psychorehabilitation aspects in older age groups

Pergamon Experimental Gerontology, Vol. 30, Nos. 3/4, pp. 423-430, 1995

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PSYCHOREHABILITATION ASPECTS IN OLDER AGE GROUPS

CLEMENS KAUFMANN and GERHARD S. BAROLIN

Ludwig Boltzmann Institute for Neurorehabilitation and Prophylaxis and Neurological Department of the Valduna Hospital Neurological Diseases, A-6830 Rankweil, Austria

Abstract--Throughout medical history, suggestion is the oldest and most common method of relieving human distress and treating physical disease. One of the oldest Egyptian documents, the Ebers Papyrus (1552 BC) states, "Lay your hands upon him to quiet the pain in the arms and say that the pain will disappear." The psy- chogenic and therapeutic potency of Native American trance dances are also well documented. In a North American tribe practicing ancient traditions, such dances were found to produce an altered feeling for time, loss of conscious control, drastic emotional outbreaks, illusions, hypersuggestibility, and a deep feeling of restored youthfulness (Jilek, 1982). These and other historical documents show the deep historical connection between somatic and mental processes. From the viewpoint of a neurologist or a psychiatrist, a combination of somatic illness, depressive syn- dromes, organic psychosyndromes, and multimorbidity is frequent in elderly patients (Kortus, 1992). Thus, integrated psychotherapy in geriatric rehabilitation is necessary and useful. Practical psychotherapeutic methods are discussed in this manu- script.

Key Words: psychotherapy, rehabilitation, geriatric rehabilitation, aging, guided affective imagery, autogenic training, respiratory feedback, group therapy, depression

INTRODUCTION

ALTHOUGH PSYCHOTHERAPY may be defined in a number of ways, a definition provided by Schultz (1973) appears to be the most applicable to the discussion of psychorehabilitative aspects of the older adult. It defines psychotherapy as "therapy using psychological practices according to a clearly described method that can be taught and learned." Although there has been major emphasis, even in medical circles, that psychotherapy affects only the mind, there has been increasing evidence that psychotherapy also has somatic effects.

Correspondence to: Clemens Kaufmann, SMZO-Donauspital, Neurologie, Langobardenstral3e 122, 1220, Vienna, Austria.

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424 c . KAUFMANN and G. S. BAROLIN

Rehabilitation can also be defined in a number of ways; however Scherzer's (1990) definition "a comprehensive and determined effort wherein the patient, in spite of existing physical and/or mental disability, undergoes a long and comprehensive training and learning process, using his own effort to achieve and retain the best possible quality of life, given his condition" provides one of the broadest concepts that can be applied to the psychorehabilitation aspects of older adults.

Rehabilitation and psychotherapy have in common that they help the patient to help her or himself. This is very different from other forms of treatment that are "done to" the patient. Rehabilitation and psychotherapy demand much more participation on the part of patients to achieve their goals.

Concerning the multimorbidity of the older age group, the polypragmatic mobiliza- tion and rehabilitation of physical, psychological, and social reserves is crucial to the effective integration of the elderly into participation in social life and gaining personal independence (Zippel, 1989). In a 3-year longitudinal study Astr6m et al. (1993) found in a population of older acute stroke patients (mean age 73 years), that after 12 months, those patients having the fewest social contacts outside their immediate families con- tributed most to depression. Likewise, disabled patients frequently exhibit anxiety about participation in social life due to their disability. For this reason, psychotherapeutically oriented single or group therapy is a very important part in the rehabilitation of elderly patients with their psychodynamically and somatic multiform problems (Radebold, 1986).

Scheidt and Schwind (1992) showed that the process of coping in stroke patients (mean age 61.8 years) showed similarities with grief reactions following the loss of important objects. In addition to grieving for associated lack of function, however, the reaction is usually complicated by the fact that the physical injury is experienced as a narcissistic trauma resulting in low self-esteem and in feelings of anger and despair. Psychotherapeutic interventions can help the patient through the mourning process and to deal with such negative affects so adaptation to a life with a physical disability is facilitated and integration into social life can be successful.

Physical disability and narcissistic trauma in combination with the social and psychological problems of retirement and aging (loss of independence, feeling of insuffi- ciency, acceptance of imminent dying) make elderly patients in rehabilitation a high risk group. Such patients face an unknown and sometimes critical psychological situation, in which they are in need of as much psychotherapy as he/she can benefit by it (Barolin, 1992). If, for instance a patient is depressed, the most elaborate physiotherapy will be to no avail, because the patient will not be able to achieve the motivation that this treatment requires. "Concomitant depression" (Barolin, 1984; Kaufmann et al . , 1992) is a term important to understand the elderly patient in rehabilitation, and it has four basic etiologies:

1. physical disease leading directly to secondary depression; 2. depression expressing a physical disorder; 3. a physical disorder leading simultaneously to physical symptoms and depression;

and 4. physical symptoms and depression occurring together by chance.

Barolin (1984) showed the epidemiological frequency of concomitant depression in somatic illness and found the highest rate (30%) in disabled stroke patients. Patients in medical services other than neurology with minor handicaps had a 14% depression rate.

PSYCHOREHABILITATIVE ASPECTS IN AGING 425

Fichter (1990) found a significant higher prevalence (7-day prevalence 5%; 5-year prevalence 9.5% for depression) in late-life depression after 65 years of age compared with people younger than 65 years. Again, these data show that older disabled adults are a high risk group for depression and, therefore, polypragmatic therapy including psychotherapy is both indicated and necessary.

Diagnosis of depression in the elderly is often difficult because there are some deficiencies in this age that make accurate diagnosis more difficult (Wolfersdorf et al. , 1992). For example, depression can be masked by aggressive or vegetative symptoms, and existential uncertainty is common. Depressive pseudodementia is also a special type of depression in the elderly. Cavanaugh and Wettstein (1983) found that depres- sives older than 65 years, compared with a younger group, are more vulnerable to cognitive impairments as a manifestation of their depression. Raskin (1986) compared two groups (one group younger than 40 years and another group older), and found that the combination of age and depression rather than age alone seemed to have the great- est negative impact on psychomotor and cognitive performance. On the other hand, it has been estimated that 10-20% of patients receiving clinical workups for dementia have nondemented depressive disorders (Snyder and Yamamura, 1977; Roth, 1980).

It appears that the disabled and cognitively impaired elderly patient is in a high risk group for exhibiting concomitant depression. The therapeutic approach for such rehabilitation patients is, thus, based on a comprehensive rehabilitative approach, with considerable emphasis on socially integrative psychotherapy. In the following sections, current psychotherapeutic methods in rehabilitation are discussed by taking into con- sideration the above-mentioned psychological deficiencies in the elderly.

PSYCHOTHERAPEUTIC METHODS

Many psychotherapeutic methods are available and used for a variety of psychological disorders. Analysis still is frequently considered a basic form of psychotherapeutic intervention, but the classical analytic methodology is not economically feasible as socially integrative psychotherapy within the context of rehabilitation in the elderly.

The group-dynamics aspect of socially integrative psychotherapy plays a role along with the actual conversational therapy as it does in a family therapy approach. In oriental cultures, the way of facing an illness is integration of the disabled elderly person into the family, which engenders safety and emotional warmth (Peseschkian, 1989). In industrial countries, integration of those patients into their families often is not common, and to some extent, integration of elderly patients into treatment groups has proved to be very advantageous (Petzold and Bubolz, 1979; Barolin and W611ersdorfer, 1986; Kaufmann, 1986; Scheidt and Schwind 1992): in this approach, the elderly are able to participate in social life, talk to people having the same past, present, and future problems, and have the feeling of not being alone with their disability. The flexibility in the formation of treatment groups is unlimited. Scholz et al. (1991), for example, mentioned the successful integration of neurorehabilitation patients with anxiety disorders into a treatment group for anxiety patients. The confrontation with rehabilitation patients with their anxieties in conjunction with the development of strategies for overcoming anxiety decreased the tendency to passiveness and withdrawal that tends to hinder the rehabilitative process.

When the purely organic approach (e.g., for spasmolysis) is most important, one should more likely use methods like hypnosis or respiratory feedback. If psychody-

426 C. KAUFMANN and G. S. BAROLIN

namic components seem to play a major role, conversational therapy or such methods as guided affective imagery (GAI) are more appropriate. This last representational therapeutic approach can be useful not only for psychotherapeutic intervention, but activities can also be trained in reality and in imagination. These techniques are discussed below. Every patient should have a right to a psychotherapeutically oriented initial session. The choice of possible further, special psychotherapeutic treatment depends on the availability of resources.

What makes psychotherapy work is (1) the patients own effort, (2) the relationship of the patient to the therapist, and (3) the relationship of group members to each other in therapy groups. The therapist plays an important role and the "doctor as drug" not infrequently contributes to a chronic "iatrogenic neurosis" when the therapist shows uncontrolled and psychologically unsuitable behavior (Balint, 1957). The necessity of a skilled, psychotherapeuticaUy oriented consultation is apparent. This conversational approach must be taught, learned, and honed. There is no firm boundary between consultation as an element of general clinical routine and a focused, psychotherapeutically oriented conversation.

THE HYPNOTIC STATE

If rehabilitation of the older adult is not purely mechanistic but also includes integrative psychotherapeutic attention, the methods that use the hypnotic state (autogenic training, heterohypnosis, respiratory feedback, GAI, and various forms of meditation outside of psychotherapy) are very prevalent, along with conversational therapy.

The hypnotic state is a third basic human state that clearly differs from sleep and waking, as has been shown with neurophysiological studies (Barolin, 1968, 1982). Sub- cortical modulation serves to narrow attention, changes bodily perception, and shifts conceptual activity from logical thought to the production of visual images. Emotional accessibility and heightened introspection increase suggestibility which, in turn, is advantageous in the rehabilitative process. A carefully formulated suggestion, organic or otherwise, can be given in this hypnotic state. The formulas used should be short, positive, personality related, and suited to the problem. The hypnotic state (which is more than just relaxation) should be clearly and dynamically terminated with energetic, voluntary muscle contractions. This tonic and dynamic effect (in the psychotherapeutic sense as well) is especially beneficial in patients who are limp, hypotonic, and depressed, as elderly often are. The easiness of application and understanding of most of the hypnotic methods make them very appropriate also for elderly patients.

RESPIRATORY FEEDBACK (RFB)

Skinner (1953) developed the principle of operant conditioning. This led, on the one hand, to behavioral therapy and on the other hand, to a variety of biofeedback methods. RFB (Leuner, 1986) seems to be especially successful in patients with concomitant depressions and masked depressions expressed by vegetative symptoms (Mehlstaub and Barolin, 1990). The simple setting, as discussed below, makes it applicable also to elderly patients: The patient's breathing alternately increases and decreases the inten- sity of a light and an acoustic signal. The patient registers this as sensory feedback to his respiratory function. Simply paying attention to this autonomic function (without


consciously trying to change it) induces a hypnotic state. At this point, a previous suggestion can be reinforced (Riedl et al., 1989). RFB is not strictly speaking psychotherapy, but occupies a, middle ground between psychotherapy and physiotherapy. But the psychotherapeutic components dominate, and RFB has parallels to autogenic training, which was a sort of godparent to RFB (Barolin, 1988).

HYPNOSIS AND AUTOGENIC TRAINING (AT)

In contrast to the predominant opinion of many physicians and psychoterapists that hypnosis is useless for organic paralysis, positive hypnosis results in patients with such central paralyses as strokes and similar disorders are documented (Simma and Barolin, 1983): After suitable preparatory talks, all patients received a posthypnotic suggestion that the hypnotic relaxation would also benefit the usual physiotherapy (which ran concurrently with all other indicated methods). Positive effects were seen on the physical level on tonus and mobility and on the psychological level on mood and motivation. Also, the evaluation of those effects was subjective (neurological examination and interviewing the patiem before and af ter hypnosis), and these remarkable positive results should be studied, in more detail.

Certain mechanisms could account for these observations. These are (1) activation of ganglional and muscular reserves; (2) decrease of tonic contractibility producing spasm; and (3) psychotropic effect.

Because conventional hypnosis is time consuming relative to its effectiveness, it should be reserved for special cases and, generally, AT is preferred as group~therapy. AT is also often used subsequent to RFB. The AT method of Schultz (1973) is a series of systematic concentration exercises used for self-induction of a hypnotic state. The group-psychodynamicallyaspect in combination with the hypnotic effects like muscular and mental relaxation, increased suggestibility, inclusion of verbal psychotherapeutic directives, or focused organic influence make this method especially applicable to the multimorbide depressed elderly patients.

GUIDED AFFECTIVE IMAGERY (GAI)

GAI, also known as symbolic drama or daydreaming, was developed by Leuner (1954, 1955). In practice, the~patient relaxes on a couch or sits comfortably in a chair, while the therapist encourages daydream-like fantasies. Vague imaginary motifs are turned by the patient's-visual imagination into series of scenes in which the patient moves as if in the real world, while keeping up a dialog with the therapist. The latter carefully structures the situation to lead the patient from conscious imaging to a hypnoid state of heightened: suggestibility where work at the symbolic level is possible. With organic disease, we typically saw and made psychotherapeutic use of the following three types of reactions (Kaufmann, 1992):

1. The patient uses a.spoataneously controlled age regression (Barolin et al., 1982) to return to his/her state before the onset of disability. He/she enjoys this return to his/her previously healthy~ life and takes from it a certain strength and encouragement that can serve to accelerate his/her progress in rehabilitation.

2. Some patients, howe~er,~ may flee into the past and deny their obvious physical disabilities. Sometimes such these patients can be led back to reality via the sym-


bolic level by reconciling them to their situation, Here, positive suggestions may be introduced into GAI. As an example, there was a 60-year-old stroke patient who was confined to a wheelchair and had lost her joie de vivre and her extroverted personality. At the symbolic level, she could gradually be encouraged to undertake excur- sions and physical activities. This subsequently increased, on the one hand, her motivation, and on the other, her ability to actually do these things.

3. Some patients showed a direct positive effect on a major disability.

The following is a description of the possibilities of GAI in rehabilitation of elderly patients. We had a 70-year-old patient with a basilar stroke whose difficulty in swal- lowing was so pronounced that he could only be fed through an indwelling nasogastric tube, For about a week, all attempts at supplemental oral feedings failed. At the second GAI session, the patient, after encouragement, was able to imagine during the hypnotic trance that he could enjoy eating a cup of yogurt in spite of the tube. He managed this first in his imagination and then in reality and the following day he ate a soft meal. After 1 more day the tube was removed and he could again eat normally. The bulbar effect remained noticeable in his speech for some time, but disappeared about 3 months after his injury.

The effect of the hypnotic state works together with whatever is introduced into it (fantasies, suggestions) and it would not be so effective without the other.

Short-term treatment usually does not produce such dramatic successes and so the future of GAI will probably be in the form of GAI group therapy based on time available (Leuner et al. , 1986). The applicability of GAI is preserved for those elderly without major cognitive impairment, because a special understanding of the method and an adequate collaboration is requested. For this reason, the therapeutic and practical use of GAI is not as far reaching in older adults as it is with RFB or AT.

REHABILITATION CONCEPT

Health is defined as a condition of physical, mental, and spiritual well-being, and reaching this condition is, thus, the primary aim of medical treatment. But there can be definite limits, and recognition of them, along with awareness of the disability itself in combination with the special psychological situation of aging can have a negative effect on the patient's psychological well-being and his/her progress in rehabilitation. This is where psychotherapy comes into play in rehabilitation and, as we have shown above, this can have physical as well as psychological effects. Isolated use of psychotherapeutically oriented talks and psychotherapy as such in rehabilitation would be just as wrong as not using these tools at all. We see socially integrative psychotherapy as an important building block within the context of a complex polypragmatic rehabilitation concept. The rehabilitative effort should focus not only on the obvious disability but on the whole person with all his/her physical, mental, and spiritual distress. A great deal can be accomplished with psychotherapy in elderly patients.

CONCLUSION

1. The aging patient, especially in rehabilitation, faces an unknown and sometimes critical situation, in which he/she is as much in need of psychotherapy as can ben- efited by it. Psychotherapy of the elderly is both necessary and also a fulfilling task


for the therapist. The increasing number of emotional problems in the elderly leads to the conclusion that therapists of different basic training and direction occupy themselves with diverse aspects of psychopathology in the elderly. Their variable experiences show that there may be different methods of working with the elderly, both in the clinic and in the private practice. Likewise, the peculiarities of concomitant depression in older adults must also be taken into account.

2. Psychotherapeut ic methods involving the hypnotic state (AT, hypnosis, GAI), and group therapies are of central importance in elderly patients.

3. RFB, combined with suggestion reinforcement, is not psychotherapy in the narrow sense, but has much in common with psychotherapeutic methods, especially when it is used on rehabilitation patients. It is easily applicable and, hence, it is also indicated in older adults with minor cognitive impairment.

4. Psychotherapy has been shown to have not only psychological but also physical effects.

5. Finally, it must again be emphasized that psychotherapy should never be used alone, but rather within the context of a complex rehabilitation scheme in the sense of a socially integrative psychotherapy.

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