Evidence Based Counseling and Psychotherapy for an Aging

Population

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Evidence-Based
Counseling and
Psychotherapy for an
Aging Population

Morley D. Glicken, DSW

AMSTERDAM • BOSTON • HEIDELBERG • LONDON

NEW YORK • OXFORD • PARIS • SAN DIEGO
SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO
Academic Press is an imprint of Elsevier
Academic Press is an imprint of Elsevier
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First edition 2009

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09 10 11 12 10 9 8 7 6 5 4 3 2 1
 Contents

Dedication ........................................................................................................xi
About the Author ..................................................................................xiii
Preface ................................................................................................... xv
Acknowledgements ............................................................................... xix

Part I Psychosocial Perspectives of Aging 1

1 Aging in America: Psychosocial Treatment Issues ........................... 3
1.1 Introduction ......................................................................................... 3
1.2 Some Demographics of Aging ............................................................ 4
1.3 Future Growth of Older Adults ........................................................... 6
1.4 Common Emotional Problems Experienced by Older Adults............. 7
1.5 Studies of Counseling and Psychotherapy Use by Older Adults ........ 8
1.6 Older Adults Benefit from Human Service Interventions ................. 10
1.7 A Personal Story: The Reality of Rural Health Care ........................ 17
1.8 Summary ........................................................................................... 17
1.9 Questions from the Chapter............................................................... 18

2 Successful Aging ................................................................................ 23

2.1 Introduction ....................................................................................... 23
2.2 Definitions of Successful Aging ........................................................ 23
2.3 Achieving Successful Aging ............................................................. 24
2.4 Optimism as an Aspect of Successful Aging .................................... 28
2.5 Resilience as an Aspect of Successful Aging.................................... 30
2.6 Attributes of Resilient People............................................................ 31
2.7 Coping with Stress Improves Successful Aging ............................... 36
2.8 Personal Story: An Example of Successful Aging: Life in the
Slow Lane .......................................................................................... 39
2.9 Summary ........................................................................................... 40
2.10 Questions from the Chapter ............................................................... 40

Part II Understanding Evidence-Based Practice 45

3 An Explanation of Evidence-Based Practice and its
Application to Clinical Work with Older Adults ............................ 47
3.1 Introduction ....................................................................................... 47
3.2 The Current State of Clinical Practice............................................... 48
3.3 Defining Evidence-Based Practice .................................................... 51
3.4 Concerns about Evidence-Based Practice from the Practice
Community ........................................................................................ 55
vi Contents

3.5 Responses to Criticisms of Evidence-Based Practice ....................... 58

3.6 Why Practitioners Sometimes Resist the Use of EBP....................... 60
3.7 Is Evidence-Based Practice Applicable to the Human Services?...... 62
3.8 A Personal Story: Life is Good At 86 ............................................... 64
3.9 Summary ........................................................................................... 65
3.10 Questions from the Chapter ............................................................... 66

4 Using Evidence-Based Practice to Diagnosis and Assess

Psychosocial Difficulties in Older Adults ........................................ 71
4.1 Introduction ....................................................................................... 71
4.2 Diagnostic Checklists ........................................................................ 78
4.3 An Evidence-Based Practice Psychosocial Assessment Using the
Strengths Perspective with Older Adult Clients ................................ 79
4.4 Summary ........................................................................................... 95
4.5 Questions from the Chapter............................................................... 96

5 Evidence-Based Practice and the Client-Worker Relationship

with Older Adults ............................................................................ 101
5.1 Introduction ..................................................................................... 101
5.2 Defining the Therapeutic Relationship ............................................ 102
5.3 Evidence of the Importance of the Therapeutic Relationship to
Treatment Outcomes ....................................................................... 104
5.4 Special Concerns About the Therapeutic Relationship with Older
Adults .............................................................................................. 106
5.5 Gender and the Therapeutic Relationships...................................... 111
5.6 Racial and Ethnic Variables in Therapeutic Effectiveness .............. 112
5.7 Summary ......................................................................................... 116
5.8 Questions from the Chapter............................................................. 116

Part III Evidence-Based Practice and Psychosocial Problems of

Older Adults 121
6 Love and Intimacy in Older Adulthood ........................................ 123
6.1 Introduction ..................................................................................... 123
6.2 Sex and Intimacy ............................................................................. 124
6.3 Natural Changes may Affect Intimacy ............................................ 126
6.4 Suggestions for Helping Older Adults Improve their Sex Lives ..... 128
6.5 Determining the Cause of Sexual Difficulties in Older Adults ....... 129
6.6 Love in a Time of Older Adulthood: A Personal Story ................... 134
6.7 Summary ......................................................................................... 138
6.8 Questions from the Chapter............................................................. 138

7 Work, Retirement, and Ageism in the Workplace ........................ 141

7.1 Introduction ..................................................................................... 141
7.2 Retirement Stress............................................................................. 143
7.3 Best Evidence for Work with Retirement-Related Stress................ 146
7.4 Bridge Jobs Between Long Term Careers and Total Retirement .... 151
 Contents vii

7.5 Personal Story: Working After Retirement ................................... 154

7.6 Summary........................................................................................ 155
7.7 Questions from the Chapter ........................................................... 156

8 Evidence-Based Practice with Older Adults Experiencing

Social Isolation and Loneliness....................................................... 159
8.1 Introduction ................................................................................... 159
8.2 Definitions and Causation of Loneliness and Isolation ................. 161
8.3 The Impact of Loneliness on Older Adults ................................... 163
8.4 Treating Loneliness ....................................................................... 166
8.5 The Internet as a Way of Coping with Loneliness......................... 168
8.6 A Personal Story: Isolation from an Adult Child .......................... 173
8.7 Summary........................................................................................ 175
8.8 Questions from the Chapter ........................................................... 176

9 Evidence-Based Practice and Older Adults Experiencing

Elder Abuse and Neglect ................................................................. 181
9.1 Introduction ................................................................................... 181
9.2 Legal Definitions of Adult Abuse and Neglect.............................. 182
9.3 Indicators of Elder Abuse .............................................................. 184
9.4 Abusive Caretakers ........................................................................ 185
9.5 Interventions with Caretakers ........................................................ 186
9.6 Treating Abused Older Adults: Effective Interventions ................ 188
9.7 Community Services ..................................................................... 195
9.8 Research Questions ....................................................................... 196
9.9 Summary........................................................................................ 197
9.10 Questions from the Chapter ........................................................... 198

10 Evidence-Based Practice with Depressed and Suicidal Older

Adults ................................................................................................ 201
10.1 Introduction ...................................................................................201
10.2 Depression in Older Adults ...........................................................201
10.3 Reasons for Older Adult Depression .............................................204
10.4 Best Evidence for Treating Depression in Elderly Clients ............205
10.5 Evaluating One’s Own Practice with Older Depressed Adults .....212
10.6 Single Subject Approaches to Evaluate Depression in
Older Adults .................................................................................. 213
10.7 A Goal Attainment Scale Measuring Improvement in Jake’s
Depression ..................................................................................... 215
10.8 Summary ....................................................................................... 218
10.9 Questions from the Chapter........................................................... 218

11 Evidence-Based Practice with Older Clients

Experiencing Anxiety ...................................................................... 223
11.1 Introduction ................................................................................... 223
11.2 Diagnosing Anxiety in Older Adults ............................................. 225
viii Contents

11.3 Best Evidence for the Treatment of Anxiety with an

Older Adult Population ................................................................. 227
11.4 A Personal Story about Social Anxiety ......................................... 232
11.5 Summary ....................................................................................... 233
11.6 Questions from the Chapter........................................................... 233

12 Evidence-Based Practice with Older Adults Who Abuse

Substances ........................................................................................ 235
12.1 Introduction ................................................................................... 235
12.2 Diagnostic Markers of Substance Abuse....................................... 238
12.3 Best Evidence for the Treatment of Substance Abuse .................. 243
12.4 Research Problems and Best Evidence ......................................... 256
12.5 Summary ....................................................................................... 257
12.6 Questions from the Chapter........................................................... 257

Part IV The Impact of Spirituality and Religion and the

Significance of Self-Help Groups 263
13 Evidence-Based Practice and the Significance of Religion and
Spirituality in the Lives of Older Adults ....................................... 265
13.1 Introduction ................................................................................... 265
13.2 Definitions of Spirituality and Religious Involvement .................. 266
13.3 The Impact of Spirituality and Religious Involvement on the
Health and Mental Health of Older Adults.................................... 267
13.4 Dissenting Views about the Benefit of Religious Involvement
and Prayer ...................................................................................... 271
13.5 Why Does Religious and Spiritual Involvement Impact Health
and Mental Health?........................................................................ 272
13.6 Should Issues of Religion and Spirituality be Included in
the Work of Human Service Professionals with Older Adults? .... 274
13.7 Dissenting View ............................................................................. 277
13.8 Conclusions ................................................................................... 278
13.9 Problematic Research Issues ......................................................... 280
13.10 Summary........................................................................................ 287
13.11 Questions from the Chapter ........................................................... 287

14 Evidence-Based Practice and the Effectiveness of Self-Help

Groups with Older Adults .............................................................. 293
14.1 Introduction ................................................................................... 293
14.2 Defining Self-Help Groups............................................................ 294
14.3 The Indigenous Leaders of Self-Help Groups............................... 296
14.4 Best Evidence of the Effectiveness of Self-Help Groups .............. 300
14.5 Q and A with the Author about the Meaning of these Studies ...... 305
14.6 A Personal Support Group Story: Coping with the Death of
Loved Ones.................................................................................... 311
14.7 Summary ....................................................................................... 313
14.8 Questions from the Chapter........................................................... 313
 Contents ix

Part V Evidence-Based Practice and Health Issues of Older

Adults 321
15 Evidence-Based Practice with Alzheimer’s disease and Dementia... 323
15.1 Introduction ................................................................................... 323
15.2 Definitions of Alzheimer’s Disease and Dementia........................ 323
15.3 Diagnosis ....................................................................................... 324
15.4 Stages of Alzheimer’s Disease ...................................................... 325
15.5 Evidence-Based Practice with AD Clients and Caretakers ........... 326
15.6 Caring for Loved Ones with Dementia ......................................... 330
15.7 A Personal Story: Taking the Car Keys away from a Parent ......... 337
15.8 Summary ....................................................................................... 338
15.9 Questions from the Chapter........................................................... 339

16 Evidence-Based Practice with Disabilities, Terminal Illness,

and Assisted Living.......................................................................... 343
16.1 Introduction ................................................................................... 343
16.2 Disabilities in Older Adults ........................................................... 344
16.3 Assisted Living .............................................................................. 349
16.4 Terminal Illness ............................................................................. 350
16.5 Best Evidence for Work with Terminal Illness .............................. 352
16.6 Nursing Homes .............................................................................. 356
16.7 Helping Older Adults Make an Informed Decision about
Nursing Homes .............................................................................. 357
16.8 A Personal Story: Reconnecting with an Absent Terminally Ill
Parent ............................................................................................. 361
16.9 Summary........................................................................................ 362
16.10 Questions from the Chapter ........................................................... 362

17 Hospice and Bereavement ............................................................... 369

17.1 Introduction ................................................................................... 369
17.2 Hospice .......................................................................................... 369
17.3 Bereavement .................................................................................. 374
17.4 Summary ....................................................................................... 380
17.5 Questions from the Chapter........................................................... 380

Part VI Policy Issues and the Future of Care for Older Adults 383
18 Final Words: Some Concerns about the Future of Older Adults.... 385
18.1 A Looming Financial Crisis for Older Americans Caused
by the Lack of Savings and Significant Increases in the
Cost of Living, Particularly Health Care Costs ............................. 385
18.2 The Lack of Available Medical Care............................................. 386
18.3 More Pressure on Older Adults to Care for their Children and
their Children’s Children ............................................................... 387
18.4 Older Men and their Special Needs............................................... 388
18.5 Making Better use of Older Adults ............................................... 391
x Contents

18.6 Concluding Words ......................................................................... 392

18.7 Personal Story: On the Joys of Being an Older
Published Author........................................................................... 394

Index .............................................................................................................. 397

Dedication

This book is dedicated to my father, Sam Glicken, who fought for the
rights of working men and women, and who was among the vanguard
of the forward thinking who promoted the health care and pension
benefits for older people we so take for granted. I miss you dad, and I
wish you were here with me now to share this book.
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About the Author

Dr Morley D. Glicken is the former Dean of the Worden School of

Social Service in San Antonio; the founding director of the Master
of Social Work Department at California State University, San
Bernardino; the past Director of the Master of Social Work Program at
the University of Alabama; and the former Executive Director of Jewish
Family Service of Greater Tucson. He has also held faculty positions in
social work at the University of Kansas and Arizona State University.
He currently teaches in the Department of Social Work at Arizona State
University West in Phoenix, Arizona.
Dr Glicken received his BA degree in social work with a minor in
psychology from the University of North Dakota and holds an MSW
degree from the University of Washington and the MPA and DSW
degrees from the University of Utah. He is a member of Phi Kappa Phi
Honorary Fraternity.
In 2009 Elsevier published his book Evidence-Based Practice
with Emotionally Troubled Children and Adolescents: A Psychosocial
Perspective. Praeger published his book A Simple Guide to Retirement:
How to Make Retirement Work for you was published in 2009. (with
Brian Haas) In 2008 he published A Guide to Writing for Human Service
Professionals for Rowman and Littlefield Publishers. In 2006 he pub-
lished Life Lessons from Resilient People, published by Sage Publications.
He published Working with Troubled Men: A Practitioner’s Guide
for Lawrence Erlbaum Publishers in Spring 2005 and Improving the
Effectiveness of the Helping Professions: An Evidence-Based Approach
to Practice in 2004 for Sage Publications. In 2003 he published Violent
Young Children, and Understanding and Using the Strengths Perspective
for Allyn and Bacon/Longman Publishers. Dr Glicken published two
books for Allyn and Bacon/Longman Publishers in 2002: The Role of
the Helping Professions in the Treatment of Victims and Perpetrators of
Crime (with Dale Sechrest), and A Simple Guide to Social Research.
Dr Glicken has published over 50 articles in professional journals
and has written extensively on personnel issues for Dow Jones, the
xiv About the Author

publisher of the Wall Street Journal. He has held clinical social work
licenses in Alabama and Kansas and is a member of the Academy of
Certified Social Workers. He is currently Professor Emeritus in Social
Work at California State University, San Bernardino and Director of
the Institute for Personal Growth: A Research, Treatment, and Training
Institute in Prescott Arizona offering management, consulting, and
research services to public and private agencies. More information about
Dr Glicken may be obtained on his website: www.morleyglicken.com,
and he may be contacted by email at: [email protected].
Preface

Let me begin this preface by informing the reader that I am an older

adult (68 when the book was written) but that much of what I read
about aging, work, retirement, and life after 65 seems to inaccurately
describe me and many of the older adults around me. We seem like a
healthy and engaged lot, many of us playing tennis and hiking well
into our eighties, and even our nineties. We stay healthy, continue to
work or volunteer, and maintain active, stimulating lifestyles. Yes, we
hurt in the morning, and pain and certain signs of aging like forgetful-
ness are annoying, but in most ways we are as physically and emotion-
ally healthy as ever, perhaps even more so. We planned for retirement
and never saw it as a permanent state of inactivity and leisure, but as an
opportunity to grow and expand as people.
And yet, many older adults haven’t had these experiences. They
come from employment that has taken its toll on their minds and bodies.
They failed to develop and maintain healthy lifestyles throughout many
of the years approaching old age. They lacked support groups and had
troubled interpersonal experiences that often left them feeling lonely,
depressed, or prone to abusing substances. Rather than planning for the
economic realities of life without work, because they had so little to
begin with, they live on the small subsidies provided by Social Security.
This book is written for them, but it is also written for the “healthy”
older adults who begin to experience depression, anxiety, prolonged
bereavement, and every emotional problem that younger clients experi-
ence, because emotional problems are part of the human condition at
any age. It is also written to urge clinicians to begin helping older adults
when they hurt emotionally, something the reader will discover often
fails to happen. Finally, it is written to encourage clinicians to use best
evidence in their work with older adults and to understand the use of
evidence-based practice, an approach that offers great hope for effective
work with many clients.
This is my third book on evidence-based practice and my 12th book
in six years. I trust that this track record and the fact that I continue
to teach and consult are strong arguments against the notion that older
xvi Preface

adults experience diminished abilities. You wouldn’t know that, how-

ever, from the experiences many of us begin to have with organizations
that no longer want us even though we’ve given our all to the health and
vitality of those very organizations. Many of us have felt the subtle and
not so subtle signs that once we are past 50 (and maybe even younger),
our worth in society and in the workplace diminishes with each year we
grow older.
Ageism, like any other stereotype or bias, is filled with misinforma-
tion and inaccuracies that lead otherwise healthy people to experience
problems as they age that would never exist in a society that values the
skills, wisdom, and work ethic of older people. In no small part many
of the problems discussed in this book result from healthy people being
treated badly in the workplace and by a society that devalues older people.
Although this book is mainly clinical in nature, I’m including a chapter on
needed social policies because they are so important to healthy aging.
People who have worked their entire lives deserve the best mental
health service available. One solution to the increasing number of older
adults who may not be aging well is to provide a competency-based ser-
vice that focuses on what works best. By using best evidence from the rap-
idly increasing knowledge-base in psychotherapy, social work, counseling,
and gerontology, human service workers can provide a research-oriented
service whose objective is to keep aging clients engaged, independent,
and healthy, even those clients who are not aging well because of poverty,
poor nutrition, substandard housing, limited educational opportunities,
lack of financial planning, elder abuse, or catastrophic losses that have
reduced life chances and limit access to an “aging well lifestyle.”
Workers providing services to older adults need to understand that
psychosocial perspectives on aging have changed in the past 40 years
from notions of disengagement, which argue that older adults will grad-
ually withdraw or disengage from social roles as a natural response to
lessened capabilities, diminished interest, and to societal disincentives
for participation, to current beliefs that people who age successfully are
those who carry forward the positive habits, preferences, lifestyles, and
relationships of midlife into late life.
Evidence-based practice is an approach that offers reason and ratio-
nality to a population of people who are often ignored by the mental
health and medical professions when they experience emotional distress.
The book provides practice-oriented information that will help workers
improve their work with older adults, as well as case studies followed
by an analysis of the work done with clients over a range of problems
 Preface xvii

experienced by older adults. The problems interfering with successful

aging include depression, anxiety, reduction in functioning, prolonged
grief, loss of friends and loved ones, feelings of isolation and alone-
ness, financial difficulties, problems with self-care and appropriate hous-
ing, health-related problems, difficulties receiving needed medical care,
addictions and substance abuse, elder abuse, and many other problems
described in more detail in the table of contents. Special features in the
book include case studies in every chapter, personal stories on success-
ful aging from older adults, and integrative questions at the end of each
chapter.
Finally, I want to make clear that the most compelling purpose of
this book is to remember the many older adults among us who suffer in
silence and isolation, and grow old without the comfort of a loving fam-
ily or a caring community. Their anguish should motivate us to open
our hearts and minds to new ideas, to new treatment approaches, and, in
Bertrand Russell’s words, to have “unbearable sympathy for the suffering
of others.”

Morley D. Glicken, DSW