Since its inception more than 100 years ago, theories and techniques of psychotherapy have experienced tremendous growth and diversification. There has been a gradual increase in our knowledge of aging as well as in our experience conducting psychotherapy with older adults. Although the core principles of psychotherapy are mostly similar to those pertaining to younger people, certain challenges and themes are unique to this population. These include a diverse range of living environments as well as an increasing need for social integration, adjusting to functional and cognitive decline, accessing services, caregiving, navigating transitions, and managing acute and chronic conditions. An increasing number of older adults are seeking treatment for a broad array of mental health problems, including depression, anxiety, insomnia, personality disorders, cognitive impairment, chronic pain, and substance use. Depending on the patient and the presenting problem, psychotherapy can be used as either a primary or an adjunctive method of treatment.

The role of doctors is commonly limited to prescribing medications. However, formulating the psychological component of an elderly patient’s presentation remains of crucial importance. This chapter explores common potential psychological sources of treatment-resistant symptoms through a clinical vignette. The literature is reviewed regarding the combination of medication management and psychotherapy for depression and anxiety.

Culturally diverse populations now include groups defined by age, gender, gender identity, language, country of origin and acculturation, sexual orientation, socioeconomic status, religion/spirituality, and geographic location. In this chapter, we will explore issues that arise when performing psychotherapy with diverse older adults, including ethnic minorities, women, LGBTQ, and veterans. Although there is limited evidence on the efficacy of specific therapy modalities with diverse older adults, review of the current literature and clinical guidance on important challenges encountered is provided. For diverse older adults, common psychotherapeutic factors – the quality of the therapeutic alliance, the ability to express empathy, and the therapist’s competence and experience – may be more important than the specific therapy modality used.

In preceding chapters, we provided a detailed review of the research and practice of four common, evidence-based psychotherapy approaches for older adults: cognitive behavioral therapy (CBT), problem-solving therapy (PST), interpersonal psychotherapy (IPT), and brief dynamic psychotherapy (BDP). However, many other psychological treatments exist and are of potential interest to the clinician treating older adults. These include all the varieties of cognitive and behavioral therapies; third-wave cognitive behavioral treatments such as acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT); mindfulness-based approaches such as mindfulness-based stress reduction (MBSR); combined approaches such as those used to treat substance use disorders in the elderly that involve cognitive and behavioral strategies, motivational interviewing, and a 12-step approach; treatments with unique proposed mechanisms, including life review and reminiscence therapies (RT); and treatments for unique conditions such as complicated grief. In addition, numerous other psychosocial/nonpharmacologic treatments do not act directly on psychological processes but are also of interest to the clinician; these include music and art therapy and even garden therapy.

Older adults have low rates of psychotherapy use despite the effectiveness of multiple psychotherapeutic modalities in late life. Frequent themes in late-life psychotherapy include coping with losses in the setting of physical and cognitive decline, dependence and debility. Choice of treatment modality is based on the abilities and needs of the individual patient rather than age alone. Therapists decide between more structured therapies like cognitive behavioral therapy (CBT) and problem-solving therapy (PST), and more exploratory, affect-focused modalities like interpersonal therapy (IPT) and brief dynamic psychotherapy (BDP). Cognitive therapies have the strongest evidence base for the treatment of depression and anxiety, especially in the setting of medical illness. Problem-solving therapies offer a behavioral approach to patients with depression and executive dysfunction. Interpersonal therapies are readily applicable for older adults struggling with complicated grief, retirement, or family conflict. Brief psychodynamic treatment can be particularly useful for patients with mild to moderate depression struggling with self-esteem or acceptance of mortality. Clinically relevant differences between treatment modalities are difficult to detect due to limited and underpowered trials. Factors common to all psychotherapies, including empathy, alliance, positive regard, and expectations may account for much of the variability in psychotherapy outcomes. Research focused on understanding the mechanism of change associated with psychotherapy is needed to clarify the role of common versus specific factors.

Most forms of psychotherapy in older adults involve individual therapy. A few randomized controlled trials (RCTs) have examined the role of group therapy in older adults, mainly outside the United States. The most studied forms of group therapy in older adults include group cognitive behavioral therapy (CBT) and group reminiscence therapy (RT) for treatment of depressive and anxiety symptoms. Fewer studies have focused on group therapy in the context of cognitive decline. This chapter will describe group therapy in older adults, including indications and evidence from RCTs supporting different approaches.

Short-term psychodynamic psychotherapy (STPP) is an evidence-based treatment modality for older adults. Similar to cognitive behavioral therapy (CBT), STPP refers to a family of distinct but overlapping therapies that share similar features. All STPP modalities are rooted in psychoanalytic theory and share the notion that unconscious emotional conflicts are largely responsible for our patients’ symptoms and suffering.

Psychotherapy is an evidence-based treatment for adults in later life with a wide variety of conditions. Simply defined, psychotherapy is the treatment of a mental disorder by psychological rather than medical means. Initial skepticism regarding the use of psychotherapy in older adults rapidly gave way as the quality of psychotherapeutic intervention improved and practitioners better understood and refined themes related to aging. From the 1980s onward, the evidence base for psychotherapy in older adults has continued to grow. Today, theory and evidence show that psychotherapy is indeed an effective treatment for a variety of conditions in older adults. In this chapter, we will review the history of psychotherapy in older adults, provide an overview of the recent evidence supporting its use, outline special issues in conducting psychotherapy with older adults, and introduce the remaining chapters of the book.

Challenges faced by older people include losses of loved ones through death; declining health, mobility, and function of the five senses; loss of independence; diminishing cognitive ability; and the struggle with Erik Erikson’s final two stages of life, namely generativity versus stagnation and ego integrity versus despair. Those who dedicate their energies to helping the elderly meet these challenges will be well served by the toolbox of techniques within the rubric of interpersonal psychotherapy (IPT). This chapter will serve as a brief overview of IPT principles, a review of the extant scientific literature on its efficacy in late life, and case vignettes to illustrate how it was used for each of the four foci of IPT, namely, role transition, grief, role disputes, and interpersonal deficit.

Medical advances have expanded life, resulting in an extended dying process that allows for time to contemplate mortality and the broader existential themes of life. This period of time is rich with opportunities for the dying person to have one last opportunity to understand and resolve issues previously left unaddressed. This chapter aims to assist clinicians in addressing the psychosocial concerns of patients approaching the end of life.