You are currently viewing Psychological Assessment and Therapy with Older Adults: What to Expect in a First Session

Psychological Assessment and Therapy with Older Adults: What to Expect in a First Session

Episode #25September 15, 2020

A couple of weeks ago, I got together (over Zoom, of course) with my dear friend, Psychologist, Dr. Quiera Lige. She shared with me that she had an older family member who would benefit from therapy, but that this family member had not known any other people in their generation to go to to therapy and didn’t know what to expect. She suggested that I create a podcast episode about what therapy actually looks like when you go to therapy as an older adult.

For older adults, there is a lot of stigma surrounding what it means to need mental health care and as a result, older adults do not tend to seek out therapy when they need it.

Older adults continue to experience mental health concerns as they age. Studies show that when older adults do engage in mental health care, the vast majority of the time they get better.

If we can help older adults who are struggling with depression, anxiety, insomnia, grief, compounded loss, trauma, medical problems – you choose, get to that first therapy session, they’re one step closer to feeling better and living a more peaceful life.

My hope is that this episode will demystify the process of going to therapy and build a bridge from suffering to healing.

Today’s episode focuses on what a first therapy session may look like if you’re an older adult with a mental health concern, a memory concern, or a family concern.

Here’s a peek inside the episode:

  • [01:37] Making the decision to schedule that first mental health appointment generally takes a lot of thought and courage. Learn what I hope you get from this episode.
  • [04:11] Many therapists are taking COVID precautions very seriously and offering tele-therapy. I discuss how to talk with your therapist about COVID safety.
  • [07:57] Some of the first objections that I hear from older adults when starting therapy is: “I don’t want you to think I’m crazy.” Or, “I don’t want you to lock me up”. If you’re considering starting therapy, it’s important to know the informed consent process , meaning, the specific situations that I would need to break confidentiality to get you support.
  • [12:19] I ask a lot of questions in a first session to get to know my client’s current concerns and about my client’s life. I reveal many of the questions I ask in a first session,
  • [16:59] Wonder what I do when people share concerns about memory loss in a first session? I describe my process here.
  • [20:59] What does a first session look like when family members come to therapy with a person with dementia? Learn more here.
  • [24:29] It’s okay and encouraged to ask your therapist questions. I share questions to consider asking.
  • [26:32] You’re not gonna click with everyone. I share what happened when I didn’t connect with a therapist I was just getting started with.

If you or someone you know is in crisis or struggling with thoughts about harming yourself or others, please reach out to the National Suicide Prevention Lifeline.

I'm Dr. Regina Koepp. I'm a board certified clinical psychologist and I specialize with older adults and families. I created the psychology of aging podcast to answer some of the most common questions I get about aging. Questions about mental health and wellness, changes in the brain like with dementia, relationships and sex, caregiving, and even end of life. Like I say in my therapy group, no topic is off topic. We just have to have a healthy way of talking about it. So, if you're an older adult, or caring for one, you're in the right place. Let's get started.

A couple of weeks ago, I was having a zoom get together with my dear friend, Dr. Quiera Lige, and she was mentioning to me that she thought that it would be super helpful if I did a podcast episode on what it looks like to actually do therapy as an older adult. And she was saying, you know, I have a family member who's an older adult, I think that they would really benefit from therapy, but nobody in our family and my family members' generation has actually gone to therapy. And so she said, maybe you could do an episode that could help my loved ones understand a little bit about what therapy might look like for them. And I thought that was a great idea. And so today, I'm going to be talking about what therapy actually looks like, if you're an older adult.

So what I'm going to be talking about today are what is the first meeting like more specifically? And what does the first meeting look like for you as an individual? What does it look like if you're worried about memory problems? And then what does it look like if you want to include your family? And so I'm going to show you three different models of what it will look like. You're going into therapy and what our first meeting looks like. First meetings are some of my favorite times in therapy. I love getting to know new people. I love hearing about what's bringing people into therapy. And I love helping people to feel less alone and to give a little bit of hope in their journey. It is not a simple thing to make a decision to start therapy, it takes a lot of thought for most people and a lot of courage. And if you're an older adult, and are considering pursuing therapy, and I hope that you are, I think probably throughout all of our lives, there are times that we would really benefit from therapy and if this is a time in your life as an older adult, I hope that maybe this episode today will help dispel some of the mystery and peel back the curtain so that you have a glimpse inside what it actually looks like and maybe be willing to take the risk if you think therapy might be helpful to you. So the other thing I want to say about older adults in therapy is that there is a lot of stigma around going to therapy and around what therapists do, that the therapist might be judgmental, that therapists might not understand you. And so my hope today is that I can help to dispel some of those myths, and also kind of provide more of a bridge between you and me, or you and a therapist.

So, if you if you decide, say, you look up a therapist, and in my show notes, I'm going to be listing where you can find therapists near you who specialize in older adults. But say you decide to give it a try and you call a therapist, what will generally happen as you call, you'll probably leave a voicemail and that therapist will like call you back. And that therapist will ask, "what are you looking for and what is bringing you to therapy at this time in your life?" And then probably schedule a time to meet.

Tele-therapy and COVID Safety

Because we're in COVID, A lot of therapists are doing tele therapy, which means that they'll do it on video, like through zoom or something or an equivalent video software that's private and confidential. You can ask especially if you're going to be doing video how to be sure that it's confidential and secure. That might be an important question to ask right now. I think telehealth is wonderful right now while we're in the midst of COVID and struggling with safety measures, and especially older adults. Many older adults that I know are being very cautious. I want you to be cautious if you're not comfortable meeting with the therapist in person right now. You have a right to ask for telehealth and express that concern. Please listen to yourself. And if that therapist can't do telehealth, maybe look for a different one that can so that you feel safe and secure. And so that you know that you're mitigating your risk. If you do decide to meet with your therapist in person and your therapist has a space for you to meet in person, you might want to ask how is the therapist and the office maintaining COVID precautions and really get clear about what they are doing for COVID safety.

So what also might happen is that therapists might have you complete intake forms. And so intake forms are forms that you complete that kind of give us a snapshot of your life and different times in your life. They'll also ask you to complete an informed consent form and I'll talk about what informed consent is in a minute because that's really important. And maybe some other documents as well like a release of information document, so that maybe your therapist could speak with your psychiatrist or your therapists could speak with your physician. I personally like to do that. I work with a very medically vulnerable population. And so oftentimes medical and mental health care overlap, and I like to be in collaboration with other providers, just to be sure that I'm giving my clients the absolute best care that they can get. So that first meeting might be anywhere between 60 and 90 minutes. Maybe some people might even do two hours. That's pretty long. I would say my my longest tends to be 90 minutes, and I take my time in an intake. Some people do 60 minutes. Some people do 75 minutes and some people do 90 minutes.

It's also pretty common that a therapist will have a different rate for intake versus follow up sessions. So if you're going to have a 90 minute intake, it might cost you some money and then follow up sessions might be less. And so you'll want to ask the therapist is there a different rate for intake versus follow up sessions. So you'll come into the office, the therapist will probably give you a little orientation when you go into the office of what to expect on the telephone ahead of time. Or on the zoom, like if they're going to have a video conference with you, they'll give you a little orientation about how that works when you're on the telephone together. That's pretty standard. Then when you get together, presumably you have all your forms completed, like maybe they sent you forms to complete between your telephone call and the first meeting. And then in your first meeting, the first thing that they say might be to orient you like to welcome you to their practice, and then to orient you to the process. So we're going to be meeting today for 75 minutes.

The Informed Consent Process

This is our first meeting and it's really important to share with you some what we call informed consent. And so that's where we lay down the sort of guidelines in therapy, like everything that you say in here is confidential. And that means that whatever you share in here is not shared anywhere else that's protected by ethics and law. HIPAA law applies to therapists. And so what you say in here stays in here, except in a couple of situations. And those situations are, if I'm worried that you're going to harm yourself or harm somebody else. I have to break confidentiality to get you support. If I'm worried that you are not able to care for yourself, and that is leading to serious risk to you that's called grave disability. So serious risk to yourself, say that you haven't showered in months, and you have cockroaches on you. I've been in that situation before, I will have to break confidentiality to get you care or in cases of abuse and exploitation or neglect. And so, cases of abuse and exploitation and neglect and older adulthood is really complicated and sometimes can be very gray, it's not always clear. There's this older adult that I'm working with being exploited financially, for example. And so, there might be situations where I would have to break confidentiality to get you support or get the situation evaluated to make sure that you're not being exploited or abused or neglected. Another is if I hear of concerns of child maltreatment, then I will would also have to break confidentiality to get children safe as well. The topic around when we would break confidentiality is probably the most challenging topic. And this is one where a lot of stigma lies. And so I hear it oftentimes from older adults. I don't want you to put me away or I'm not going to tell you what's going on because I don't want you to hospitalize me. And so I try to do my best in answering all of the questions you have around the specifics. What does it mean to me? Like, what would it take for me to be worried about you that if you left my office, you might harm yourself or harm somebody else. And my motto tends to be that I am very transparent. And so if I have to break confidentiality, to get you support, my tendency is to tell you first and so that you're not surprised. So I don't pull the rug out from underneath you. And the reason for that is that our relationship is the most important thing. You trusting me or you trusting your therapist is the most important thing. That's where I believe healing happens in a trusting relationship with the secure base where you can reveal the most painful parts of your experience where you can be vulnerable, and where you can get some help and support and have somebody there with you.

I'll also say that, in some cases, like in some medical systems, your provider might not review informed consent with you. And that's because in some medical systems, informed consent is supposed to be at the time that you're signing all those documents and that you agree to all of these exceptions to confidentiality. It is good practice, however, for therapists to review informed consent Anyway, okay, so once the informed consent is out of the way, then we go on to my favorite part of the intake. So an intake is just the term that we use to identify the first meeting, where we're going to collect a lot of information.

How do I start a first session?

The first meeting often doesn't look like therapy, it looks like gathering information. Typically, what's the best is if in a first meeting, you're starting to get to know the therapist, like the therapist is expressing warmth and what we call unconditional positive regard, like they want to just hear from you. And in this meeting, part of the goal is building the relationship with you. And part of the goal is gathering information about what's bringing you into therapy, and also where you come from and what your life experience has been and who's in your family and all of these sorts of questions. And so I'm going to review what that looks like at this intake meeting. I say, "well tell me what's bringing you into therapy now." And then I just let you talk. "What's concerning? What's bringing you in now? Why this time in your life? How did you make the decision?" And then I want to hear what you have to say I want to hear what your first concern is. And then I want to hear what your second concern is in your third concern. And so what's really important to me is to understand what's bringing you into therapy now.

And then I'll ask a little bit about "tell me about what you're currently experiencing from a mental health side of things." And so I might ask you about depression symptoms or anxiety symptoms, I might ask you about your sleep, your relationships, how you're getting along with people, if you're feeling irritable or angry, having trouble concentrating, all sorts of symptoms. To help me understand your current symptoms. They might also give you a kind of paper and pencil assessment. And it's like a checklist like, for older adults, there's an assessment called the geriatric depression scale, there are anxiety scales. And so I might ask you to complete a questionnaire to help me understand more about your current symptoms.

Then, I'll ask about "tell me about mental health treatment in your past. Have you been to therapy before? What was that like? What did you go to therapy for? Was it helpful? What was the most helpful thing that you experienced in therapy? What was your relationship like with your provider? What worked well for you? What didn't work well for you?" And then I'll also ask about your substance use history. "Have you ever struggled with substance use? Has it been a problem for you? Are you in recovery?" I'll also ask you about any history of suicidal behavior or psychiatric hospitalizations. That's really important because I want to know your full life experience in addition to what you're experiencing right now.

Then, I'll ask also about your medical history. And medical history is actually very important to me and working with older adults. Because a lot of times medical problems overlap with mental health problems. Sometimes medical problems can make mental health problems worse or cause sleep problems. Sometimes medications can create challenges. And so I really want to know what your experience is, medically. I also want to know if you've had medical hospitalizations or any head trauma or accidents, falls, things like that.

Then I'll ask about your relationship history. Like if you're currently in a relationship, your history of relationships, your happiness or discontent in relationships, how your relationships tend to start and end. What kinds of patterns do you have in relationships, romantic relationships, and then also family relationships, like "where did you grow up? And who raised you? And who was significant in your life? Who were you closest with?" I'll probably ask about any maltreatment as a child or an adolescent, and how you worked through that or if you've had the chance to work through that.

In this first meeting, I'll also ask about your living environment. So I'll be curious to know like, "do you live in a single family home, an apartment, do you live in a senior community and over 55 community? Do you live in long term care? Do you live in a personal care home or boarding care home?" I'm just going to be very curious about where you currently live as well. And then also about your work history and your hobbies and your interests, your friends, how social you are or aren't. Oh, everything that makes you, you is what I'm curious about.

What do I do in a first session when clients express concerns about memory problems?

Say that you come in and the first thing you tell me is that you're concerned about your memory. Then I ask you questions around your memory. So do you remember how earlier I mentioned that I will give you a questionnaire for depression or anxiety? Well, there is also a questionnaire that I'll give you for assessing how your brain is working. And that's called a cognitive screener. And so we're going to screen how your brain is doing, cognitively. So there are a couple of screeners that we use for that. You might remember all of the the Trump sort of nonsense around this screener. So what it does is it just gives us a snapshot of how your brain is working. It does not tell us if you have dementia or not, it tells us whether or not we think you need further assessment for dementia at this time. And so if you come in and you're sharing with me that you're concerned about your memory, then I would probably give you a cognitive screener if there's time. If there's not time in that first meeting, you can imagine there might not be time with everything else, then I might, you know, in our next meeting, prioritize that.But at some point in the first couple of meetings, I'm going to give you a cognitive screener. And also, I'll be giving you the results of that screener when we're together. So you won't be guessing.

If you're coming in and you're sharing that you're concerned about memory problems, I'm also going to ask you, is your family concerned? And what are they noticing and saying, I'll also ask you for family history. I'll probably ask you for family history around mental health conditions and other medical history as well. But in this case, specifically for memory, I'll ask you about your family history of any memory disorders like a dementia disorder. I'll also probably ask you about how you're doing with managing your money and how you're doing with driving and how you're doing with managing your medications. And grooming and taking a bath and all of that, especially if you're worried about memory. So, this is a hot topic, especially when we get to memory disorders, or memory problems because most older adults do not want to lose driving abilities, do not want to lose managing money abilities, do not want to lose the ability to make decisions for their life. And so this is where it's essential that you trust your provider. If you don't trust your provider, you might not be honest with her about how you're doing with managing money or how you're doing with driving or how you're doing with managing your medications. The challenge here is that you might need support, and your provider will need to know that.

The other thing here is that you really want to be clear that you're working with a provider who knows older adults and knows cognitive disorders. And this is because there are some myths with dementia disorders that as soon as you're diagnosed with the dimension disorder, then you, you know, you lose driving, you lose money management, you lose medication management, you need lots of assistance. That is not true. It happens in stages, it happens gradually, typically, unless you're kind of living with a stroke or something that happens immediately. So there's time to prepare. Generally, if you come in early enough, if you want more information about dementia disorders and memory concerns, I have a free Memory Loss Guide that I'll link to in my show notes you can download, I highly recommend that you download it, because it kind of lets you know what you need to be on the lookout for. And also it tells you what the benefits are of early diagnosis. And actually, the earlier you get assessed and evaluated, the better and that guide will tell you why. And I'll link to a podcast that also talks about the benefits of early diagnosis of a dementia disorder as well.

What does a first session look like when family members are involved?

Speaking of dementia, so say that a person has dementia and the family are struggling managing the sort of behaviors with the person living with dementia disorder and are deciding to bring the loved one with dementia to therapy. That was a large part of my practice. So for 10 years, I was at the Atlanta VA Health Care system where I worked in a Geropsychiatry outpatient clinic. Probably half of the families that I worked with were this category of family where there's a person living with dementia at different stages of dementia. And I work with the person with dementia and their family together. Okay, so in this case, if the family is all coming in together, what I might do in a 90 minute meeting is meet with everybody together, get as much information as I can get with everybody together, build a relationship with everybody together, learn about the family, learn about family dynamics, and then sometimes ask to meet with people individually. So sometimes I'll meet with the family for 20 minutes all together, then I'll ask to meet with the person living with dementia for 20 minutes alone, then I'll ask to meet with the family members alone. If the person living with dementia is not safe to be in a waiting room alone, then I asked families to bring another family member to sit with the person with dementia. So, what I like to do is, is mix it up. And that's because sometimes caregivers cannot clearly say or candidly say what they're concerned about in front of their loved one with dementia. And at a certain stage of illness. That's the healthiest choice the family is making. And I respect that. And I often recommend that, and so I'll have the family meet with me separately and the person with dementia in the waiting room. I'll also meet with the person living with dementia separately and try to assess where they're at in their illness and also with the families report and meeting with the family separately. I'll do a caregiving assessment. So I'll ask in addition to everything I said earlier, I'll also then ask about like, well caregiver, if it's a daughter or spouse or a son, I'll ask, "well tell me how it's going for you. And do you have support? And do you have certain questions? And what do you need as a caregiver and as a person? And where are your own boundaries with all of this?" And so, a lot of times that I'm meeting with families with dementia, it's a lot of mixing and matching in the sessions.

There are many situations where a person living with dementia and their loved one or their caregiver come in, and there's no family member to sit with the person with dementia in the waiting room. So, in cases like that, depending on the stage of the dementia, I'll meet with the family together, and then I'll also tell the caregiver that I'll talk with the caregiver separately, maybe on the telephone, just to get a clear and more candid picture of what's going on and what their needs are as well.

How does an initial session usually end

So at the end of the meeting, I'll generally share with the individual, if it's an individual presenting to treatment or the family, if it's the whole family presenting to treatment, what my impressions are about what's going on. And if there's a diagnosis, I'll probably share a diagnosis like depression or anxiety or insomnia, dementia. And we'll talk about my recommendations for treatment. And so I lay it all out for families and for individuals in a first meeting. So you don't have to guess what I'm thinking and what I recommend.

It's important to ask your therapist questions

Let me just also say that I make room for my clients to ask me questions as well. So I'll say, "do you have specific questions for me? Is there anything I haven't asked you that you think would be helpful for me to know?" And I'd also say, if you're worried that maybe the therapist might not understand you or might not have have the skill set to provide care to you. It's okay to ask questions. Like "what specific training do you have working with older adults," you're allowed to ask your therapist that. "What specific training or experience do you have working with adults with medical problems?" If a client were to ask me that, or a family were to ask me that, I would be so appreciative. And I would tell them, well, I've been working for 10 years well, longer, 15 years with older adults and their families. And this is the kind of care I provide. I would be so willing to answer that. If you're an LGBTQ older adult or an older adult with an ethnic minority identity, you can ask, "what experience do you have working with LGBTQ families or LGBTQ older adults?" or, "what experience do you have working with older African American adults? What experience do you have with Asian American older adults?" You're allowed to ask these things. You're allowed to see if your therapist is a good fit for you. Your therapist might not have to be African American or Asian American, or LGBTQ, to provide good quality, great care, but you have to be able to trust your clinician. And so you really want to hear the answer to these questions. You want to hear how the therapist is answering these questions so that you can check in with yourself about how you feel about how they answer. And then how they answer will give you information as to whether or not this is a therapist that you can trust or grow to trust or be willing to take a risk with.

If it's not, okay, so say you ask these questions and you're not comfortable with the answer. It's okay to find a different therapist. And I will say give it a couple of meetings and see if it improves and if it doesn't, it's okay to stop and try to find somebody else.

What happened when I didn't connect with a new therapist

You know, I've done a lot of my own therapy in my life for several several years in different cities and different lengths of time in different cities, based on where I was living. I'll tell you that I've had a few different therapists over my life and had great experiences. I had one negative experience in therapy, I met with this mental health provider three times, and just didn't feel like we connected very well. I was at a time in my life where I wanted to work with a male therapist to work on some personal things related to men. And so I met with this male therapist, and I didn't really, you know, connect with him very well in the first meeting, the second meeting the same. I felt like it didn't feel... I felt like we had a cultural miss a few times, and I didn't feel like I could trust him. And so after three, I gave it three sessions. And then I decided, you know what, I don't want to spend my time and money with this person. I don't think that this person or this experience is going to be helpful to me. And so I ended that relationship. And I found another therapist, another male therapist, who was awesome. So I didn't give up, right? I knew that I wanted to work on this aspect of my own psychological healing, and that I wanted to do that with a man based on a recommendation from my previous therapist who was a woman at the time. And I wanted to give it a shot. So even though the first man didn't work out, the second one did, and I'm really glad that I pursued it. So, it's okay if you don't jive with the first therapist, try a different one. What's not recommended though, is overlapping with therapists. So it's not a good idea to have two therapists at once, unless they're working in the same program and collaborating in your care.

I hope that this episode demystified a little bit about what a first meeting looks like in therapy and, more specifically, what it might look like if you're an older adult, or wanting to bring your family into therapy. I'll tell you I love family being included and I love individual therapy. It really just has to do with where my client is at and what they need. If you find that you are struggling, if you're finding that you're feeling depressed or anxious, especially during COVID are lonely and isolated, please, please consider reaching out to a mental health provider. I'm going to put a list of how to find mental health providers in the show notes. Please look for one. Your mental health is just as important as your physical health. And really they are fundamentally connected. So please take some time to care for yourself too.

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As always, the information shared in this episode is for educational purposes only, and should not take the place of licensed medical or mental health care. I'll see you next week. Same time, same place. Lots of love to you and your family. Bye for now.

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