Using a Cognitive Behavioral Therapy Group to Treat Depression and Anxiety in Older Adults
Case Presentation
A 71-year-old married man was seen regularly by his geriatric physician for hypertension, irritable bowel syndrome, depression, and anxiety. He requested frequent medical appointments and always came prepared with a list of questions about his health. His anxiety increased when he read about his conditions and medications in medical guides and on the Internet. He had been given several trials of antidepressants, but perceived intolerable side effects from each. His physician referred him to a cognitive behavioral therapy (CBT) group for treatment of depression and anxiety. The patient was retired from his career as a pharmacist at a local drugstore. He had enjoyed the status and challenge of his job and, after retirement, believed that he no longer had a purpose in life.
Depressive symptoms had been present during his working years, but his anxiety had developed after retirement. He became disinterested in previously enjoyable activities and withdrew from social contact, such as membership in a service organization. He became disorganized and lost confidence in his abilities. He had trouble making decisions and was continually looking for reassurance that he would be alright. In an initial interview with one of the group facilitators, the patient described his physical illnesses at great length. He brought with him a carefully packed kit including several medications, instructions for taking them, a selection of snacks, and an outer garment in case of a change in weather. He described how he always double-checked this kit each time he left his home. His score on the Geriatric Depression Scale was 15 out of 15, and his score on the Burn’s Anxiety Inventory1 was 50, indicating severe anxiety.
Discussion
Mood disorders, especially depression and anxiety, are common conditions among older adults. Although mood disorders can be related to physical as well as psychological factors, distorted thoughts or beliefs often serve to create or maintain dysfunctional mood states. At the same time, when feeling depressed or anxious, individuals tend to find evidence that supports distorted or negative thoughts. Cognitive therapy was developed in the late 1950s by Aaron Beck to help individuals overcome depression. Current research shows a growing body of evidence attesting to the benefits of CBT, whether alone or in combination with appropriate psychotropic medication, for treatment of late-life depression and anxiety.2-5
The cognitive model proposes that distorted or dysfunctional thinking influences mood and behavior, and that realistic evaluation and modification of thinking produce an improvement in mood.6 Using cognitive therapy does not imply replacing inaccurate negative thoughts with inaccurate positive thoughts, but rather describing a situation or event in accurate, realistic words. Outpatient CBT groups offer cost-effective, clinically efficient help for mood disorders.7,8 The group discussed in this article was offered to those over the age of 60. Seven participants attended 10 weekly sessions of 11/2 hours each facilitated by two clinical social workers. Concepts of cognitive therapy were introduced in an educational mode, using tools such as lectures and reading assignments. Members were given homework assignments to enhance their understanding of the therapy and to work toward identified goals. Weekly sessions followed a similar format and included these components:
Go-around question. Each session began with a brief go-around question such as, “What was a core value of your family of origin?” Discussion following this question emphasized how family values learned in formative years can affect thoughts, attitudes, and behaviors throughout life. When discussing core values, the patient described in this case became more aware that his perfectionism was related to his father’s high standards and refusal to accept mistakes. Although the patient’s attention to detail and scrupulous habits were very helpful to him as a pharmacist, they created problems when dealing with other aspects of his life.
Mini-lecture. At each session, one of the therapists gave a 10-20 minute lecture presenting basic concepts of cognitive therapy. Lecture topics included an overview of cognitive therapy; identification of automatic thoughts; cognitive distortions, such as overgeneralization, mind-reading, all-or-nothing thinking, “should” statements, catastrophizing, and labeling;9 goal setting; problem solving; and techniques to correct distorted thinking. These lectures built on each other to increase knowledge and capacity to use cognitive techniques. Reading assignments reinforced the concepts presented in lectures.
Discussion of current problems. Participants were often dealing with stressful situations involving relationships, physical health problems, losses, or life changes. As they discussed their problems, participants often made statements that appeared to illustrate distorted thinking. At those times, one of the therapists would ask, “Can we work together to see if that thought is accurate?” The job of the therapist was not to tell participants how to think, but to help them find evidence for or against the accuracy of the thought. As participants became familiar with the concepts and techniques of cognitive therapy, they were encouraged to point out distortions to fellow group members. The facilitators’ goal was to enable group members to take part in the process of identifying distorted thoughts and suggesting alternative, accurate thoughts.
During the course of the therapy sessions, the patient was able to identify an underlying automatic thought that created anxiety about his health: “If I am not continually vigilant and totally knowledgeable about my health, something terrible will happen.” With input from the group, he was able to recognize distortions in this thought, such as catastrophizing and all-or-nothing thinking. He was able to balance this thought by stating it more accurately: “With my doctor’s help, I can monitor and maintain my health without focusing on it for hours each day.” In other areas of his life he learned to modify thoughts to be specific and accurate. When he thought, “I have no purpose in life,” he learned to ask, “Where’s the evidence?” By asking this question, he could substitute a more rational analysis of his life. “Although I have retired from my career, I am important to my family and could be of value to my community in a number of ways.”
Goal setting and review of goals. Periodically throughout the sessions, participants were asked to set concrete goals and to report on their progress toward reaching these goals. Goals were routinely reviewed to see if they had been completed or needed alteration. When the patient recalled how much he enjoyed creating illustrations for his high school newspaper, he set a goal of taking a drawing class at the recreation department.
Homework assignments. Homework assignments were given weekly. These reinforced learning and provided opportunities to use techniques that participants learned in the group. One assignment was to keep a record of dysfunctional thoughts.10 Individual assignments were given to address particular issues. For example, the patient was given an assignment to explore options for drawing classes.
Whereas cognitive therapy implies a structured approach to effecting change, we have found that, with older adults, flexibility is desirable. Older adults may experience health problems, losses, and changes in lifestyle that require venting, discussion, and problem solving. As the sessions progress, it is expected that participants will take a more active role in pointing out distortions and collaborating on finding more rational responses to events. At the end of each 10-week series, group members are offered the option of joining an ongoing monthly group composed of past members of the weekly series.
Outcome of the case patient
The patient made significant progress during the 10-week group. He worked diligently to understand the concepts and apply them to his life. He clearly benefited from recognition of cognitive distortions and substitution of more rational thoughts. He understood that he had been reacting to life events based on negative thinking patterns developed in early life, and was able to apply techniques learned in the group to think more realistically and lessen his feelings of depression or anxiety. He also profited from the problem-solving discussions. He was able to consider alternative ways to deal with problems based on suggestions or experiences of other group members. An additional benefit was the social support of sympathetic individuals. Participants often say, “It helps a lot to know that I’m not alone in my depression.” Because of one or a combination of these factors, the patient reported feeling better at the end of the 10 sessions. At the last session, his Geriatric Depression Scale score was 6 out of 15 and his Burn’s Anxiety Scale score was 15, indicating only mild anxiety. Now, in monthly support group meetings, the patient reports that, although he is still conscientious about his health, he no longer focuses on the possibility of catastrophic illness. He no longer packs and carries his “survival kit,” and reports that at his last medical appointment his doctor asked, “Is that all you want to talk about? Where’s your list?” He continues to attend drawing classes and has submitted illustrations to the senior center newsletter. He has again affiliated himself with his service organization. In the monthly support group, he is extremely helpful to other group members who struggle with the concepts. When he hears a member express a distorted thought, he gently asks, “Where’s the evidence?”