As a Consultant Clinical Psychologist who’s worked with older people in the NHS for many years, I’ve lost count of the number of times I’ve heard the following questions at a first appointment: Was I sure I could see them for psychological therapy as there must be people younger who really needed help instead? Was I sure there were enough resources within the NHS for them to be helped? Did I really believe change was possible at their age?
I always felt deeply sad that older people experiencing distress did not feel entitled to receive the high quality services that younger people receive, including psychological therapies. It also struck me that many older people in later life internalise the ageist ideas around them that change is not possible and that other, younger people deserve to be helped more than them. That somehow they are less worthy.
In 1905 Freud stated that “the elasticity of mental processes on which the treatment depends is, as a rule, lacking – old people are no longer educable”. He was referring to his belief that people over 50 could not benefit from therapy. Today this would rule out a rather large number of the population! Yet, if we look at how current psychological therapies cater for older people, it seems that Freud’s legacy lingers on…
In recent years we have seen the development of ‘ageless’ mental health services, as many services for older people have been absorbed into general adult services. Although this change could be welcomed as an indication of age equality, the majority of clinicians have seen a very different reality. For example, the Improving Access to Psychological Therapies (IAPT) programme focuses on anxiety and depression and is supposedly open to adults of all ages. However, there is significant under-representation of older adults amongst the population accessing this programme; In its first year, 2008/9, just 4% of patients were over 64, and this had only increased to 6.6% by 2013/2014. The message is clear; older adults are not accessing psychological therapy in the numbers expected.
So what are the barriers preventing them from doing so?
Ageism amongst both the public and professionals is a major one. I have heard GPs say “but isn’t depression an inevitable consequence of ageing”, implying that it is pointless referring older people for therapy as nothing can really be done compared to treating depression in younger people. The reality is that IAPT services have actually found that there are higher recovery rates for those over 65 years old and that they are more likely to complete a full course of treatment than other age groups. If some professionals have this therapeutic nihilism then what hope is there for older people experiencing mental health difficulties later in life – especially given that a GP is most people’s gateway for referral to other services?
There are also organisational obstacles for people in later life who try to access psychological therapies. For example, IAPT services historically never offered home visits, which was clearly a barrier for many older people with mobility and other physical health problems. Furthermore, surveys of the national IAPT workforce have indicated that the majority of workers “lack confidence” in working with older people and do not understand the range of issues affecting them, including the complexity of cognitive changes, physical health co-morbidities and ageing and later life issues.
This must change. Older people need to believe that they are entitled to access the type of talking therapies that can alleviate distress and enable them to live the sort of life they want. They need to be able to ask for talking therapies and consider themselves as worthy of receiving the same help available to younger adults.
Personally, I have found it inspirational to work with people in the later stages of life. The life experience of older people means that they have a wealth of knowledge, experience and wisdom to draw upon within therapy. My role is often to help someone recognise their abilities, knowledge and wisdom when they may be more used to people pointing out their disabilities, deficits and losses.
In my experience, the most reflective people in therapy have been older people. Not knowing how much time they have left encourages people to reflect on what they still want for their lives and to try to make the changes needed to achieve this. There is no greater privilege than being able to go on a journey with someone at this stage, to hear their story and create change together.
Dr Philippa Hyman
Consultant Clinical Psychologist
Red & Yellow Care