If your 75-year-old client stops coming to therapy, it might not be them, it might be your approach. I know this is hard to hear, but stay with me. I.
You are a skilled therapist. You know how to build rapport. You know how to guide clients through complex and painful situations in life. You know how to treat depression, anxiety.
But if your usual techniques with your older clients aren't engaging like they do with other age groups, or your sessions are feeling flat, or you're feeling stuck or. Is not engaging... the issue might not be treatment resistance.
It's that therapy. Just like people needs to evolve with age. So today we're talking about how therapy shifts later in life, and five clinical changes that you can make in your practice starting today.
I'm Dr. Regina Koepp. I'm a board certified clinical psychologist, a geropsychologist and I founded the Center for Mental Health and Aging. Each week I bring you a mental health and aging tip that you can use in your practice starting today.
My goal is to give you all the tools that you need to meet the mental health needs of older adults, and this is because graduate programs and healthcare systems are.
Under training and under serving older adults, and together we can change that. All right, today, let's talk about how therapy that works for 30 year olds doesn't always work for 75 year olds. And what you can do about it.
Here's why this matters. Most therapists receive little to no training about providing psychotherapy to older adults, and instead the training programs and even continuing education programs center around midlife or younger adulthood, not older adulthood,
creating a huge gap in mental health care.
Most therapists are trained to work with adults, but that training tends to center around midlife or young adulthood, and it. Excludes often older adulthood.
So when a 75-year-old walks through your door grieving the death of a spouse, or navigating a complex or life altering medical condition, or adjusting to a major life transition, like a move, your usual toolkit might not cut it. And if therapy doesn't evolve with age, clients can feel unseen or misunderstood or blamed for not engaging, but in fact, the problem isn't treatment resistance. Older adults actually benefit from therapy at the same rates as other age groups. The problem is that we don't have the tools to modify our practice to meet the mental health needs of older adults. But that changes today.
So what exactly changes as we age that affects the therapy process? So the first are priorities. There is a psychologist Laura Carstensen, who out of Stanford in the nineties, developed a theory called the Socioemotional Selectivity Theory, and her theory suggests that the closer we get to the end of our life contrary to popular belief, we don't become more depressed. We actually begin to focus on what really matters, and that's where the selectivity comes in. And so you might see then older adults pruning relationships because maybe those relationships are not as helpful or toxic or don't enrich their life. And so priorities shift. It becomes less about doing and more about what brings me meaning and a sense of purpose and fulfillment. So this is really important, especially for therapists like myself. I'm a 49-year-old psychologist who I'm at a very different stage of life than my clients who are 65 and older. My average age is 83 of clients, and i'm at a very different stage of life, so I have to manage my own life stage and my assumptions about living based on my own life stage when I work with older clients, that we could be in a very different stage of life and having very different priorities and life experiences, and I have to be careful not to project those onto my clients. And so this socio-emotional selectivity theory suggests the perceived time that we have left in life influences our goals.
So when it comes to the socioemotional selectivity theory, it's less about age and more about stage, which is the amount of the perceived amount of time the person has left in life. For example, a 60-year-old could be living with a terminal illness and a 93-year-old could be living. With the terminal illness or not, but just by being 93 and having less time ahead of her, she may be thinking more about what's, what my priorities are rather than what my goals are. And so I like to think of this as in middle age is a lot about doing, and later in life it could be about doing too. But often I find it's about being like, how do I want to be, what do I want my being? To include peace and harmony and activities that promote peace and harmony for me. So maybe it's savoring the moments rather than accumulating more and more experiences.
This is in tandem with a second shift that happens, which is a shift around an increase as we age for physical vulnerability. While at the same time, an increase in psychological and spiritual depth. And so if we only focus on what's wrong, if we only focus on the physical decline and vulnerability, we will miss. What is strong? The strength coming from a reserve of life experience and resilience of recognizing what do I value in life because I have enough lived experience to know this and what don't I want in my life, which could go back to that selectivity theory.
So when it comes to balancing physical vulnerability with psychological and spiritual strength therapists really have to hold both the vulnerability and the strength, and you know how to do this. You're really good at that.
So another experience that happens as we age is that our life experience deepens. So we have experienced more live life. We've experienced all of the different ages and stages of life that have brought us to this point in our life, and we bring that, or our clients bring that with them to therapy,
and so instead of focusing only on the symptom and the presenting problem to also include this full, rich lived life that the person has.
Older adults have lived through wars and pandemics and civil rights movements, political administrations, and multiple losses and transitions, and they bring all of that with them. The stories are rich and profound and vital to the work in therapy. And finally how others treat them also changes and not in the best ways.
So many older adults describe feeling invisible or treated as irrelevant or spoken over, and this is known as ageism. Ageism is bias and discrimination based on age, and it's infused in everything in society. One way that this plays out is I have some clients who, when visiting their medical provider, won't allow a family member to enter the session with them because the family member will take the session over, or the provider speaks directly to the family member and not to the older adult, which can be incredibly demeaning.
Even well-meaning physicians or providers. And this happens in therapy too.
Another way that this plays out in therapy is when we infantalize older people. So when we're overly cautious, of course we need to be careful and thoughtful and tactful when bringing up challenging conversations. However, when we fragilize
Older people or infantilize, treat them like a child in psychotherapy. This is a way that ageism plays out and a way that we as therapists or psychologists, social workers, mental health providers, can interfere with the healing process.
And if you need one more example, assuming a lack of capacity when an older person makes an unhealthy choice for their life. So I've worked with many therapists who consult with me about their clinical work with older adults and. They'll contemplate or wonder about capacity. And in some cases that is justified. And in other cases, it is a manifestation of ageism, assuming that because the person is older and made an unhealthy choice, they must not have capacity to make healthy choices when in fact we're all entitled to make unhealthy choices for our life and we operate clinically and ethically with the assumption that every adult, including older adults, has capacity to make their own decisions for their life.
So if we don't adapt our practice for older adults, we risk pushing them out. We risk making them feel like they don't belong or that they can't benefit because they're not doing it the way you want them to do it. We risk retraumatizing them, misdiagnosing them, or over pathologizing them. And on the opposite, [00:10:00] we risk overlooking some really important mental health concerns and treating those concerns if we don't have ways to adapt our practice.
So how do we adapt our practice for older adults? I was supervising a psychology postdoc fellow who was learning to work with older adults and she. Wanted to hit the ground running. She was working with an 84-year-old client and the client was presenting with anxiety, generalized anxiety disorder, and the therapist thought, great, I'm gonna give this patient CBT and we're gonna tackle the anxiety and the therapist was starting to get frustrated when the 84-year-old client.
Wasn't moving along as, as she, the therapist wanted. And so she came into supervision and was saying she was feeling stuck with this client.
So I encouraged the therapist to slow down to spend more time building rapport and trust and orienting the client to the therapeutic process.
And to be more conversational rather than clinical, to be more human rather than therapist. And so this brings me to my first recommendation, which is to start with trust and orientation. And so of course you, you know that how important trust is. But I think when it comes to older adults, and especially if you are a different generation than the clients that you're working with, bridging and. Aligning with trust is really critical in starting the therapeutic relationship. And so slow down,
spend time really getting to know your client, joining them, building rapport, understanding their whole life, not just the symptomatic presentation that's bringing them in, understanding them as a whole person. It is important to remember that older adults didn't grow up with therapy being prominent in society Often the messages that many older adults received about psychotherapy were really stigmatized messages about, being psychologically defective if you went to therapy, which of course we know is not true.
But these are the internalized messages that some older adults have. And so slowing down building trust and then orienting the person to the therapy process can be very helpful. And so often in a first session when I'm meeting an older adult or an older family together, I'll give an orientation of even how that first meeting will go.
I'll say. Welcome. I'll bring folks in, sit them down, and I'll provide a little orientation like in our first meeting today, we will be meeting for about 75 minutes. I'll spend some time getting to know you and what's bringing you into therapy. I'm gonna ask you lots of questions, but at the end of our time together, I'm gonna share with you my impressions and make some recommendations. And then we'll go from there. You get to decide, do you have any questions for me about how this works?
And then they'll say yes or no. And of course I review confidentiality and consent and limits of confidentiality. And then we get started, and here's why this is important, that because there are so many messages, especially when older adults.
Came up about therapy being used as punishment and even people being harmed in therapy. I find the transparency about the process is really important. The idea, I'm asking you lots of questions, but then I'm gonna share with you my impressions and make recommendations.
That's a transparency. I'll even share with you how I came to these impressions and recommendations so that there's a lot of collaboration, transparency, and openness. So that's number one. Start with trust.
Number two, as a therapist, if you wanna modify your practice for working with older adults. It's critical that you know what's typical with aging and not typical with aging. So depression and anxiety, not typical with aging. Dementia, not a normal part of aging.
Dementia is an illness, not all fatigue is just a part of getting older, and so it's really important that you know what's normal and not so that you can educate your client and so that you know what needs to be treated, what needs to be referred for medical care, what you can provide psychotherapy for and so on. without a clear understanding of how mental health conditions or cognitive disorders present in older adulthood, we run the risk of overlooking really important medical or mental health concerns or pathologizing what are actually really healthy aspects of aging.
And this is where training comes in. Training helps you to spot the difference.
The third strategy is to move from coping to healing. So I like to say that [00:15:00] there is a difference between coping and healing. In my mind. Coping helps us to navigate symptoms and improve symptoms and help to create maybe a steady base. Healing on the other hand, requires a deeper dive, requires more time, requires a lot of contemplation, and work and therapy.
Change takes time. Healing takes time, and no time does not heal all wounds. Many older adults will present a therapy, carrying decades of pain from a historical event that they're wanting to work on in therapy or that are coming up in therapy underneath the symptoms.
And so it's really important that we move from a coping only mindset to a healing mindset when working with older adults. And this is because later in life, the work often moves toward meaning making. There's a saying that as we age, we need to bring together the strands [00:16:00] of our lives into a meaningful narrative. And so psychotherapy helps us and helps people to do that, to, to weave together the strands of a person's life into a beautiful narrative.
With all of its pain, with all of its beauty and complexity. And so some questions to consider as you're doing this work are what are some of the most meaningful moments in your life?
What have you been most proud of? What have you been most regretful of? If you could change one thing, what would you change?
The work can be slower, deeper, and profoundly moving and meaningful, and it's really about integration.
And so the fourth is to draw on strengths and resilience.
We often, in society, in healthcare, and in mental healthcare, fragilize older adults, and I wanna caution you around this because it's a natural human tendency to wanna care for people and. That caring can sometimes go too far into fragilizing and to being overly cautious.
And so older adults are not fragile by default. In fact, they tend to be incredibly resilient, and that's because as we age, we build more and more resilience, and that's because resilience is built through hardship and older adults have had more opportunity throughout life to build that resilience because they've experienced more hardship. When we focus solely on symptoms or problems, we miss the strengths and resiliency that older adults already possess and we see. This is supported by research too, that some of the common strengths and resiliences are wisdom, self-compassion, better problem solving skills, faith, tenacity, and life perspective. And sometimes if you're lucky, even a sense of humor. And so how can you cultivate these and call on these in your work in therapy?
So number five is to provide therapy that's both person centered and interconnected. So as therapists, we often feel very comfortable working with individuals, but when family gets thrown into the mix, it can be quite unsettling. Very few of us receive any training of how to incorporate Family members into an older adult's care. And and this is very different than including parents of children into a child's care because your client is autonomous and there are times, however, that the family may have very real concerns about your older client. Being person centered while also thinking about the systems that your older client is operating in is critical to providing effective care.
And this is because older adults are embedded in many systems, a family system, a caregiving system, maybe long-term care communities, social services, spiritual communities. And so I've had pastors come with clients to therapy or family members attend therapy with clients and so on. And so finding a way to hold both.
Having a person centered approach and also a systems framework, and finding a way to do that without diminishing the autonomy of your client and also not alienating the system from the client's care.
This is why training to provide aging informed care is really critical because this is hard to do and we don't receive training about how to do this in graduate school.
Without training, this work can feel like a minefield, and with training, this work could be a bridge to more effective care.
So this is exactly why I created a 90 minute continuing education course on becoming an aging informed therapist. You will learn five other clinical [00:20:00] skills that you can use in your practice and earn one and a half CE credits. I hope that you'll join me. You can learn more in the description below.
You have an essential role in helping older adults get the very best mental health care. Because older adults deserve high quality mental health care just like everybody else. And you deserve high quality training.
So the next time a technique in therapy isn't landing, don't assume treatment resistance.
Instead ask, does this technique match my client's stage of life or what they're grappling with? Or do I have the training I need to meet these mental health needs?
I am Dr. Regina Kepp. If you liked this video today, would you subscribe or share it? It really helps to get this message out and to make sure that more therapists, have the resources that they need to meet the mental health needs of older adults.
And remember, there's no expiration date on healing, transformation or growth.