Therapeutic relationships with the elderly may vary in length and depth, but they all share the aim of helping the individual feel better about himself and improving his ability to cope with his life situation as he perceives and experiences it. The focus of the relationship then is on the elderly individual. In some settings he is called a client, in others, a patient. The particular term used may reflect not only the attitudes that the staff hold toward him, but also the philosophy of treatment that is offered to the elderly. The term "client" suggests that the elderly person has sought service in a nonmedical setting and is seen as having some choice over whether he enters into, accepts, or terminates the treatment that is offered. The term "patient" may imply that the person is defined as sick and in need of medical care. In approaching a "patient" there may be a tendency to focus on the pathology, either physical or mental, and there may be a corresponding lack of attention paid to the individual's strengths. Opportunity for the elderly person to make decisions about his treatment may be limited and his preferences may go unheeded. Neither of these descriptions may fit a particular setting in which therapeutic relationships occur, but it is important for the professional to be in touch with whatever the prevailing attitudes in the agency are and to think through how these attitudes affect the way in which he relates to the elderly person.
It is equally important for the professional to sort out his feelings about working with elderly patients. There is a tendency in our culture to equate old age with illness in spite of the fact that 80% of our elderly age 65 and over are active and function quite well. Health care professionals are apt to be biased even more than laymen since most of the elderly persons they see will be ill or in poor health. Only 5% of the elderly in the United States are confined to institutions for physical or emotional illness but in 86% there are chronic health problems of one type or another. Still, these statistics should not obscure the fact that the great majority of the elderly function quite well in spite of the limitations that come with aging. Biases toward the elderly are often further compounded by the belief that behavior problems in old age are related to organic degeneration in aging and there is not much one can do to reverse such changes. If so, it is not likely that treatment goals will be set that will bring about changes in behavior. Professionals are also likely to confuse the fact that chronic physical illness and chronic mental illness do not necessarily go hand in hand. Emotional illness in the elderly can be of an acute nature even though they suffer from a chronic physical illness. The goals for treatment then should be established to meet both long-term and short-term needs of the elderly regardless of whether they pertain to physical or emotional problems.ardless of whether they pertain to
Old people have the ability to change and adapt. Given time and emotional support, they can adjust and modify their behavior in significant and enduring ways. Each person learns ways of coping with the problems he meets throughout life. Sometimes the coping behaviors he's learned are not adequate to handle the situations that he must face. When the usual techniques fail, people turn to emergency coping behaviors that may not be effective either. The individual may not know how else to handle the problem and may cling to old patterns that get him into trouble with others and "turn them off." The therapeutic relationship may be designed to change a particular behavior problem or improve interpersonal skills. It may also enable the client to achieve an intellectual or emotional understanding of his problems. Other goals may include changing the client's self-perception and comfort level by reducing anxiety or depression. Changing the client's life style may be still another goal, but major personality restructuring is not generally a feasible goal for the elderly client.
There are a number of key areas to evaluate when entering into therapeutic relationships. Attempts to change behavior must be based on a thorough evaluation of the client's physical, social, and psychological status in order to determine whether the behavior is amenable to change and if so, what the best approach to change may be. A number of the physical illnesses to which old people are prone affect behavior as well. It is important to distinguish between behavior problems that are functional and those that are associated with physical illness or may be medication induced.
The assessment of the patient's physical condition should be given early consideration. Is he showing symptoms of a physical illness? Has it been diagnosed and is it under medical supervision? Many people delay seeking medical treatment even when they know something is wrong. The elderly are no exception. It may be a matter of lack of transportation, the high cost of treatment and medicines, fear of what one may find is wrong, or simply a reluctance to "give-in" and admit that they need help. If physical illness exists, it is important to identify the behavior changes that may be associated with the illness.
The elderly are often put on large numbers of medication without careful attention being paid to the interaction or potentiating effects that may occur between drugs. Recent or sudden changes in behavior should be evaluated carefully in reference to changes in medications or dosages that are used to treat physical illness. The elderly are also likely to have their favorite patent or over-the-counter (OTC) remedies that they use regularly regardless of what the doctor may prescribe. Obviously the mixture of some of these medicines can lead to trouble.
The assessment should include a review of the medications or treatment program that the patient is receiving, including a check for over-the-counter preparations as well as those prescribed by the physician. Some of the elderly will prefer homemade remedies and if they work, that's the end of it. If they don't, then they may consult a physician. In addition, the therapist should determine how much of what is prescribed the patient actually takes. A drug history should also explore how much OTC preparation he is taking. The dosage levels that the person takes should be identified in order to determine whether changes in behavior can be explained by dosages that are too high or too low.
If the behavior problem appears to be related to the physical condition, a drug, or treatment program, the question should be raised as to whether or not the problem can be alleviated by adjusting the medical regime. A thorough physical examination may be the best and quickest approach to treating a behavior problem.
The psychosocial assessment should determine whether or not the behavior can be traced to recent events in the elderly person's life that have represented a loss of things that hold physical, social, or emotional value for him. It should also determine whether the changes in behavior are of a more gradual nature that have occurred over the years and become progressively worse. It is quite possible to work with clients who have longstanding emotional problems, focusing on only certain aspects of the problems that are judged to be more amenable to treatment or in which recent changes have occurred.
Every therapeutic relationship should begin with a warm, friendly approach. I know a man, who, when he meets someone, always acts as if that person is the one he most wanted to see at that very moment. He focuses his complete attention on him, shakes his hand, and conveys such warmth and genuine interest in the person that one feels enveloped with his caring. Unfortunately he is not in one of the "helping professions," he is a researcher, but he exemplifies the kind of caring that needs to come through in a therapeutic relationship. Touch is an important component in the process of communicating. It can be an effective means of relating to the elderly when it is a warm and spontaneous gesture.
The keystone of the therapeutic relationship is listening. Listening requires more than casual attention. It means setting aside one's own concerns and fantasies. It also means seeing the client not as a problem or illness category, but asa person who may be experiencing problems, whose being and experience extend far beyond the problem he brings for therapy. The problem, whatever it may be, is best understood and approached within the context of uniqueness that each client presents.
The professional should be alert to the responses that the elderly person evokes in him as they interact. It is the mark of a professional to be able to help people he may not like or to continue to work with someone who makes him angry. Unfortunately, professionals are as likely to be biased against the elderly as are others in our culture. Being sensitive to the negative feelings that may be aroused can enable the professional to grow by working through his feelings. If the professional finds he or she cannot function effectively with a particular client, he/she should seek supervision to help resolve the conflict.
The First Interview
The primary objective in the first interview is to gather information about the elderly person and to assess the nature of the presenting problem both from the elderly person's perspective and from the professional's point of view. A second objective is to establish rapport with the person. Rapport is defined here as a harmonious quality of interaction between the elderly and the professional involving a positive sense of liking, respect, and trust. Rogers describes the professional therapist's attitude as one of positive and unconditional regard for the client.1 It is this quality composed of concern, acceptance, empathy, and respect that needs to come through in the interview. People respond to it. It motivates cooperation and helps ensure that the relationship will continue. If the words and the feeling tone of the interview are consistent, it conveys the feeling that the verbal offer of help is genuine. It is generally helpful if the- therapist likes the patient as the therapist is more likely to work hard for him and convey the caring he feels. However, it is not necessary to like a patient in order to be helpful.
The third objective of the interview is to establish a contract with the patient. A contract involves a consensus or agreement that is reached between the elderly person and the professional as to the problems that need resolution and those that the elderly person is willing to work on. In most cases there are multiple problems, some of which will require long-term treatment, others that may be more limited in scope or have a higher priority in the elderly person's mind. It is wise to begin with the problems that the client feels are most important. If there are areas in which changes can be made quickly, it demonstrates the value of treatment to the client and will bolster his faith that changes can also occur in areas where the problems are more difficult to resolve. He needs to develop confidence in the professional and in himself that they can work together and that such an alliance will eventually enhance his ability to cope with his life situation. The client should feel that the therapist is on his side and working on his behalf.
The foregoing description of the first interview is designed for the situation in which the elderly person seeks help and has already identified some problem(s) that he wants resolved. The professional may, however, be called into work with an elderly patient who has not asked for help but whom others have identified as having behavior problems that they judge to need help. In such situations, the first objectives are to assess the scope and nature of the problem and to establish rapport with the elderly person. The elderly person should be told that "your son asked me to stop by and see you," or "the staff asked me to stop by," or whatever may be appropriate. It may take longer in such situations to establish rapport. It is essential to find out the patient's perception of his behavior and start from his point of view. Even the nonverbal person who refuses to talk with you can be drawn out in time and meanwhile his silence can tell the astute observer a great deal about what he is feeling. Needless to say, the goals and progress of the elderly client are never discussed with a third party unless the client knows about and agrees to such action.
The setting for the interview may vary ranging from the elderly person's home, the bedside and hospital room, a lounge area in an extended care facility, or a professional's office. The setting ought to provide privacy although it may not be possible to separate the patient from others completely. If the material to be discussed is likely to be confidential, then privacy should be assured. In other circumstances it is still possible to establish rapport and provide a supportive relationship while using good judgment about tfie choice of topics to be pursued in the interview if the conversation can be overheard.
The professional needs to position himself closer to the elderly person than he might to someone younger, keeping in mind losses in vision and hearing that occur with aging. Professionals often wear white but if possible, they should wear bright colors when working with the elderly. Bright colors are more easily seen and may liven up an otherwise drab setting. The professional should speak distinctly, yet slowly in a volume that the elderly person can hear. It is important not to hurry the interview nor to use numerous questions in quick succession. The physical condition of the elderly person may prevent using the first interview as previously described. It may take two or three interviews to achieve even a tentative contract. The needs of the client should always dictate the approach that is used and not some predetermined guideline.
Clients need an orientation to the task that is to be the focus of the relationships. The focus of the task in therapy is to assist the patient to solve personal problems. Here the task is personal rather than impersonal. It is easier for clients to understand what is involved in an impersonal task such as taking medication, exercising, having a physical examination, etc, than it is for them to understand the nature of the personal task that is the goal of therapy. Talking about problems and focusing on feelings is not always viewed as constructive and goal-oriented. It is harder to "get a handle on" than are the more concrete tasks that make up physical or recreational therapy. Orientation to the task that is the focus of the relationship represents an issue that must be dealt with in the early phase of the relationship.
Key Issues in the Relationship
There is a natural history of all relationships. There is a beginning and an end. Most relationships will move through several phases. The initial phase may be thought of as an orientation phase, in which the client and the therapist meet as strangers and then gradually get to know each other. The initial contract is negotiated in this phase and a beginning alliance is formed. Considerable testing and false starts may occur in this phase. The second phase may be described as an intermediate or working phase in which the client has come to accept the therapist as a helping person and has come to grips with the problems he must resolve. There is less avoidance of the task at hand and more real energy being put toward reaching a solution. The final phase is focused on termination. The issue of separation for both the client and therapist is of prime concern. Too often, this phase is neglected because severing the relationship is painful. Not enough time is given to preparing the client for termination. Therapists fail to appreciate the type of emotional bonding that occurs in a therapeutic relationship and often underestimate the time needed to adjust to the loss of support that termination involves. In a relationship of some length, these phases may be differentiated more clearly than in a brief one.
In addition there are likely to be crises at certain points in the relationship. The professional can manipulate a crisis by manipulating constraints on the relationship. Confronting the client on significant issues and not allowing him to evade the problems he faces may cause him discomfort and acute anxiety, but it may also enable him to resolve the conflicts.
There are certain issues that will appear sooner or later in all relationships. They may occur simultaneously or in some unspecified sequence. Each may surface and reoccur from one interview to the next. One of the issues that appears early in the relationship is that of control. Who will control what happens during the client-therapist interaction. Relationships develop along several axis, one of which is dominance-submission. If both individuals insist on dominating the relationship, it will probably fall apart. If the client dominates the relationship, it is unlikely that any therapeutic change in his behavior will be affected. It is the therapist's responsibility to assume control of the relationship in such a way as to create a noncompetitive atmosphere that supports the client's strengths, focuses on the problem areas, and assists the client to resolve them. The client is encouraged to do the problem solving. He is not forced into a submissive role and offered a "wise" solution prematurely.
A second issue in the relationship is that of trust and self-disclosure. Clients may never have learned to trust people earlier in their lives and the therapist will be no exception. Those who have had some trusting experiences with people but who have been "burned" somewhere along the line may be less resistive than others who've had a long series of disappointing relationships. Nevertheless, even for clients who have had good relationships in the past, a new and unfamiliar person, even one who offers to help them, may not be welcomed with open arms. There is an old Buddhist proverb that says, "why do you hate me so much, I haven't even tried to help you?" The wisdom of this proverb lies in the insight it provides us regarding feelings people have about being "helped." To need help is to be in a dependent position. Most people want to be self-sufficient and control the way they live rather than have it dictated by others. The elderly are no exception but increasing age is often associated with increasing loss of control over one's life. Loss of control over some aspect of one's life often leads to depression that may be more or less severe depending upon how significant the loss is to the individual. Anger about needing help, the loss of control, and related lack of confidence may interfere with the development of trust in the relationship. The anger may be projected onto the therapist as the client makes unreasonable demands for his attention or services. Patience, consistency, and limit setting are useful tools in such situations. The therapist must recognize what the client is experiencing and understand the dynamics of the behavior pattern.
Clients will continue to test throughout the relationship to see if you mean what you say. Telling a client what you can and cannot do for him through the therapeutic relationship establishes a common base line of understanding but it does not mean the client will not test the limits of that relationship. The client is not likely to disclose the thoughts and ideas he holds secret to someone he cannot trust. To disclose "secret" information to someone who will abuse such knowledge or to have it used against one can be disastrous. Trust that can withstand such risk taking is not built overnight. Neither should the therapist be misled by confidences that are shared too easily. The content of such exchanges are likely to be those that are easy to talk about but still a safe distance from more significant or deeply felt concerns. The therapist must attend to what is not talked about as well as what is, in order to pursue areas that appear to be problematic for the client and painful for him to deal with.
Another issue that may or may not be related to the achievement of a sense of trust is the issue of intimacy. If the client and therapist are of opposite sexes, issues around intimacy may appear early in the relationship. Sexuality in the aging client is not a moot point. It may in fact be exaggerated if the client does not have other sexual outlets. Often the spouse has died and older women in particular have few suiable men in their own age group to turn to. Sexual fantasies about the therapist are not uncommon among men and women clients even if no attempt is made to act them out. The sharing of personal experiences and intimate feelings may lead the client to feel very close to the therapist. This closeness may be interpreted as a sexual response and acted upon in that light. For some clients the closeness and sharing simply act to enrich the client's life and enhance his response to the therapy. However, the young therapist is likely to become uncomfortable if the client makes sexual advances or asks questions of a personal nature. Such moves should be understood in light of the patient's needs and the context in which they occur. Gentle but firm redirection from the therapist coupled with an exploration of the meaning behind these advances can help to establish the nature of the therapeutic relationship and sort out how it differs from other social relationships that the client may have known or be seeking.
The management of the expression of feelings is another important issue that pervades the relationship. Each person has learned ways of expressing feelings in his life. Each has his own style. The patterns vary by sex, age, and ethnic (group) heritage. In the early phases of the relationship, there may be more need to cover up feelings, to maintain a certain facade. As time goes on and the relationship deepens, there is less need to distort the expression of true feelings. The test of a mature relationship is whether or not individuals can express their true feelings without risking the destruction of the relationship. The nature of the therapy may in fact be directed toward identifying feelings that the patient is experiencing and acting upon, but does not recognize or acknowledge in himself. During termination, the therapist and patient alike must work through the feelings of separation and the loss that each faces. For the elderly patient, loss is not likely to be a new experience. Care must be taken that sufficient time and attention is given to discussing the impending separation. Abrupt or abortive termination should be avoided. It may be desirable to transfer the patient to another therapist if further work is needed when the professional is transferred or leaves the agency or institution before treatment is completed. The transfer of a client should be given careful consideration and recommended only if it meets his needs. It should not be used as a way of avoiding a painful termination or to assuage feelings of guilt that professionals often have over leaving a client. Missed or broken appointments during this phase are likely to be a sign that the patient is having difficulty managing his feelings about termination and may need help expressing them. Anger and feelings of abandonment are not uncommon. Missed appointments may also represent the client's determination to control how and when the relationship will end, and to avoid a painful goodbye.
Finally there is the problem of individual differences that both the client and therapist must deal with. Our society does not foster a great tolerance for individual differences despite protestations and slogans to the contrary. To be effective the therapist must learn to respect and appreciate life styles and value systems different from his own. The latter is easier said than done. The issue is particularly salient with the elderly client. A young therapist and an elderly client may experience a real generation gap if the therapist is not in touch with the cultural attitudes and biases he may have picked up toward aging. Studies have shown that medical personnel do not like to work with older people. Professionals often hold the view that changes in behavior are due to organic deterioration in the elderly and therefore individual or group therapy would be wasted on them. Clearly, such negative attitudes will interfere with and even prevent the elderly from getting proper treatment. Pfieffer, Butler and others have noted that the elderly are good candidates for psychotherapy and respond well to it.2'3
In summary therapeutic relationships with the elderly may be characterized in the following ways. Such relationships are unilateral as they focus on the needs of the client and not on the needs of the therapist.
The interaction is planned and goal-oriented. The goals for the relationship are those that the client and therapist have agreed upon as relevant to the client's needs and take into account the social context in which the elderly person functions. Key issues that will emerge in the relationship are control, trust and self-disclosure, intimacy, management of the expression of feelings, and tolerance for individual differences. Finally, the therapeutic relationship is time limited. The relationship ends when the goals that were established for it have been achieved.
- 1. Rogers C: Client Centered Therapy. Boston, Houghton-Mifflin Co, 1951, pp 19-64.
- 2- Busse ?, Pfeiffer ?: Mental Illness in Later Life. Washington, DC, American Psychiatric Association, 1973, pp 8-16.
- 3. Butler R, Lewis M: Aging and Mental Health. St. Louis, CV Mosby, 1977, pp 137-157.
- Burnside IM: Nursing and the Aged. New York. McGraw-Hill, Inc. 1976.
- Busse EW, Pfeiffer ?: Mental Illness in Later Life. Washington, DC, American Psychiatric Association, 1973, pp 8-16.
- Butler RN, Lewis MI: Aging and Mental Health. St. Louis, CV Mosby, 1977, pp 137-157.
- Edinburg GM, et al: Clinical Interviewing and Counseling: Principles and Techniques. New York, Appleton-Century-Crofts, 1975.
- Kennedy E: On Becoming A Counselor. New York, The Seabury Press, 1977-Kanfer
- FH, Goldstien AP: Helping People Change. New York, Pergamon Press, Inc, 1975.
- Rogers C: Client Centered Therapy. Boston, Houghton-Mifflin Co, 1951, pp 19-64.