The November BABCP Article of the Month is from the Cognitive Behaviour Therapist (tCBT) and is entitled “Embedding the silver thread in all-age psychological services: training and supervising younger therapists to deliver CBT for anxiety or depression to older people with multi-morbidity” by Georgina Charlesworth

Older people respond better to psychological therapy than working age adults – a consistent evidence-based conclusion from analyses of large datasets and national surveys. For example, the National Audit of Psychological Therapies in 2012/13 showed 58.5% of those aged 65+ met criteria for post-treatment recovery compared to 45.5% of adults aged 64 or younger (Chaplin et al., 2016). Taking primary care only, we see a 64% recovery rate for over 65s compared to 51% for adults aged 18-64 (NHS Digital, 2020).

But which psychological therapies are driving this success? Not necessarily CBT, it seems. In an analysis of data from over 100,000 IAPT attendees in London (2008-1029), older services users were, again, more likely to reliably recover than their younger counterparts (52.5% vs 41%; Saunders et al., 2021). CBT was the most commonly offered approach for all ages. Yet, the proportion of people receiving CBT was notably different for older and younger cohorts. For the 18-64 year olds, nearly half (46%) received CBT and only 1 in 14 (7%) received (non-CBT) counselling. In contrast, for the over 65s, only a third (33%) received CBT and as many as 1 in 6 (16%) received counselling (Saunders et al., 2021, tables H3 and H4, supplementary materials).

The proportion of older people in Saunders et al dataset was very small – fewer than 4%. This is unsurprising given the under-representation of older people in psychological services is another consistent finding (Chaplin et al., 2015; NHS Digital, 2020). Lower CBT receipt coupled with higher recovery does, however, flag up a problem for the CBT community. Given the investment in CBT training and the expectation that older people’s mental health is embedded as a ‘silver thread’ across all of the ‘adult’ mental health Long Term Plan ambitions, including Improving Access to Psychological Therapies (IAPT), community-based services for people with severe mental illnesses (SMI) and crisis and liaison mental health care(www.england.nhs.uk/mental-health/adults/older-people/), how can we support therapists to deliver CBT in a way that meets the needs to older people?

As part of a special issue marking 50 years of the BABCP, I have written about CBT with older people with multi-morbidities. I summarise the evidence base for CBT with older people, review practice-based evidence from five older-adult case studies from the Cognitive Behaviour Therapist and consider the interpersonal challenges that can arise. The cases were drawn from a range of service settings, although none from IAPT. All five cases had been referred for due to low mood and/or anxiety, often in the context of significant physical health difficulties. In each study, a bottom-up, idiosyncratic approach was used for case formulation and treatment planning, as is often necessary in a population with not only co-morbidities but multi-morbidities, where single-diagnosis CBT protocols are a poor fit.  Learning from the case studies suggests CB therapists need competences in: formulating the person in the context of their physical and social environment; working trans-diagnostically; and considering the client’s frame of reference to inform idiosyncratic adjustments. Supervisors can also support therapists to address common therapy-interfering beliefs and behaviours such as: the understandability trap, too much respect, therapeutic nihilism, fears of ageing, dependency & death, neurocognitive overshadowing and adultism.

CBT cannot yet be considered the treatment of choice for people in later life. Might it become so during the next 50 years of the BABCP? Although not yet universally available (NHS Benchmarking network, 2022), we might hope the IAPT-long-term conditions (IAPT-LTC) initiative will enhance provision for older people. We can look forward to greater use of transdiagnostic and modular approaches (Schaeuffele et al., 2021; Steffen et al., 2022), further developments in gerontologically-informed CBT (Laidlaw, 2010; Kadri et al., 2022), the extension CBT for SMI in later life (e.g. Tyler et al., 2022) and the adoption of flexibility within fidelity (Kendall, 2021).

References:

Age UK (2021) Improving Access to Psychological Therapy (IAPT) Positive Practice Guide. Age UK/BABCP. https://babcp.com/Therapists/Older-Adults-Positive-Practice-Guide

Chaplin, R., Farquharson, L., Clapp, M., & Crawford, M. (2015). Comparison of access, outcomes and experiences of older adults and working age adults in psychological therapy. International Journal of Geriatric Psychiatry, 30(2), 178-184. DOI: 10.1002/gps.4122

Kadri, A., Leddy, A., Gracey, F., & Laidlaw, K. (2022). Wisdom enhancement and life skills to augment CBT outcomes for depression in later life: a series of N-of-1 trials. Behavioural and Cognitive Psychotherapy, 50(5), 508-527. doi:10.1017/S1352465822000224

Kendall, P.C. (ed) (2021) Flexibility within Fidelity: Breathing life into a Psychological Treatment Manual.  https://doi.org/10.1093/med-psych/9780197552155.001.0001

Laidlaw, K. (2010). Enhancing cognitive behavior therapy with older people using gerontological theories as vehicles for change. Casebook of Clinical Geropsychology: International Perspectives on Practice, pp. 17–31.

NHS Digital (2020). Psychological Therapies, Annual report on the use of IAPT services 2019-20. https://digital.nhs.uk

NHS Benchmarking network (2022) Health Education England Adult IAPT Workforce Census 2021.  www.hee.nhs.uk/sites/default/files/documents/HEE%20Adult%20IAPT%20Workforce%20Census%202021%20-%20February%202022%20%5BPDF%2C%202.03MB%5D.pdf

Saunders, R., Buckman, J. E., Stott, J., Leibowitz, J., Aguirre, E., John, A., … & Pilling, S. (2021). Older adults respond better to psychological therapy than working-age adults: evidence from a large sample of mental health service attendees. Journal of Affective Disorders, 294, 85-93. https://doi.org/10.1016/j.jad.2021.06.084

Schaeuffele, C., Schulz, A., Knaevelsrud, C., Renneberg, B., & Boettcher, J. (2021). CBT at the crossroads: The rise of transdiagnostic treatments. International Journal of Cognitive Therapy, 14(1), 86-113. https://doi.org/10.1007/s41811-020-00095-2

Steffen, A.M., Thompson, L.W. & Gallagher-Thompson, D. (2022) Treating Later-Life Depression: a cognitive-behavioural therapy approach. Oxford University Press, New York. https://doi.org/10.1093/med-psych/9780190068431.001.0001

Tyler, E., Lobban, F., Sutton, C., Hadarag, B., Johnson, S., Depp, C., … & Jones, S. H. (2022). A pilot randomised controlled trial to assess the feasibility and acceptability of recovery-focused therapy for older adults with bipolar disorder. BJPsych Open, 8(6), e191. https://doi.org/10.1192/bjo.2022.582

Author bio:

Georgina Charlesworth is a Consultant Clinical and Health Psychologist in the NHS, and an Associate Professor at University College London. She has worked with older people with and without dementia and their families since the early 1990s. She completed the Oxford Cognitive Therapy course in 1997 and regularly teaches on CBT with people in later life.

From Richard Thwaites, the Editor-in-Chief of tCBT: Why I chose this article : I have chosen this month’s BABCP Article of the month due to both the importance of the subject area and also the lack of submissions that tCBT receives on this topic.  Dr Charlesworth has provide an inspiring call to arms both for IAPT staff and potential referrers (where clinical outcomes are excellent but referrals are limited) but also secondary care staff where the availability of evidence based therapies such as CBT can vary greatly between teams and areas.