Schema therapy has evolved since the late 1980s as an efficacious and increasingly widely used psychotherapeutic treatment for personality disorders and many other complex disorders that correlate with underlying maladaptive schemas. Only recently, attention among clinical geropsychologists has been growing for the application of schema therapy in older adults. Schema therapy is very feasible for both therapists and older patients. Schema therapy is an integrative psychotherapy, which draws on the cognitive-behavioral, attachment, psychodynamic, and emotion-focused traditions. In this treatment model, early maladaptive schemas are considered core elements of persistent and pervasive psychopathology, including personality disorders. The goal of treatment is to decrease the impact of maladaptive schemas and to replace negative coping responses and maladaptive schema modes with more healthy alternatives so that patients succeed in getting their core emotional needs met. The emerging attention for schema therapy in older adults is in line with the increased attention for personality disorders in later life, and also with the maturing field of psychotherapy for older adults. The first scientific evidence for the feasibility and the effectiveness of schema therapy has recently been shown. Despite these developments, much work is still to be done. The question is whether schema theory, which was developed for adults in young and middle adulthood, equally applies to those in later life. Although the first tests of effectiveness of schema therapy in older adults are encouraging, age-specific adaptations of existing therapy protocols, both for individual and group schema therapy, are wanted. Furthermore, the research that has been conducted so far has focused on the young-old. Especially for the growing and highly complex group of oldest-old patients, the development of feasible and effective schema-based interventions is needed. Integrating age-specific moderators for change, such as wisdom enhancement, attitudes to aging, and integrating the action of positive schemas, deserves recommendation.
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Schema Therapy With Older Adults
A.C. Videler
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Schools and Approaches to Psychotherapy
Kathleen Someah, Christopher Edwards, and Larry E. Beutler
There are many approaches to psychotherapy, commonly called “schools” or “theories.” These schools range from psychoanalytic, to variations of insight- and conflict-based approaches, through behavioral and cognitive behavioral approaches, to humanistic/existential approaches, and finally to integrative and eclectic approaches. Different and seemingly new approaches typically have been informed by older and more established ones. For instance, cognitive behavioral therapy (CBT), one of the more widely used approaches, evolved from traditional behavior therapy but has become sufficiently distinct by adding its own complex variations so as functionally to represent an approach of its own.
New approaches abound both in number and in complexity. Modern clinicians have had to become increasingly widely read and creative in trying to understand the ways in which patients may be helped. The sheer number of approaches, which has climbed into the hundreds, has challenged the field to find ways of ensuring that the treatments presented are effective. The advent of Evidence Based Practices (EBP) throughout the healthcare fields has placed the responsibility on those who advocate for particular types of treatment scientifically to demonstrate their efficacy and effectiveness. While this movement has brought standards to the field and has offered some assurance that psychotherapy is usually helpful, there remains much debate about whether the many different schools produce different results from one another. The debate about how best to optimize positive effects of psychotherapy continues, and there remain many questions to be asked of psychotherapy theories and of research on these approaches.
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Sport Psychology Considerations in Intercollegiate Athletics in the United States
Christopher M. Bader and Scott B. Martin
As a field of study, sport psychology is relatively young, gaining its formalized start in the United States in the 1920s. Then and now, the practice of sport psychology is concerned with the recognition of psychological factors that influence performance and ensuring that individuals and teams can perform at an optimal level. In the past 30 years, sport psychologists have made their way into intercollegiate athletics departments providing mental health and performance enhancement services to intercollegiate student-athletes. The differentiation between mental health practice and performance enhancement practice is still a source of some confusion for individuals tasked with hiring sport psychology professionals. Additionally, many traditionally trained practitioners (in both mental health and performance enhancement) are unaware of the dynamics of an intercollegiate athletic department. The interplay of the practitioner and those departmental dynamics can greatly influence the efficacy of the practitioner.
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Stigma and Health
Katherine Nieweglowski and Patrick W. Corrigan
Stigma is a complex process that results from the interaction of stereotypes, prejudice, and discrimination. When applied to health conditions (e.g., mental illness, HIV/AIDS, diabetes, obesity), stigma can contribute to a lack of recovery and resources as well as devaluation of the self. People with stigmatized health conditions may be too embarrassed to seek treatment and others may not provide them with equal opportunities. This often results in discrimination in employment, housing, and health care settings. Strategies have been proposed to prompt stigma change with strategic contact between those with the health condition and everyone else likely to have the best effects.
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Substance Use in Later Life
Stephen J. Bright
In the 21st century, we have seen a significant increase in the use of alcohol and other drugs (AODs) among older adults in most first world countries. In addition, people are living longer. Consequently, the number of older adults at risk of experiencing alcohol-related harm and substance use disorders (SUDs) is rising. Between 1992 and 2010, men in the United Kingdom aged 65 years or older had increased their drinking from an average 77.6 grams to 97.6 grams per week. Data from Australia show a 17% increase in risky drinking among those 60–69 between 2007 and 2016. Among Australians aged 60 or older, there was a 280% increase in recent cannabis use from 2001 to 2016. In the United States, rates of older people seeking treatment for cocaine, heroin, and methamphetamine have doubled in the past 10 years. This trend is expected to continue.
Despite these alarming statistics, this population has been deemed “hidden,” as older adults often do not present to treatment with the SUD as a primary concern, and many healthcare professionals do not adequately screen for AOD use. With age, changes in physiology impact the way we metabolize alcohol and increase the subjective effects of alcohol. In addition, older adults are prone to increased use of medications and medical comorbidities. As such, drinking patterns that previously would have not been considered hazardous can become dangerous without any increase in alcohol consumption. This highlights the need for age-specific screening of all older patients within all healthcare settings.
The etiology of AOD-related issues among older adults can be different from that of younger adults. For example, as a result of issues more common as one ages (e.g., loss and grief, identity crisis, and boredom), there is a distinct cohort of older adults who develop SUDs later in life despite no history of previous problematic AOD use. For some older adults who might have experimented with drugs in their youth, these age-specific issues precipitate the onset of a SUD. Meanwhile, there is a larger cohort of older adults with an extensive history of SUDs. Consequently, assessments need to be tailored to explore the issues that are unique to older adults who use AODs and can inform the development of age-specific formulations and treatment plans. In doing so, individualized treatments can be delivered to meet the needs of older adults. Such treatments must be tailored to address issues associated with aging (e.g., reduced mobility) and may require multidisciplinary input from medical practitioners and occupational therapists.
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Suicide in Later Life
Kim Van Orden, Caroline Silva, and Yeates Conwell
Suicide in later life is a significant public health problem around the world—a problem that will increase in magnitude in the coming years with the impact of population aging. Adults age 70 and older have higher suicide rates than younger groups worldwide in both lower-income and higher-income countries. While suicide rates tend to increase with age, suicide in later life is not an expected or normative response to stressors that accompany the aging process. Instead, a constellation of risk factors places an older adult at elevated risk for suicide. These factors can be remembered as the Five D’s: psychiatric illness (primarily depression); functional impairment (also called disability, often associated with dependency on others); physical illness (particularly multiple comorbid diseases); social disconnectedness (including social isolation, loneliness, family conflict, and feeling like a burden); and access to lethal (deadly) means. The greatest risk occurs when multiple domains of risk converge in a given individual. Approaches to prevention can address the Five D’s. Given that older adults are reluctant to seek out mental healthcare and that standard primary care practice cannot easily provide it, models of primary care-based integrated care management for mental disorders, including in older adulthood, have been developed, rigorously tested, and widely disseminated. These models play an important role in suicide prevention by integrating treatment for physical and mental illness. Upstream, selective prevention strategies that target disconnectedness—such as engaging older adults as volunteers—may serve to reduce disconnectedness and thereby reduce suicide risk. Universal prevention strategies that involve growing the geriatric workforce may address disability by increasing older adults’ access to medical and social service providers with expertise in improving physical, cognitive, and social functioning, as well as improving quality of life. Addressing ageism and building age-friendly communities that use strategies to integrate older adults into society and promote social participation hold promise as universal prevention strategies. Ultimately, effective suicide prevention strategies for older adults must focus on improving quality of life as well as preventing suicide: strategies such as psychotherapy and medication for psychiatric disorders must be supplemented by prevention strategies for older adults give at all ages in addition to treating psychiatric disorders and suicidal thoughts is needed to address the problem of suicide in later life.
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A Systematic Meta-Review of Internet-Based Cognitive Behavioral Therapy (ICBT)
Quincy J. J. Wong, Alison L. Calear, and Helen Christensen
Internet-based cognitive behavioral therapy (ICBT) is the provision of cognitive behavioral therapy (CBT) using the Internet as a platform for delivery. The advantage of ICBT is its ability to overcome barriers to treatment associated with traditional face-to-face CBT, such as poor access, remote locations, stigmas around help-seeking, the wish to handle the problem alone, the preference for anonymity, and costs (time and financial). A large number of randomized controlled trials (RCTs) have tested the acceptability, efficacy, and cost-effectiveness of ICBT for anxiety disorders, mood disorders, and associated suicidality. A meta-review was conducted by searching PsycINFO and PubMed for previous systematic reviews and meta-analyses of ICBT programs for anxiety, depression, and suicidality in children, adolescents, and adults. The results of the meta-review indicated that ICBT is effective in the treatment and prevention of mental health problems in adults and the treatment of these problems in youth. Issues of adherence and privacy have been raised. However, the major challenge for ICBT is implementation and uptake in the “real world.” The challenge is to find the best methods to embed, deliver, and implement ICBT routinely in complex health and education environments.
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Thought Suppression
Christine Purdon
The idea that suppressing an unwanted thought results in an ironic increase in its frequency is accepted as psychological fact. Wegner’s ironic processes model has been applied to understanding the development and persistence of mood, anxiety, and other difficulties. However, results are highly inconsistent and heavily influenced by experimental artifact. There are a substantial number of methodological considerations and issues that may underlie the inconsistent findings in the literature. These include the internal and external validity of the paradigms used to study thought suppression, conceptual issues such as what constitutes a thought, and consideration of participants’ history with and motivation to suppress the target thought. Paradigms that study the products of failed suppression, such as facilitated recall and attentional deployment to thought relevant stimuli may have greater validity. It is argued that a shift from conceptualizing the persistence of unwanted thoughts as products of failed suppression and instead as internal threat stimuli may have merit.
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Twin Methodology in Psychological Studies
Darya Gaysina and Ellen J. Thompson
Psychological traits, including temperament, cognitive functions, and emotions, vary between people. The key aim of twin studies is to investigate the role of genetic factors (nature), environmental factors (nurture), and their interplay, in individual differences of various traits. In the last few decades, the classical twin design (i.e., univariate twin studies and multivariate twin studies), as well as other types of twin studies (e.g., children of twins studies) have been widely used in investigations of psychological traits. Importantly, large-scale twin studies have been established in different countries around the globe, and they have facilitated nature and nurture investigations across different geographical, social and cultural settings. However, when interpreting findings of twin studies, specific methodological assumptions and limitations need to be considered. For example, the equal environments assumption (EEA) suggests that similarities for both monozygotic and dizygotic twin pairs reared in the same family are roughly the same, but this may not always be the case.
Among the most important findings of twin studies of psychological traits is the establishment of relative contributions of genetic and environmental influences on health and behavior. Substantial contributions of genetic factors have been demonstrated for many psychological traits, but none of the studies psychological traits is 100% heritable. Also, twin studies have demonstrated that genetic effects can be modified by sex, age, as well as by environmental influences. Moreover, our genetic makeup can shape our environment. Taken together, studies using the twin design have made the significant contribution to our understanding of etiology of individual differences of many psychological traits.
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Worry and Rumination
Ed Watkins
Worry and rumination are both forms of repetitive negative thought (RNT) characterized by repetitive and often uncontrollable thinking about negative content. Rumination is typically defined as repetitive thinking about the symptoms, causes, circumstances, meanings, and consequences of negative mood, personal concerns, and upsetting experiences, often with a focus on depressive experience. Worry is typically defined as repetitive thinking about future potential threat, imagined catastrophes, uncertainties, and risks and is conceptualized as an attempt to avoid negative events, prepare for the worst, and problem-solve. Worry and rumination are implicated in the exacerbation of negative mood and negative thinking, reduced central executive resources, impaired problem- solving, and prolonged sympathetic activation and emotional responses to stress and, as such, transdiagnostically contribute to the onset and maintenance of multiple emotional disorders, including major depression, anxiety disorders, insomnia, eating disorders, substance and alcohol abuse, and psychosis. Both worry and rumination are implicated in poor response to psychological interventions—greater reduction in RNT is associated with greater symptom improvement, whereas no change in RNT is associated with no improvement or worsening of symptoms. Rumination and worry appear to be moderately genetically heritable and predicted by environmental factors such as early adversity, stressful life events, and unhelpful parental styles. RNT is a common pathway between multiple risk factors, including neglect, abuse, bullying, and chronic stress, and later psychopathology. Pathological worry and rumination share an abstract processing style, negative biases in attention and interpretation, and impaired executive control and are mental habits. Both worry and rumination have been hypothesized to serve an avoidant function. Interventions that target these mechanisms appear to be effective at tackling RNT, particularly rumination-focused cognitive-behavioral therapy and mindfulness-based interventions. More efficient interventions for anxiety and depression may result from interventions that target multiple of these proximal mechanisms.
