by Edna Wallace, LMFT

On May 31st, 2019, I presented on treating older adults suffering from major depression, severe anxiety, or bipolar disorder. We had a full house for this luncheon talk, against the backdrop of beautiful Shoreline Park and delicious food at Michael’s Restaurant.

The talk started with an exploration of loss. The “golden years,” as some refer to that stage, are often times of great loss. I had the participants talk at their tables about “what I stand to lose (or have lost).” Lots of roundtable discussion was generated; of course, all aspects of loss were expressed—from deaths of people closest to them through to divorce, loss of independence, loss of capabilities, loss of memory, and loss of purpose. Audience members expressed feelings of fear and grief, thinking of all these losses.

I went on to discuss features of depression, anxiety, and bipolar disorder in older adults. I talked about isolation, mounting mail and bills, hoarding, cognitive and physical impairments, chronic pain, staying in bed all day, anhedonia, and rumination (being stuck in regrets). If the last stage in the Ericksonian Stages of Development is Integrity vs. Despair, the depressed older adult looks back over their life with huge regrets. Some of the precipitants to depression and severe anxiety include the failure to navigate the transition to retirement; feelings of incompetence (or “being left behind”); pain and illnesses; avoidance of help and senior resources, and discomfort with psychotherapy (for dealing with childhood abuse or trauma). I talked about the higher suicide completion rate for older adults than their younger counterparts. I discussed how some medical conditions, surgeries, or medications can lead to depression or anxiety in older adults (for example, heart surgery has a link to depression, and Parkinson’s comes with high anxiety).

I went on to discuss treatment of these disorders, focusing on the psychiatric programs that El Camino Hospital offers. These are group-based day programs, with a mixture of CBT, DBT, Process, Art, and occupational therapy groups—where the patient comes in for the whole day (in the partial hospitalization level of care) or for half a day (in the intensive outpatient milieu). There is weekly case management/therapy and weekly psychiatrist visits for patients needing acute care due to their anxiety, depression, or bipolar disorder. For older adults, there is also OATS, a 15-week outpatient, psychiatric program with 2 groups a week (process and psychoeducational) and monthly case management and psychiatrist visits.

I stated that “patients get better just by coming in.” That is, with acute depression or anxiety, the older adult has been isolating for so long and ruminating all day in their private hell, that by coming in and being around other people, learning from the other patients, acquiring skills, and eating lunch together, the patients start rallying and getting out of themselves. They learn the lesson “I am not alone in my pain and distress” in a very visceral way. They start developing hope and focusing on what they can still do. They start making plans; taking “baby steps”; setting SMART goals for the weekend. And, of course, there is the medication management, as the program psychiatrist sees the patient weekly in the PHP and IOP levels of care and monthly in OATS. There are also nurses, with whom the patient can consult on a daily basis, as necessary. Transportation to these programs is included (and paid for) by El Camino Hospital, enabling the older adult who can no longer drive safely to come in. This counters the oft-heard rationale, “But I can’t drive that far for treatment.”

I talked about the value of reminiscence therapy in treatment of older adults. I had my captive audience of marriage and family therapists do a second round of roundtable discussion: this time on “one’s favorite oldie music” and “one’s best or worst job.” This discussion was hard to wrap up; people really got into it! I talked about how that’s the same case for older adults with depression and anxiety. Not only do they get into it with relish, but they forget (for the moment) their worries and upsets and are totally in the moment, reviewing fond memories, connecting with others.

I talked about the needs of older adults. The audience did my job for me: they came up with a whole slew of needs. I emphasized many of them: need for visibility, purpose, connection, empathy, respect, and compassion. I talked about how these needs are addressed in the intensive programs that El Camino Hospital offers. I talked about how we encourage the depressed, anxious, or bipolar patient to get re-engaged in their community. I gave out a handout on “choosing after-care activities.” I talked about resistance and how the patient often puts up obstacles (withholding feelings, low self-esteem, worry, substance abuse, or denial). I said, “recovery is not a linear process.” I talked about how the patient is expected to provide a “discharge plan” before she graduates. This plan includes aspects such as “my primary coping skills; how I will stay well; my support people, early signs of relapse; emotions that get me into trouble; positive self-talk; my mantras; my pleasurable activities; why I can’t go back to the way I was; and how I will ask for help”. I gave some case examples, such as Mike (not his name), who came into OATS from the community and had been extremely isolated. In the beginning of the program, Mike had needed the hospital tables for protection from the other group members; by the end of his 15 weeks in OATS, he said “you couldn’t shut me up” and would go out with the other patients for lunch on Thursdays. I provided a list for some geriatric community resources, including the Village concept, senior centers, and geriatric care managers.

I ended my talk by emphasizing how much we rely on the audience! That is, we need community psychotherapists in conjunction with our Mental Health and Addictions programs at El Camino Hospital. We need the MFTs not only for referrals, but for ongoing treatment as well, because in both the IOP and the OATs levels of care, the depressed or anxious patient must have an outside therapist for weekly or fortnightly therapeutic sessions.

The talk was superbly successful, with positive evaluations, and lots of questions and comments. This is obviously a topic that generates concern, curiosity, fear (because who isn’t getting older?) and tons of engagement! Thank you for the privilege of allowing me to share my experience with a dedicated group of marriage and family therapists!

Edna Wallace has been providing psychotherapy for over 15 years. She has worked with the older adult community for the majority of that time. She has a private practice in Los Altos and co-leads a weekly interpersonal process group with Dr. Benjamin Page. Edna can be reached at www.ednawallace.com.