Try Integrated Psychotherapy for Complex Issues


STOCKHOLM – Integrated individual psychotherapy may be the best method for addressing complex issues that are often unique to geriatric patients, Dr. Joel Sadavoy said at the 12th Congress of the International Psychogeriatric Association.

“The elderly often present to us with a confusing number of problems, and [these problems] originate from many different sources,” said Dr. Sadavoy, president of the IPA.

Older adults are less likely than younger individuals to have support, since they may be no longer married, retired from the work that defined their identity and purpose, and have lower physical health and strength.

Psychopathology in geriatric patients may be more complex than in younger adults because of the interplay between the adaptive challenges of old age, such as illness or loss, and the individual's personality and psychological structure, such as the ability to maintain self-esteem and security in the face of adversity.

The psychological structure of an older adult will strengthen or weaken their coping capacities, according to the so-called diathesis-stress model described by Dr. Aaron T. Beck and Margaret Gatz, Ph.D., Dr. Sadavoy said.

Some clinicians suggest that the use of two or more interventions, such as combining medication and cognitive-behavioral therapy in the course of a single treatment is integrated therapy.

But a more focused definition of integrated psychotherapy is “the concurrent application of more than one psychotherapeutic technique to address symptoms that arise from different levels and sources, both from within a patient and from their environment and interactive surroundings,” he said.

Dr. Sadavoy suggested that integrated psychotherapy works best if it addresses each of three sources of psychopathology in the patient:

▸ Lack of understanding and knowledge about illness and aging.

▸ Maladaptive thoughts and actions that originate from age-related cognitive distortions and perceptions, shifts in interpersonal relationships and identity, and a lack of problem-solving ability.

▸ Psychodynamically determined reactions and emotions that originate from lifelong, unconscious psychological conflicts and perceptions (Can. J. Psychiatry 1994;39:S19–26).

The third source “is of great importance but is probably the most difficult and subtle to deal with,” Dr. Sadavoy said.

A psychotherapist must have broad training and sufficient practice in using the full array of interventions for these sources of psychopathology to implement an integrated approach successfully, he said.

Dr. Sadavoy uses psychoeducation to address misinformation and deficits in knowledge.

Maladaptive cognitive and interpersonal responses and difficulty in problem-solving are dealt with through clarification and modification of cognitive distortions, interpersonal coaching and training, and teaching of problem-solving techniques. “These are three types of therapy that have been shown to be effective in studies of younger and, in some cases, older patients,” said Dr. Sadavoy, who is a professor of psychiatry at the University of Toronto.

He treats the unconscious conflicts and self-perceptions of older patients with psychodynamic therapies that employ interpretation and working within the transference in therapy.

The degree to which each intervention is used depends on which elements of psychopathology are most evident in a given patient, he said.

During treatment, the psychotherapist should undertake “some major history taking” to gather data on each of the three sources of impairment, organize the data, and develop an integrated intervention plan.

In an example of when an integrated approach works best, Dr. Sadavoy described the case of a 72-year-old woman who showed depressive symptoms, anxiety, and low functioning after a focal cerebrovascular lesion abruptly changed her husband's personality and cognitive function.

The woman's husband had agitation, severe paranoid depression, and executive dysfunction. The man developed new, bizarre behaviors and was unable to run the family business any longer. She felt abandoned. She believed that her husband's symptoms were the recurrence of a depressive episode that was associated with a business failure he had had many years before.

At that time, she was very angry with him because she had to take over the business and rearrange her life in order to do so. Now she felt that she was going through the same thing again, and even though she was concerned for him, she could not shake the feeling of resentment, Dr. Sadavoy explained.

She was at a time in her life when she expected to feel more secure, but she was not sure about whether she could deal with the situation as she had done in the past because of her age, diabetes, and hypertension.

The woman was born into a business-oriented family that had no interest in the arts or intellectual pursuits, unlike her, and she had always thought that her parents were judgmental and rejecting of the things that differed from their perspectives on life.


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