of many ways couples can connect. From this viewpoint, compartmentalizing sex as separate from the relationship and from emotional experience is problematic.
Anderson, C., Dimidjian, S. & Miller, A. (1995). Redefining the past, present and future: therapy with long-term marriages at midlife. In N. Jacobson & A. Gurman (Eds). Clinical Handbook of Couple Therapy. (pp.247-260).
Goldstein S. & Preston, J. (1984). Marital therapy for the elderly. Canadian Medical Association Journal, 130, 1551-1553.
Johnson, S. & Zuccarini, D. (2010). Integrating sex and attachment in emotionally focused couple therapy. Journal of Marital and Family Therapy, 38(4), 431-445.
Johnson, S & Zuccarini, D. (2011). EFT for Sexual Issues An integrated Model of Couple and Sex Therapy. In J.Furrow, S. Johnson & B. Bradley (Eds.). The Emotionally Focused Case Book: New Directions in Treating Couples (pp. 219-246)
Leiblum, S & Segraves, R. (2000). Sex therapy with aging adults. In S. Leiblum & R. Rosen (Eds.). Principles and Practice of Sex Therapy, Third Edition (pp. 423-448)
Johnson, Sue (2016, March 31). Attachment and the Dance of Sex: Integrating Couple and Sex Therapy. Retrieved from http://drsuejohnson.com/attachment-sex/attachment-and-the-dance-of-sex-integrating-couple-and-sex-therapy/
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by Bob Uslander, M.D.I have spent most of my 25 years as emergency physician, caring for people in crisis. In recent years, I have found my true calling as a physician devoted to caring for and supporting people with complex and terminal illnesses in their own homes. Over the years I have witnessed “good deaths” and “bad deaths.”
In the course of my work, and through my discussions with patients and family members, I have identified five primary needs that are universal among people at the end of their life. In my experience, when these needs are adequately met, the final chapter of life can be a meaningful, healing time, both for the person whose life is ending and the loved ones they leave behind. This kind of death could well be considered a “good death.” A “bad death” results when one or more of these needs goes unmet, and the opportunity for a peaceful, healing, transformative end of life experience is lost. “Bad deaths” can be challenging for everyone involved, often leaving lingering regrets among surviving loved ones. Once a loved one dies, there is no way of unmaking the decisions we made or undoing the things that were done while they were still alive.
I believe that it is possible to facilitate “good deaths.”
This is why I choose to write and speak about dying, and a large part of why I developed my current medical practice. My goal is to ensure that we get it right while we can, so people have the best possible experience as their illness progresses and their life comes to a close, and those left behind can feel that they did everything they could to create that experience.
For the caregivers of a person with a complex or terminal illness, it can be very difficult to accept that there are no remaining cures and that death is imminent. Knowing how to make their loved ones’ days more peaceful is empowering. As a professional, my goal is to help loved ones understand the following needs of the ill and dying: (1) Dignity; (2) Understanding; (3) Choice/Autonomy; (4) Planning; (5) Comfort, In my opinion, if these needs are fulfilled, death can be a peaceful experience for everyone involved.
Dignity : We are cared for with awe and reverence at the beginning of our lives, cuddled and sung to, admired and loved. Should we not receive just as much reverence and awe as our life comes to a close?
Dignity is critical for a successful and transformative end-of-life experience.
At the end of our life, if we are treated with love and appreciation, we will feel dignified. It shouldn’t require any more explanation than that. People who are loved will not be allowed to remain in urine-soaked clothing; they won’t be left in isolation or allowed to be in unremitting pain. People who are loved and appreciated—treated with dignity—will receive adequate attention to make sure their needs are being met.
Understanding: People need to know what is happening to them and be told the truth. Well intentioned medical professionals, and certainly, family members and friends often withhold information from a person who is dying in order to offer some sort of hope, or to keep them from feeling upset or sad. Ironically, in these situations, the person who is dying is usually aware that the end is near, and they they are not being told the whole truth. There is a sense of mistrust or betrayal that permeates the relationships in these settings, and the atmosphere becomes more stressful and less healing. Lack of understanding breeds fear.
Dying takes courage.
People have a greater ability to handle “bad news” than most people think they do, especially when it relates to themselves and their mortality. We have greater difficulty accepting and dealing with bad news about others than we do about ourselves, which is a major reason why these honest conversations may not take place. It is less often that the individual can’t deal with it, and more likely that the family members just aren’t comfortable confronting the truth head on.
Creating an atmosphere of truth, honesty and open sharing is one of the pillars of a healing and transformative end of life journey. It can be difficult to make the leap, especially for families who have historically been emotionally reserved and distant. Families may need some guidance and support to start more open conversations, which can then lead to positive emotional changes among all involved.
It is also imperative that the medical professionals actively facilitate honest communication and ensure understanding among patients and family members. They often allow the patients and family members to lead these discussions and only reveal as much information as they are asked to, relieved to say less when allowed. But patients and families will frequently need more information down the line, when it is not readily available from a trusted source, so they will seek that information from less reliable sources. It is our responsibility as health professionals caring for people nearing the end of their lives to make sure they have all the information they need to make the best possible decisions and avoid the typical traps that befall those who are ignorant of this information.
Choice: People want autonomy, i.e., the ability to choose what happens to them for as long as possible. Even in the situation where someone is told their illness has no cure, choices exist. Despite our best intentions, making a choice for someone else robs them of dignity, which can have a devastating impact on a person going through the final stages of their life.
Choice is closely tied to understanding. People can only make appropriate choices about their care and their life when they have a clear understanding of what they are dealing with. Choices differ depending on the projected time left to live; a person given three weeks to live will make very different choices than one given three years. Choices also depend on one’s personal values, which may be different from those of loved ones. While a loved one may focus on prolonging the patient’s life, the patient himself or herself may focus on their quality of life. For example, if a course of chemotherapy will likely allow them to live for another two months, but will make them weak and nauseated and unable to do what they enjoy, they may choose not to undergo treatment to better enjoy their time in the present. Indeed, research shows that people tend to choose quality of life over quantity of life. I have found this to be consistently true in my own professional experience.
Each situation and each patient will be facing different choices, but the concept applies to every situation; giving a person as much free choice as possible near the end of their life is critical for creating the most positive, nurturing and transformative experience possible.
A Plan: In my experience, this need varies among people. There are people who do not need to have a well-developed plan as they approach their final days of life. People who did not set much store in planning, rather, did things more spontaneously, tend to approach the end of life with a similar attitude. For lifelong planners, however, this need may be an important one to fulfill. For these people, having a plan and knowing what it is factors heavily into all of the other needs—understanding, choice, comfort and dignity.
When my patients and families need a plan laid out, I take the opportunity to discuss the different paths their journey could follow, and we do some planning around each possibility. The end-of-life journey seldom follows a straight and predictable path, but we do the best we can. There are usually twists and turns, both major and minor, that need to be navigated.
Most patients and families who are forced to navigate this end of life journey have far too little guidance when it comes to planning. This promotes confusion, anxiety and fear, which as I have already discussed, can interfere with the peaceful, transformative experience we should be striving for.
Comfort: Both physical and emotional comfort are important for a person’s well-being at the end of the their life, and must be met as best as possible for a positive experience. When physical pain, or other distressing symptoms, such as nausea, shortness of breath, itching, etc., are poorly controlled, there is really no way for the experience to be peaceful or transformational. Similarly, when someone is feeling emotional discomfort or spiritual unrest, transformation is impossible to achieve. There will still be a transition, but without a transformation.
In Abraham Maslow’s theory of the hierarchy of needs, physical security is near the base of the pyramid—it is quite literally, the basis of our other experiences. Just as in every developmental stage of life, as a person approaches death, their safety, security and physical comfort are among their most urgent needs. Until we address those, the rest of the needs can never be adequately met.
Getting to know each individual we care for is crucial for providing adequate comfort. What is comforting for one person will differ from what is comforting for another person. It is up to the team supporting each patient, including his or her loved ones, to determine what they need for maximal comfort, and to make sure it is provided for them.
For one patient it will be relief of pain, for another patient it will be knowing that their legal affairs are in order, while for another it will be will be an honest discussion about past regrets or unresolved issues. For some people, massage will be comforting, or music, or watching old movies. For others, narrating a life history or spending time with friends will provide comfort. We are all comforted by different things, though as we near the end of our lives, our focus shifts, and those around us must recognize this and respond accordingly.
When the needs of those facing the imminent end of their life go unmet, it is usually because of a lack of knowledge about what is needed and what is available, and/or a lack of funds available to pay for these services. The only way to ensure that you are able to have these needs met is to be a strong advocate for yourself or your loved one, and to ask for the commitment and partnership of your health care provider. It may take a little effort to find the provider who is willing to have an open discussion with you and address your needs. Caring for sick and dying people is very much part of a medical professional’s job description, but few have the necessary training and capacity to be of optimal help. Professional care managers such a nurses, social workers, and geriatric specialists with training and experience in advocating for and navigating people through the health care system may be a good option.
The goal of this article is to primarily educate other professionals, family members, and patients themselves, in order to minimize “bad death” experiences. I hope to also bring awareness about professionals such as myself, who are devoted to caring for the dying, and expanding the conversation about these important end of life issues.
Death should not be the taboo subject it is in our society. It should be recognized for what it is: a fundamental and transformational part of life.
Bob Uslander, M.D. has been practicing medicine for more than twenty-five years, currently as an integrated care physician in San Diego, leading a team of holistic practitioners serving the elderly, those experiencing complex illness and end-of life. Care management services are an integral component of his practice.
He is dedicated to helping people live with joy, and without fear and struggle, at any stage of life, though especially in the face of challenging or terminal illness. His team of elite healing professionals, including massage therapists, music therapists, a gourmet chef and others, allow patients to experience rich sensations of life in the comfort of their homes as they face their challenging and heroic journeys.
Dr. Bob can be reached via email at Bob@DrBobUslander.com. Additional information can be obtained by visiting his website: http://www.drbobuslander.com/
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