Cognitive-behavioral therapy (CBT) has been one of the most widely studied and efficacious treatments for older adults. Though it includes a variety of interventions ranging from the cognitive work of Beck et al. (1979) to the behavioral work of Lewinsohn et al. (1976), its most common application is a blend of both cognitive and behavioral techniques. The conceptualization underlying CBT is that much of psychopathology is learned and maintained by a combination of distorted, dysfunctional thinking about oneself and the world and reduced behavioral or environmental reinforcement. Thus, therapeutic intervention seeks to change unhelpful thinking, increase positive behaviors, and reduce negative actions. CBT is typically highly structured, directive, time-limited, and focused on current problems.

The CBT model has been widely used for many disorders in older adults and reported in case reports and empirical investigations. A series of studies by Gallagher-Thompson et al. have shown that CBT is highly efficacious for depression (Thompson et al., 1987; Gallagher-Thompson and Steffen, 1994; Thompson et al., 2001; for a more thorough summary see Teri et al., 1994). In particular, there is evidence for its efficacy with depressed outpatients and inpatients, the medically ill as well as healthy, in individual or group format, and when delivered by a trained therapist or self-taught through bibliotherapy (Scogin et al., 1987, 1989, 1990). Relative to the stringent criteria of the APA Task Force on empirically supported treatments, CBT was identified as ‘probably efficacious’ for treatment of depression in community residing older adults who are cognitively intact, have minimal comorbidities, and are not suicidal (Gatz et al., 1998). In addition, cognitive-behavioral forms of therapy have demonstrated efficacy for alleviating sleep disturbances (for review see Morin et al., 1994 and Gatz et al., 1998), generalized anxiety (Wetherell et al., 2003), and behavioral problems associated with dementia (Teri et al., 1998; Allen-Burge et al., 1999). A case example illustrating the use of CBT with a depressed elder is presented later in this chapter.

A wide variety of treatments are offered under the rubric of psychoanalytic/dynamic therapy, including insight-oriented and supportive approaches. Many of them concern the historical causes and larger patterns of current behavior, restoration of healthy defenses and positive self-perception, and examination of the client–therapist relationship. This treatment is typically less directive, and often seeks to help identify and resolve unsettled issues from earlier in development and explore their impact on current functioning.

From a psychodynamic perspective there are some unique developmental tasks and transferences to be addressed in therapy with older adults. These age-appropriate themes include grieving for losses, fear of physical illness, disability and death, and guilt and despair over past failures (Pfeiffer and Busse, 1973; Hildebrand, 1995). One specific developmental tension that is beautifully illustrated in Shakespeare's King Lear and The Tempest, is the dialectic between the decline and sense of impending death that is associated with aging versus growth and liberation (Deats, 1996; Hildebrand, 2000). Transference issues are atypical, but may reflect concerns related to one's family of procreation (i.e., spouse and children) rather than one's family of origin; while countertransference may be influenced by unresolved issues with parents, one's own fears of aging and/or negative cultural stereotypes regarding aging (Gallagher-Thompson and Thompson, 1996).

Unfortunately few empirical investigations have examined the efficacy of psychodynamic therapy for use in older adults. A study by Thompson et al. (1987) demonstrates that brief psychodynamic psychotherapy is equally efficacious in the treatment of major depressive disorder in older people as behavioral and cognitive interventions. Seventy percent of subjects showed remission or significant improvement after 16–20 treatment sessions compared with minimal spontaneous improvement in a delayed-treatment control group. Although it has an extremely small sample size and no control group, the work of Lazarus et al. (1984, 1987) provides some promise that psychodynamic therapy is useful for older adults (for an excellent though less current review, see Newton et al., 1986).

One time-limited integrative therapy with a heavy influence on psychodynamic conceptualization and technique is cognitive analytic therapy (CAT; Ryle, 1990). This structured therapy has two primary influences, as its name implies, cognitive-behavioral and psychoanalytic. CAT is gaining popularity in the UK and Europe, and its application with older adults has recently been discussed (Hepple, 2002). Its premise is that experience about oneself in relation to others becomes internalized in early development as a repertoire of reciprocal roles that act as templates for subsequent interactions. Insight and change are promoted through the exploration of these experiences in the here and now, particularly the therapeutic relationship, using a variety of cognitive, behavioral, interpretative and creative tools and techniques. CAT has not yet been formally evaluated, but has been suggested as potentially beneficial for treatment-resistant depression or dysthymia, stable personality difficulties with traumatic or abusive antecedents, and somatization disorders (Hepple, 2002).

Interpersonal psychotherapy (IPT) has multiple theoretical underpinnings, including psychodynamic, and has received empirical support with older adults (Klerman et al., 1984). This treatment is manual-based, highly structured, and short term. Its underlying premise is that regardless of the etiology of psychopathology, understanding and renegotiating relationships plays a key role in reducing symptoms, restoring function and possibly preventing future disturbance. IPT focuses on current relationships in four general problem areas: role transition, role dispute, abnormal grief, and interpersonal deficit.

Monthly IPT sessions demonstrated efficacy as a monotherapy and in combination with antidepressant pharmacotherapy as a maintenance treatment strategy to prolong recovery and prevent recurrence of major depression (Reynolds et al., 1999). The older patients in this randomized clinical trial had had current major depression and at least one prior episode during the past 3 years. Combination of IPT and antidepressant medication not only improved duration of recovery but social adjustment as well (Lenze et al., 2002).

In addition to a review of IPT as applied to late-life depression, Miller et al. (2001) have reported preliminary findings on IPT combined with antidepressants in cognitively impaired depressed elders. Uncomplicated bereavement-related depression also responds well to IPT (Miller et al., 1994). Additionally, this type of counseling has been shown effective in the treatment of subsyndromal depression in postsurgical patients following hospital discharge (Mossey et al., 1996).

Reminiscence therapy (RT) involves recalling the past as a way to increase self-esteem and social connection. RT typically occurs in a group format in which individuals are encouraged to remember and share memories of the past, with personal artifacts, newspapers, and/or music often used to stimulate memories. These sessions are frequently structured with the therapist picking the topic. This very popular counseling tool is regularly used with well elderly to gain perspective on their lives and thus is popular in senior centers, residential settings, and retirement communities rather than as clinical intervention for those older adults with major mental health or personality disorders (Thorton and Brotchie, 1987; Gatz et al., 1998).

Life review therapy (LRT: Butler, 1963), a more intense type of RT, involves the reworking of past conflicts in order to gain a better understanding and acceptance of the past. These types of therapies are based on the work of Erik Erikson (1959, 1982) and his eight-stage model of psychosocial development. The underlying premise is that an older adult can be helped through the last stage of Erikson's model, ego integrity versus despair. It is thought that if older adults can satisfactorily formulate and accept personalized answers to existential questions such as, ‘Who am I?’ and ‘How did I live my life?’, they will achieve integrity. As this treatment is so individualized, it is difficult to manualize; however, Haight and Webster (1995; Webster and Haight, 2002) have done so. Although LRT involves various therapeutic approaches, not all of which are clearly defined (Haight et al., 1997), effect sizes of 1.05 have been reported for LRT versus no treatment in controlled therapy studies of geriatric depression. However, superiority over a no treatment comparison condition does not demonstrate specific efficacy for the particular brand of therapy. A case series of older trauma survivors with posttraumatic stress disorder successfully treated with LRT was recently reported (Maercker, 2002); thus, this may be a good therapy for clients that need to focus on/confront past trauma issues.

Unfortunately, the application of family therapy with older individuals remains underdeveloped, and research investigating its efficacy is virtually nonexistent (Qualls, 1995; Knight and McCallum, 1998). One area in which there may be an increased demand and relevance is therapy with families caring for a cognitively impaired elderly member (Bonjean, 1988; Qualls, 2000). Individual and family therapy for spouse-caregivers and families of Alzheimer disease patients was efficacious in postponing nursing home placement. Family therapy may be used as a separate modality or to elicit family members’ involvement as facilitators of individual therapy for older individuals.

Another area in need of further investigation is the application and provision of psychotherapeutic services to those with cognitive impairment. A significant minority of the elderly population experience limitations in their cognitive abilities due to progressive dementia, and many of these individuals also experience comorbid emotional distress. Owing to their cognitive deficits, such as memory loss or decreased capacity for judgment and problem solving, persons with dementia are usually not considered to be good candidates for traditional psychotherapy. However, the symptoms and behaviors of persons with dementia should not be viewed solely as manifestations of biology, but rather, as being affected by social, psychological, and environmental contexts as well (Kasl-Godley and Gatz, 2000). Thus, patients with dementia are able to derive some benefit from psychological interventions. Various CBT, environmental, and supportive interventions may help cognitively impaired older adults reduce disruptive behaviors and excess disabilities, increase or maintain positive behaviors, improve memory or learn coping skills to manage loss of cognitive skills, increase quality of life, reduce excessive burden on health-care delivery systems, alleviate symptoms of depression or anxiety, or help adjustment to multiple losses (Gatz et al., 1998; Kasl-Godley and Gatz, 2000). Research on the degree to which cognitive deficits operate as moderators to limit their use (e.g., within what ranges of cognitive dysfunction traditional talk therapies can be used effectively, and with what modifications) is needed.

Many psychosocial interventions currently in use with older adults with dementia are based on uncontrolled case studies and anecdotal reports. However, there are some studies examining the feasibility of conducting therapy or the effectiveness of therapy for particular purposes with older adults (for reviews, see Cheston, 1998; Gatz et al., 1998). Use of behavioral and environmental treatments for behavior problems and memory and cognitive retraining for some forms of late-life cognitive impairment may be effective. However, there is much dispute about cognitive training, in particular. Support groups and CBT can assist those with early-stage dementia to foster coping strategies and reduce distress. RT may provide mild to moderate stage individuals with interpersonal connections. Behavioral approaches and memory training target specific cognitive and behavioral impairments and help to optimize remaining abilities.

One intervention that is often used with memory-impaired older adults is reality orientation (RO), which involves exposing cognitively impaired patients to stimuli that facilitate orientation to time or place (for a manual, see American Hospital Association, 1976). The most widely used type of RO takes place anywhere from once a week to several times a day and involves the rehearsal of basic orientation facts such as the day, date, time, and the weather. In 24-hour RO, patients are reoriented on the nursing home units throughout the day, either by staff or environmental cues such as big clocks and calendars.

Other types of therapies such as problem-solving therapy and eclectic approaches are also being applied to older individuals. For more information, the interested reader might seek Duffy (1999) or Frazer and Jongsma (1999).

As previously noted, the most widely researched disorder in the geriatric mental health field is depression. In 1991, the US National Institute of Health convened a panel of experts from the biomedical and behavioral sciences to address the diagnosis and treatment of depression in late life (National Institutes of Health Consensus Development Panel on Depression in Late Life, 1992). Since then, an update from the consensus conference has been published (Lebowitz et al., 1997) as have numerous reviews, including Areán and Cook (2002). Despite widespread knowledge of the efficacy of major treatment modalities for some disorders or problems occurring in old age, there are still numerous areas in the field in need of further investigation. A brief review of the noteworthy areas follows.

Most industrialized countries report that suicide rates rise increasingly with age, with the highest rates occurring for men age 75 and older (Pearson and Conwell, 1995). In a comparison of age differences in suicidal intent in psychological autopsy studies, older adults were more likely to have avoided intervention and taken precautions against discovery and were less likely to communicate their intent to others, as well as less likely to have a history of previous attempts (Conwell et al., 1998). These distinctive features present a challenge to detecting and treating high-risk elderly. Although suicide in older adults is a major public health problem, there are as yet no effective interventions for reducing suicidal behaviors in this population (Pearson and Brown, 2000). However, given the strong relationship of depression as a risk factor for suicide, improving the detection and treatment of late life depression in primary care settings, where older adults often seek treatment for emotional difficulties, seems to be a promising approach (Brown et al., 2001).

Studies of bereavement-related distress, now referred to as complicated or traumatic grief reactions, have begun (Frank et al., 1997). Clinical researchers at the University of Pittsburgh's Western Psychiatric Institute and Clinic have completed an open treatment trial of traumatic grief therapy conceptualized and treated similar to exposure therapy for posttraumatic stress disorder (e.g., reliving the moment of death, saying goodbye to the deceased, and in vivo exposure to situations that clients have been avoiding since the death) (Shear et al., 2001). This protocol appears to be a promising intervention for debilitating grief in older adults.

Alcohol abuse is common among older adults, with roughly 12% of older women and 15% of older men regularly drinking in excess of limits recommended by the National Institute of Alcoholism and Alcohol Abuse (i.e., no more than one drink per day; Adams et al., 1996). Hazards of drinking among older adults may include increased risk for falls, accidents, and interference with medications. Alcohol abuse may also present differently in the elderly, as the level of drinking necessary to be considered hazardous is lower than the level for younger people, and many late-onset alcoholics do not develop dependence (Levin et al., 2000). However, there is reason to hope that elder-specific interventions can lead to reductions in alcohol consumption (Blow and Barry, 2000). Several large-scale projects have shown promising outcomes with interventions of varying length, most notably Project GOAL—Guiding Older Adult Lifestyles (Fleming et al., 1999), the Gerontology Alcohol Project (Dupree et al., 1984), and the Michigan Outcomes Study (Barry et al., 2001). Project GOAL demonstrated that 15–20 minutes of physician provided advice and education about the negative consequences of excessive drinking can significantly reduce frequency of excessive drinking. More lengthy interventions utilize motivational interviewing techniques (Miller and Rollnick, 1991) and/or skills training (Dupree and Schonfield, 1999). Structured nonconfrontational techniques that reinforce values incompatible with drinking (e.g., maintaining good health) and teach coping skills for avoiding alcohol in high-risk situations (e.g. bereavement) have shown comparable outcomes among older and younger adults (Blow and Barry, 2000). More effort is needed to bring these interventions into primary care and community settings.

Techniques for treating certain mental health problems, such as anxiety disorders, prescription medicine misuse (i.e., benzodiazepine), personality disorders, and psychoses, have been sorely lacking (Gallo and Lebowitz, 1999). Epidemiological evidence indicates that anxiety disorders are more prevalent than either depression or severe cognitive impairment among older adults (Regier et al., 1988). However, despite its prevalence, very little psychotherapy intervention research has been conducted on anxiety (for reviews, see Niederehe and Schnieder, 1998; Wetherell, 1998).

One noteworthy investigation was the randomization of older adults with generalized anxiety disorder (GAD) to the CBT group, a discussion group organized around worry-provoking topics, or a waiting period (Wetherell et al., 2003). Older adults in both active conditions improved relative to the waiting-list; however, CBT showed large effects while the discussion group showed medium-sized effects. These results provide limited support for the superiority of CBT to a comparison intervention.

Additionally, a version of CBT that targets the needs of older adults with GAD in the primary care setting was preliminary tested against usual care (Stanley et al., 2003). Outcome data suggested significant improvements in worry and depression after CBT relative to usual care.

Mohlman et al. (2003) are the first to test the efficacy of CBT as compared with an enhanced version (ECBT) that included learning and memory aids such as homework reminders and troubleshooting calls, and a weekly review of all concepts and techniques for treatment of late-life GAD. ECBT resulted in improvement on more measures and yielded larger effect sizes than standard CBT, when each was compared against a wait-list control group. These findings provide evidence that content and procedural modifications may be necessary to maximize the effectiveness of CBT therapy with older people with mild cognitive impairments.

Prescription medication misuse may be a particular problem for older adults, in particular the use of benzodiazepines (Gallo and Lebowitz, 1999). Anxiolytic medications are the most common treatment for anxiety in older adults and benzodiazepines figure prominently (Blazer et al., 1991). In addition, benzodiazepines are commonly prescribed and used for depression, insomnia, and other sleep disturbances in older individuals. Despite the expressed concern of the American Psychiatric Association (1990) Task Force Report on Benzodiazepine Dependency regarding the ‘appropriate therapeutic use, toxicity, abuse and risk of inducing a drug-dependent state’ in older adults, there are reasons to believe that use is high and often inappropriate (Hanlon et al., 2002). The serious negative side-effect profile, including associations with significant morbidities such as sleep disturbance, cognitive difficulty, impairment in activities of daily living, motor vehicle crashes, and problems with gait (e.g., accidental falls and fall-related fractures) has been well-established (Bertz et al., 1997; Hemmelgarn et al., 1997; Hanlon et al., 1998; Ray et al., 2000). Though pharmacotherapy has been successful in reducing or eliminating benzodiazepine misuse, CBT has also been shown effective in helping older individuals successfully discontinue or reduce inappropriate use (Gorenstein et al., in press; Morin et al., 1995).

As in younger populations, older adults with personality disorders may be less willing to engage, adhere, and benefit from traditional mental health interventions (Lynch et al., 2003). Although to date no outcome study has specifically focused on treating personality disorders in older adults, evidence from case reports and data on effects of personality pathology on treatment of depression suggests that this is a worthy area of future investment (for a recent review, see DeLeo et al., 1999). Pilot data provides preliminary evidence for the feasibility of applying dialectical behavior therapy (Linehan, 1993) to depressed older adults, a significant minority of whom meet criteria for a personality disorder (Lynch et al., 2003). It has been suggested that the increase in life events and disability found in later life may ‘unmask’ maladaptive personality traits that have been dormant in mid-life; the concept of reemergent borderline personality traits (Hepple 2003b for a review of this area). Distress and behaviors arising from this can often be misconstrued as resulting from organic pathology. A clinical case example is presented later to help illustrate this point.

Although there is a large scientific knowledge base on schizophrenia among younger adults, much less is known about late-life schizophrenia and its treatment (Palmer et al., 1999). What is known about its treatment is mainly pharmacological, the use of conventional neuroleptics and the newer serotonin–dopamine antagonists (Jeste and McClure, 1997). However, recently Patterson et al. (2003) developed and evaluated a psychosocial intervention to improve everyday living skills of older patients with schizophrenia and other chronic psychoses. Preliminary findings suggest that older patients with longstanding psychotic disorders may benefit from participation in this skills-training program.

There are a growing number of older individuals who reside in long-term care settings. A US network termed Psychologists in Long-Term Care has developed standards for psychological practice in long-term care facilities (Lichtenberg et al., 1998). Other guidelines and resources for professionals exist, such as information on competency determinations, work within the structure of an interdisciplinary team, and staff development (US Department of Veterans Affairs, 1997; Gallagher-Thompson et al., 2000b; Zeiss and Gallagher-Thompson, 2003).

Although several excellent examples of CBT and its application to older adults have been presented elsewhere in case report form (Dick and Gallagher-Thompson, 1995; Crowther and Zeiss, 1999; Karel et al., 2002), a brief highlighted review of a treatment case is described here to help illustrate the applicability of CBT conceptualization and practice with older individuals. A manual that describes this approach is available for both therapist and client (Dick et al., 1995; Thompson et al., 1995). Additionally, Coon and Gallagher-Thompson (2002) utilize case vignettes to illustrate CBT homework challenges and successful approaches to address adherence barriers.

Mrs W was a 79-year-old, widowed, retired, Caucasian woman who sought treatment for depression at the Older Adult and Family Center at the VA Palo Alto Health Care System. Her symptoms at this time warranted a diagnosis of major depressive disorder and dependent personality features. Mrs W's husband had passed away about 2 years prior and her two sons had moved to a different state. She reported intense feelings of loneliness, disappointment, and frustration that her physical ailments (i.e., congestive heart failure with edema and shortness of breath) had made her less mobile and more dependent on others.

A program of individual weekly CBT was initiated beginning with an introduction to the CBT model and Mrs W was encouraged to apply the skills learned in session outside of therapy (i.e., via homework assignments). In order to help reduce depressive thoughts about herself, she was taught to use a daily thought record, and trained in challenging negative beliefs. In order to increase engagement and enjoyment in pleasant events, the client was taught to the use mood monitoring and activity tracking.

The first session, included thorough history taking, a description of current problems, and completion of assessment measures, such as the MMSE (Folstein et al., 1975), and the Beck Depression Inventory (BDI; Beck and Steer, 1987). At the end of the first session, the therapist presented an introduction to the cognitive-behavioral model of depression on a whiteboard (e.g., how thoughts and behaviors affect functioning, see Figure 32.1) and using materials the client had talked about gave examples of the antecedent, belief, and emotional consequences. The client was easily able to summarize the model and was asked to read material on CBT.

At the beginning of every session, Mrs W completed the BDI to monitor depressive symptomatology. In the second session, the collaborative nature of the relationship between the therapist and client and the importance of practicing new skills learned in session (e.g., homework) were discussed, specific goals of therapy were outlined, and the CBT model was revisited. Mrs W was reminded that CBT was a short-term treatment and that goals must be manageable within the time allowed. Her target complaints were she would like to be cured of her depression and would like to find more satisfying things to do with her life. In session 3, Mrs W was taught how to notice and monitor ‘unhelpful thoughts’ following stressful events. This involved introducing her to an unhelpful thought diary (three columns: antecedent, belief, and emotional consequences). In order to help Mrs W understand the impact and strength of her thoughts on her mood, she was taught to assign a belief rating from 0 (not strong at all) to 100 (completely true) to each thought. A useful analogy was used to help her understand the effects of unhelpful thoughts on mood: listening to a radio station with a headset. It was explained that if the headset is clear, if it is correctly connected to the radio receiver and positioned securely on one's head, then the station will come in clearly (Thompson et al., 1995). It was further explained that if the headset is not on properly, there may be misinterpretation of the signal or information from the radio. A list of unhelpful thoughts entitled ‘Signals from your negative headset’ was given to Mrs W and the therapist explained negative distortions such as attaching negative labels of oneself, having unrealistic expectations for oneself, viewing a situation in terms of extreme outcomes, and tendency to blow events out of proportion. The therapist and Mrs W worked together to identify examples from the patient's current life. Over the next several sessions, Mrs W was taught how to challenge her unhelpful thoughts (e.g., challenging their validity). She was given a list of techniques entitled ‘Fine tuning your signal’ that included challenges such as engaging in specific behaviors to obtain additional information in challenging unhelpful assumptions, considering alternatives, and weighing the advantages and disadvantages of maintaining a current thought, emotion, or behavior.

Fig. 32.1 Cognitive-behavioral model.

Through individual sessions and homework assignments, Mrs W was able to challenge her own thinking as well as allow the therapist to provide her with new information that challenged her unhelpful thoughts. Mrs W was able to recognize that she was recognizing only negative aspects of her current situation and discounting positive accomplishments (see Box 32.1 for partial completion of homework assignment). She was attaching a negative label to herself and sending herself negative messages, such as ‘I'm dumb,’ because of age-associated impairments. Attributing these limitations to aging and not to self was a step toward recovery for Mrs W.

Mrs W did not drive and since her husband's death had abandoned pleasant activities due, in part, to transportation problems. It was important to get her reactivated behaviorally. Mrs W completed the Older Person's Pleasant Events Schedule (OPPES; Hedlund and Gilewski, 1980; Gallagher and Thompson, 1981) a self-report measure designed to measure frequency of engagement in pleasant activities and perceived enjoyment of the activities regardless of whether or not they had been undertaken. She was encouraged to take part in events that once gave her pleasure in which she was no longer engaging (i.e., take an art and computer class) and to increase socialization by broadening her opportunities for social contact. The therapist helped Mrs W arrange transportation to a local senior center to better occupy her daytime hours, a time during which she was home alone. She reported that doing so lessened her feelings of loneliness and her dependency on other care providers. Additionally, Mrs W was encouraged to reconnect with friends from her childhood via telephone and postal mail. Mrs W completed a 15-session course of CBT for depression. At the end of treatment she noted that she had made significant gains in reducing her depression and had regained previously forgotten hobbies.

Mrs S was a woman in her late seventies who presented to mental health services in the UK for the first time following the death of her husband. She complained of feelings of depression, panic, ‘nameless dread,’ and a variety of unexplained physical symptoms. She felt suicidal at times and had taken an overdose of sleeping tablets on two occasions. She found it very difficult to be alone at home and her nocturnal calls to neighbors, her daughter, and emergency services had become problematic. After two admissions to an older persons’ psychiatric inpatient unit the team felt at a loss as to how to help Mrs S. She did not show signs of pervasive depression and often acted as the ‘life and soul’ of the unit, entertaining other patients with her dramatic and musical skills. Her mobility deteriorated, however, although staff felt this was under ‘voluntary control’ and she needed a great deal of staff time and attention for physical care.

As discharge approached, her physical abilities seemed to deteriorate and she became more anxious, depressed, and in need of reassurance. Attempts at discharge to her home resulted in a rapid escalation of suicide threats and emergency phone calls, resulting in readmission.

Following a series of individual sessions with a psychologist using a CAT approach, it became clear that Mrs S had a borderline personality constellation that had reemerged following the death of her husband whom she had nursed for many years. She was the oldest of five siblings and had to become a ‘parental child’ towards her siblings to avoid her mother's criticism and physical abuse. In session 3 she disclosed sexual abuse occurring over many years by her father (which she had not disclosed to anyone before). Disclosing this material was very upsetting for Mrs S but staff noticed that her physical problems and dependency improved and she was more likely to talk about real feelings rather than physical symptoms or ‘nameless dread’. By processing the core pain of the abuse, even at this stage of her life, Mrs S was able to gain insight into her patterns of somatization and becoming ‘the manipulator’ to escape from the distress of helplessness, anger, and guilt. Figure 32.2 highlights this pattern.

The emotional pain had been uncovered in late life due to her husband's death and the breakdown of Mrs S's defensive procedure in which she behaved ‘as if’ she were an ideal care provider to her husband (and deny her own needs). After the sessions ended Mrs S was able to choose to move into a residential home setting and did not re-present to services in the following 5 years.