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Department of Psychological Medicine, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE
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Abstract |
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A postal questionnaire was sent to 100 departments of psychotherapy within the UK in an attempt to gauge the use of psychotherapy services by patients in the third and fourth age.
RESULTS
Eighty-seven per cent of respondents felt that the needs of this group for psychotherapy were not met as well as those of younger people in their catchment areas. This is most marked in people over 65 years of age who are infrequently referred to psychotherapy departments. Suggestions are made for improving services.
CLINICAL IMPLICATIONS
The psychotherapy needs of this group need to be considered in service planning. All professionals need educating about the availability and applicability of the psychotherapies for the older patient. Without additional resources it seems unlikely that the needs of this patient group will be met.
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Introduction |
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The psychoanalytic world has moved on since Freud's comment that "Near or above the age of 50 the elasticity of mental processes, on which the treatment depends is, as a rule lacking - old people are no longer educable" (Freud, 1905). The dynamics of ageing (King, 1974; Hildebrand, 1990), psychoanalytical (Cohen, 1982; Hildebrand, 1988; King, 1974, 1980; Segal, 1958) and psychotherapeutic work from different theoretical orientations with older people (Myers, 1984; Nemiroff & Colarusso, 1985; Hess, 1987; Sadavoy & Leszcz, 1987; Hunter, 1989; Porter, 1991; Sadavoy, 1994; Haley, 1996; Bouklas, 1997; Terry, 1997) are now extensively described. Has this body of work percolated through to clinical psychotherapy practice in the NHS? Difficulties in satisfactory adaptation to developmental tasks in younger people often underlie referrals to psychotherapy services, but does this happen in older people? The present survey was undertaken to address these questions.
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The study |
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TopAbstractIntroductionThe studyFindingsCommentReferences |
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Findings |
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TopAbstractIntroductionThe studyFindingsCommentReferences |
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Services for the elderly
Of the 61 services, only eight (13%) felt that the psychotherapy needs of
the elderly in their catchment area were being met as well as those of younger
patients. Of these eight; three described established psychotherapy services
within departments of old age psychiatry, linked but separate from the
departments of psychotherapy, three described areas of special interest within
departments of psychotherapy and the other two well established consultation
and supervision links with old age psychiatry services.
There were a number of reasons given by those respondents who felt that the needs of the elderly were not being met as well as those of younger populations. The most common comment was that patients were not being referred in numbers which reflected demography. This is particularly the case in people over 65 (see Table 1).
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This imbalance was often attributed to purchaser issues and the separation of departments of psychotherapy and old age psychiatry in different trusts. To some extent, the figures support this view as the discrepancy between referrals and population figures is most stark after the age of 65, the most common cut-off point between general and old age psychiatry services. Old age psychiatrists and physicians also refer less often than general adult psychiatrists, physicians and GPs (see Table 2).
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However, psychotherapy departments also took some responsibility for this discrepancy. A common picture was of poorly resourced departments who had identified this need but lacked the resources to address it. Seventy-six per cent of respondents felt that they would be unable to meet the needs of the elderly within their present resources. Of the 24% who felt that this was possible, a number commented that this would only remain the case if the present low level of referrals was maintained.
Once referred, there was little evidence that older patients were being discriminated against in the assessment for, or provision of, treatment. There was no upper age limit for referrals in 87% of departments and all the departments with upper limits cited contractual links with adult services with shared age cut-offs as the reason for such limits. Treatments offered to the older patients reflected the full range of those available within each unit, although the very small samples in the majority of replies makes it difficult to make knowledgable comparisons with younger age groups. For the sample as a whole the waiting times for assessment (mean 3.0 months, range 0.3-12 months) and treatment (mean 7.5 months, range 0.5-24 months) were the same for all ages. In places who felt the psychotherapy needs of the elderly were as well met as those of younger people, the median waiting times for assessment were 1.75 months (interquartile range 2.8 months) and 2.0 months for treatment (interquartile range 11.5 months). Where treatment needs were not felt to be met as well as in a younger group the median waiting time for assessment was 3.0 months (interquartile range 1.25 months) and treatment 6.0 months (interquartile range 5.1 months). There was no significant difference in waiting times for assessment (Z=-1.1655, non-significant, Mann-Whitney U) or treatment (Z=1.7515, non-significant Mann-Whitney U) between services who felt needs were being met and those that felt they were not.
When asked how psychotherapy units might help to meet the needs, responses fell into the following broad categories.
Define the need
While there was a feeling that the needs of the elderly were not being met,
this was based on examination of referral patterns and anecdotal knowledge of
local services. Many replies identified the lack of a needs based assessment
and suggested collaboration between psychotherapy departments and old age
psychiatry units to clarify this.
Developing links
The striking feature of units who felt that needs were being met was the
presence of staff with a particular interest in psychotherapy of the elderly
who had developed a service in either old age psychiatry or psychotherapy
services. Many of the other replies echoed this theme with a recognition of
the need to make strong links between the two services and develop a culture
of joint working. This was not only to encourage referrals, but to develop a
range of opportunities to think about patients and develop knowledge and
skills in staff from both services.
Education
Many respondents related their anxiety about seeking referrals of older
people to their own lack of experience in treating this group and a need for
further training. Some comments were made about the need to educate general
practitioners, psychiatrists and multi-disciplinary teams about the use of the
psychotherapies with older people.
Specific developments
The areas of consultation and liaison were most frequently mentioned with
the establishing of work discussion groups and staff supervision more
prominent than specific treatment proposals. This, in part, probably reflects
the picture of overstretched services with little capacity to easily
assimilate more referrals without more manpower, but, more positively, also
reflects awareness of the need for an increase in ‘Level A’ and
‘Level B’ psychotherapy expertise
(Department of Health,
1996).
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Comment |
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TopAbstractIntroductionThe studyFindingsCommentReferences |
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The present study suggests that staff in psychotherapy departments do not consciously ascribe to Freud's view that older people are untreatable psychologically, because when patients are seen there is no difference in the treatments offered to them and a younger age group. They also spend the same amount of time on waiting lists as younger people. It is, however, difficult to be clear about this as the numbers referred, particularly in the over 65-year-old age group, are tiny. Patients in the 55-65-year-old group, while more commonly referred are still underrepresented in demographic terms. This reflects the recent Gallup survey for Age Concern (Gallup & Age Concern, 1999) finding that one in 10 people had noticed a difference in the way they were treated in the NHS after their 50th birthday. This suggests that there is a pressing need for education about the availability of psychotherapy for this population and their capacity to use it, particularly within old age psychiatrists and physicians.
There is also some suggestion that psychotherapists are either unaware of the extent of the needs of this group, or fearful that their services would be swamped if a full acknowledgement of these needs was made. The majority of respondents were not able to envisage fulfilling these needs within services as they presently stand. These needs are growing. The percentage of the population in these age bands is forecast to rise steadily with predictions that 41% of the adult (over 16) population will be over 55 in 2031 (Carnegie Inquiry Report, 1993). This has obvious resource implications.
A more hopeful reading of this study is that psychotherapeutic needs of this patient group are being met, but psychotherapy departments are unaware of this activity. On balance, however, this seems a vain hope. While respondents were mindful of the lack of needs-based assessment, they also demonstrated sufficient knowledge of local old age psychiatry services to make informed comments about service provision. It is also possible that units offering adequate services were either not contacted or did not respond. Sadly, a more realistic reflection of the present state of psychotherapy provision for this group might be contained in the comment of one respondent that "they just get forgotten". It is worrying that some of this group of patients believe that this ‘forgetting’ is a more active process of discrimination (Gallup & Age Concern, 1999). It seems timely to begin to hold them in mind.
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References |
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CARNEGIE INQUIRY REPORT (1993) Life, Work and Livelihood in the Third Age. Dunfermline: Carnegie United Kingdom Trust.
COHEN, N. A. (1982) On loneliness and the ageing process. International Journal of Psychoanalysis, 63, 149-155.
DEPARTMENT OF HEALTH (1996) NHS Psychotherapy Services in England: Review of Strategic Policy. London: HMSO.
FREUD, S. (1905) On Psychotherapy. Standard edition, Vol 7. London: Hogarth Press.
GALLUP & AGE CONCERN (1999) Survey into Age Discrimination in the NHS. London: Age Concern.
GARNER, J. (1999) Psychotherapy and old age
psychiatry. Psychiatric Bulletin,
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149-153.
HALEY, W. (1996) The medical context of psychotherapy with the elderly. In A Guide to Psychotherapy and Ageing: Effective Clinical Interventions in a Life-Stage Context (eds S. H. Zarit, B. G. Knight et al), pp. 221-239. Washington, DC: American Psychological Association.
HESS, N. (1987) King Lear and some anxieties of old age. British Journal of Medical Psychology, 60, 209-215.
HILDEBRAND, H. P. (1988) The other side of the wall: a psychoanalytic study of creativity in later life. International Review of Psychoanalysis, 15, 353-363.
HILDEBRAND, H. P. (1990) Towards a psychodynamic understanding of later life. In Clinical and Scientific Psychogeriatrics (eds M. Bergner & I. Sandford). York: Springer Publishing Co.
HUNTER, A. J. G. (1989) Reflections on psychotherapy
with ageing people, individually and in groups. British Journal of
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250-252.
KING, P. (1974) Notes on the psychoanalysis of older patients. Journal of Analytical Psychology, 19, 22-37.[Medline]
KING, P. (1980) The life cycle as indicated by the nature of the transference in the psychoanalysis of the middle aged and elderly. International Journal of Psycho-Analysis, 61, 153-160.
MYERS, W. A. (1984) Dynamic Therapy of the Older Adult. New York: Jason Aronson.
NEMIROFF, R. A. & COLARUSSO, C. A. (1985) The Race Against Time. New York. Plenum.
PORTER, R. (1991) Psychotherapy with the elderly. In Textbook of Psychotherapy and Psychiatric Practice (ed. J. Holmes). London: Churchill Livingstone.
SADAVOY, J. (1994) Integrated Psychotherapy for the elderly. Canadian Journal of Psychiatry, 39, 19-26.
SADAVOY, J. & LESZCZ, M. (1987) Treating the Elderly with Psychotherapy. Madison, CT: International Universities Press.
SEGAL, H. (1958) Fear of death: notes on the analysis of an old man. In The Work of Hanna Segal. London: Jason Aronson.
TERRY, P. (1997) Counselling Older People and Their Carers. London: Macmillan.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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