Toward Holistic Care: Integrating Spirituality and Cognitive Behavioral Therapy for Older Adults

Abstract

Based on the particular mental health needs of older adults, this article formulates a theoretical approach integrating spirituality and cognitive behavioral therapy (CBT) for counseling older adults. CBT is easily applicable and highly appropriate for use with the older adult cohort. Its efficacy is well documented, specifically for disorders commonly experienced by older adults. However, as presenting problems of older adults frequently include spiritual and existential concerns, the incorporation of spirituality and meaning-making with CBT is ideal for serving this cohort. This article presents a theoretical approach to spiritually integrated CBT by formulating a modified style of assessment, formulation, beginning therapy, cognitive restructuring, behavior modification, and termination.

KEYWORDS:

• Cognitive behavioral therapy
• spirituality
• older adults
• pastoral counseling

As life expectancy in America increases and the older adult population grows, caregivers in a variety of helping professions are called to understand and address the particular psychological and spiritual needs of the aging. Faced with many life transitions and diminishments, older adults represent an underserved population both spiritually and psychologically. For this reason, this article aims to integrate a spiritual component with cognitive behavioral therapy (CBT), a commonly utilized psychotherapeutic orientation, in an effort to meet the holistic needs of the aging. This approach can be utilized by caregivers of all backgrounds, but is specifically suited to the trained pastoral counselor. Further, this article assumes basic familiarity with CBT although core concepts of the modality will be explained. To accomplish the task at hand, the following three queries must be addressed: (1) What is CBT with older adults? (2) Why should spirituality be incorporated into therapy with the aging? and (3) How can spirituality be integrated within CBT for older adults?

AGING AND MENTAL HEALTH

Prior to examining the use of CBT with older adults, it is necessary to gain a rudimentary understanding of aging and mental health. In America today, older adults do not receive the same mental health services as other generations and thus are generally underserved. The misunderstood and overlooked status of mental health in older adults dates back to the beginning of psychotherapy. In 1905, Sigmund Freud contended that because learning stops at age 50, older adults are not good candidates for psychotherapy (Knight & Satre, 1999). “The legacy of Freud's assertion that older people lack the mental plasticity to change or to benefit from psychotherapy has deterred many potential therapists from working psychologically with depressed or anxious older adults” (Laidlaw, Thompson, Dick-Siskin & Gallagher-Thompson, 2003, p. 21). Freud's invalid contention perpetuated the misconception that “you can't teach an old dog new tricks,” and guided the history of therapy for many decades. In addition to Freud's foundational stereotype, other myths perpetuate negative understandings of psychotherapy with older adults. In addition, many people falsely believe that depression is normal during older adulthood. Therapists may also share this belief, thus normalizing the mental health problems of older adults and, perhaps, failing to provide appropriate treatment. Finally, because depression and anxiety in older adults may be accompanied by physical disability or chronic illness, therapists may understand depression as an automatic response and not as a situation that is treatable.

Despite the myths regarding psychotherapy with the aging, mental health services for older adults are more important than ever. Many factors complicate the treatment received by older adults, including detection rates and insurance and Medicare regulations. It is estimated that around five million older adults in America today suffer from depression alone, without taking into account all other mental health disorders (National Institute of Mental Health, 2007). However, detecting mental illness in the older adult is often difficult for various reasons. According to a report from the surgeon general (USDHHS, 1999), “Primary care providers carry much of the burden for diagnosis of mental disorders in older adults, and, unfortunately, the rates at which they recognize and properly identify disorders often are low.” This is because older adults more often present mental health concerns to a primary physician rather than seeking help from a mental health professional. Thus, the physician is challenged to navigate the muddy waters of extensive somatic and psychological symptoms. According to research, the needs of up to 63% of older adults with mental health disorders are not met due in part to poor detection by the aging themselves and by their primary caregivers (Rabins, 1996).

In addition to low detection rates of mental illness, treatment is often expensive and older adults may not have insurance to supplement Medicare. For those without supplementary insurance, Medicare coverage may render mental health services unattainable. Medicare Part A only covers inpatient mental health services. Medicare Part B covers outpatient mental health services, but at present coverage is only 50%. American Psychiatric Association (APA) Medical Director James H. Scully, Jr. (2005) stated:

It is simply unacceptable to compel patients who receive outpatient mental health services to pay 50 percent of the cost of their care out of their own pockets. Medicare patients receiving other medical care pay 20 percent. This is discrimination, plain and simple.

Due to the increased aging population in America today, legislation must be enacted to end such discrimination.

Based upon this limited introduction to aging and mental health, we now turn to examine why cognitive behavioral therapy is an effective treatment for the mental health care of older adults. First, Laidlaw et al. (2003) contend that CBT is an effective therapy with older adults as it focuses on the here and now, teaches individuals techniques for managing stressors, is a structured and task-oriented approach, educates older adults to self-monitor for mood fluctuations and cognitive distortions, and helps older adults to challenge stereotypes about aging. CBT is also well suited for older adults because the diagnosis is secondary to the formulation. Finally, the therapist and the client work collaboratively toward understanding the client's negative cognitions and behaviors, which lessens any stigma of being labeled mentally ill. This may be helpful for those older adults not raised in the proverbial age of psychology.

In addition, the efficacy of CBT is well-documented for the types of disorders often experienced by older adults. For decades, clinical trials have revealed the efficacy of CBT in treating depression and anxiety, both common disorders among older adults. Depression is one of the most frequent mental illnesses experienced by older adults. “Depression during later life is often referred to as the ‘common cold’ of geriatric mental health” (Laidlaw et al., 2003, p. 43). Although depression is not a normal part of aging, it is widespread. In addition, generalized anxiety disorder is also common in older adults. Anxiety may or may not be comorbid with depression, but “anxiety is among the most prevalent psychiatric disorder in older adults” (Kogan, Edelstein, & McKee, 2000, p. 109). According to a study involving 2,051 adults over the age of 55, 20% of participants presented with anxiety symptomolgy (Himmelfarb & Murrell, 1984).

Finally, CBT is effective in addressing the relationship between mental and physical health, and addressing physical disability and chronic illness because it is not a loss-deficit approach. According to Knight & Satre (1999), other therapeutic approaches focus on the deficiencies of the client, meaning that “the work of therapy with the elderly is to assist in their adjustment to the natural losses of late life and grieving for them” (p. 21). In contrast, CBT does not view losses as a normal part of development simply due to the prevalence of such losses. The goal of CBT is to recognize the significance of a loss and to then optimize functioning through changing one's cognitions and behaviors. CBT offers a more positive psychological model for addressing diminishments in older adulthood such as physical disabilities and chronic illness as opposed to a typical loss-deficits model of therapy.

UNDERSTANDING CBT WITH OLDER ADULTS

Prior to examining CBT with older adults, it is important to briefly illustrate the basic principles of CBT. CBT is a “here-and-now” approach to counseling which posits that our thoughts mediate stimuli and emotion. Therefore, it is not a particular stimulus or event that causes distress but rather our interpretation. Sometimes such interpretations are distorted and do not accurately reflect reality. CBT aims to help the client identify distorted automatic thoughts and related behavioral patterns in order to reframe them. Although CBT is a here-and-now approach, distorted automatic thoughts often relate to our core beliefs which, most often, are deeply embedded from childhood. What is CBT with older adults? CBT with older adults is simply the utilization of a cognitive behavioral therapy approach with any individual over the age of 65. In order to formulate a model for integrated spirituality and CBT with older adults, it is first necessary to explicate how CBT with older adults affects the client's role, the therapist's role, and the therapeutic content.

CHANGES IN THE OLDER ADULT CLIENT'S ROLE

In CBT with older adults, it is likely that the client's needs and role will be slightly different than in therapy with younger adults. Therapists must be aware that when working with older adults there is a higher likelihood of physical problems, limited cognitive capacity, and different life incidences due to the older adult's cohort experience (Laidlaw et al., 2003). Therefore, it is evident that there are cognitive, emotional, physical, and contextual distinctions when working with older adults. First, regarding cognition in older adulthood, the most prevalent cognitive change is a general slowing in cognitive abilities, probably due to slowing in the central nervous system (Knight, 2004). Older adults may also experience changes in their attention, such as the inability to tune out background noise. Working memory, that is the ability to make connections between new and old information, is also affected in older adulthood. Older adults experience a “reduced capacity for abstraction and greater distractability” (Wilkinson, 1997, p. 2). However, in utilizing CBT, Laidlaw et al. (2003) contend that any decrease in cognitive functioning can be overcome through increased attention to the psychoeducational component of CBT.

Therefore, based on the cognitive changes in older adulthood, changes in the CBT model are required. Foremost, the pace of therapy may need to be slower than with a younger adult. “A reduction in the speed of information processing is not a barrier to communication if the therapist reduces the conversational flow of each session, with a greater latency between patient speech and therapist speech” (Morris & Morris, 1991, p. 407). In addition, due to cognitive changes, the therapist may find it helpful to repeat important concepts. “With such a patient, it may prove necessary to present fewer new ideas than usual per session, to use frequent repetition of these ideas, and to elicit frequent feedback to make sure the patient understands and participates in the therapy” (Grant & Casey, 1995, p. 564). A decline in the working memory of the client may also make it necessary to simplify one's language and to avoid the complicated jargon of CBT. Such cognitive changes do not prevent the use of CBT with older adults. Rather, as Knight & Satre (1999) contend, “An important strength of this mode of therapy is the ability to adapt it to different cognitive levels of clients by adjusting the amount of cognitive work done by the therapist” (p. 11).

In addition to cognitive changes, the older adult's emotions may affect the CBT model as well. Older adults experience less extreme emotions, but also more complex emotions. According to Knight & Satre (1999), due to the plethora of older adults' past experiences and the tendency for previous memories to be recalled, the emotions of older adults are likely to include a mix of positives and negatives and therefore are more complex. As such, Knight & Satre (1999) advocate recognizing the multiple positive and negative emotions inherent, and then focusing on problem-solving solutions. They utilize a case study in which a mother feels happy that her daughter is able to care for her, but simultaneously feels that she is a burden. Knight & Satre (1999) write

Rather than considering the cognition about burden as irrational, it may be helpful to construe the daughter's willingness to care as a sign of her love and also to elaborate the observations that lead to concerns about being a burden and to encourage problem solving strategies to limit the burden as much as possible. (p. 13)

By understanding the positive and negative emotions inherent in the same situation, as well as the context of the older adult, therapists can better identify negative automatic thoughts.

Finally, the ecological context of older adulthood is often distinct from the context of other age groups. Foremost, older adults inevitably encounter losses, including death, separation, retirement, and illness. Oftentimes, the losses experienced by older adults decrease their systems of support. “In such instances, CBT focuses on supporting the patient's coping skills. At times, the magnitude of the loss may be a subject of cognitive distortion. Even more frequently, the patient underestimates his or her own ability to cope” (Grant & Casey, 1995, p. 567). In addition, societal conceptions of aging impact the context of the older adult. Through CBT, negative beliefs and stereotypes that are perpetuated by society and thus adapted by the older adult can be challenged and altered.

CHANGES IN THE THERAPIST'S ROLE

As indicated above, it is crucial that the therapist conscientiously reduce the speed of therapy in CBT with older adults, in addition to abandoning confusing CBT jargon. It is also helpful for the therapist to understand the cohort of older adult clients. Therapists must take into account characteristics of the older adult cohort that individuals will maintain throughout the life span, including certain attitudes, beliefs, and aspects of one's personality (Knight & Satre, 1999). By understanding the cohort of the older adult, the therapist is better equipped to assess the core beliefs and automatic thoughts of the client. Gaining an understanding of any cohort becomes much easier through increased exposure with that particular subgroup of humanity. In working with older adults, therapists will also benefit from more thorough understandings of physical illness. This may be difficult for the nonmedically trained therapist; however, exposure to various illnesses will assist the therapist in determining the role of physical limitations in the cognitions of the older adult. According to Knight (2004)

The increased proportion of chronic illness and disability with each decade of life and the increased correlation of the physical and the psychological in later life make it impossible to function without the ability to discuss physical problems and to understand when a problem may have physical causes. (p. 21)

Knight (2004) advocates acquainting oneself with skilled doctors and nurses who can serve as resources regarding specific cases of physical illness. Finally, the therapist may benefit by adapting specific tools and charts for CBT with older adults. Instead of utilizing many of the commonly employed CBT manuals, therapists should look to manuals adapted for CBT with older adults. Tools and homework assignments should be specifically designed to address such differences (e.g., Thompson, Gallagher-Thompson, & Dicks, 1995).

CHANGES IN THERAPEUTIC CONTENT

Older adults often present different content, concerns, and problems in therapy than those of younger cohorts. As is evident throughout this examination, physical disability and chronic illness play a much larger role in CBT with older adults. In addition, the need for life review, or reminiscing, may also be more pronounced in work with older adults. Although the here-and-now approach is a benefit of CBT with older adults, the present must not be the only focus of therapy. “At times, the here-and-now focus should be relaxed, allowing for appropriate life review” (Grant & Casey, 1995, p. 565). It may be counterproductive to limit reminiscing, and talking about the past may allow the therapist to see how core beliefs have operated throughout the life span. Knight & Satre (1999) address the benefits of reminiscence when they write, “With the elderly client, the cognitive therapist may be working on scripts rather than automatic thoughts and in working on editing the life span construct itself, rather than editing schemata about specific social interactions” (p. 14). In addition, if the client is experiencing existential doubts and having difficulty coming to terms with the meaning of her life, reminiscing and life review may also prove therapeutic. Grant & Casey (1995) label this approach existential CBT. They write:

Depressed elderly patients may not realistically be able to evaluate their lives because of the systematic errors in thinking that characterize depression … Existential CBT is used to help the patient to develop a less negative life appraisal … Existential CBT involves assisting the patient in regaining a sense of control, purpose, and self-efficacy (p. 568).

Such an approach supports the client in gaining a sense of mastery over her life, and allows the therapist to help the client to conceive a more realistic life appraisal. Further, reminiscence may facilitate coping with loss. “Reminiscing about life experiences is thought to occur as a precursor of developmental change, and is used to facilitate adjustment to major life changes such as bereavement” (Morris & Morris, 1991, p. 410).

In addition to including life review, CBT with older adults may also focus more on problem solving. Morris & Morris (1991) write, “Elderly people often experience a sense of loss of control over their environment and in problematic situations. For example, physical ill-health, and social and economic limitations can result in a person feeling hopeless or helpless” (p. 411). The increased need for problem solving with older adults results in two changes in therapy. First, just as in CBT with children and adolescents, it is important that goals are modest and attainable. Clients may feel overwhelmed by their problems, and making goals manageable can lessen feelings of helplessness or loss of control. Therefore, realistic and achievable goals help foster a sense of agency.

Second, problem solving in the case of older adults may require collaboration with the client's family, caregivers, and environment. According to Knight (2004)

Most discussions of psychotherapy with the elderly emphasize—and correctly so—the complex nature of the problems faced by elderly persons and the need for intervention in nonpsychological areas of their lives. (p. 40)

Due to the complex needs of older adults, therapists are often more helpful if they are able to combine casework with therapy. This means they must be knowledgeable about local senior services and referrals. Therapists should be willing to consult with the client's family and caregivers toward solving problems and securing services. Therapists may take on more of a role as treatment coordinator with certain older adult clients (Grant & Casey, 1995). Therefore, therapists should be prepared to effectively engage the client in problem solving and to coordinate various treatment options and resources when appropriate.

SPIRITUALITY AND OLDER ADULTHOOD

With a basic understanding of how CBT is modified for use with older adults, it is now crucial to examine the role of spirituality in later life. Simply stated, why should spirituality be integrated within CBT for older adults? To begin answering this query, this article will examine the following four reasons: the importance of spiritual therapy for older adults; the role of holistic care; the spiritual and existential nature of older adults' problems; and the implications of clinical research.

First, the American Association of Pastoral Counselors (AAPC) and the Samaritan Institute (2000) conducted a survey regarding the importance of spirituality in therapy. The impetus for this study was an effort to reform Medicare coverage, thus allowing reimbursement for therapy with pastoral counselors and psychotherapists. These organizations appended questions to a national political survey of one thousand individuals conducted by Greenberg Quinlan Research in October 2000. According to their survey, older adults indicated the need for spiritually integrated therapy. Listed below are just some of the findings:

• 83% feel their spiritual faith and religious beliefs are closely tied to their state of mental and emotional health.

• 75% of respondents say it is important to see a professional counselor who integrates their values and beliefs into the counseling process.

• 75% of individuals over the age of 65 said it is important to them to get assistance from a mental health professional who knew and understood their spiritual beliefs and values, while 63% of individuals over the age of 65 said it was very important.

It is evident that older adults feel that spirituality and faith are an integral part of mental health.

A second reason for the incorporation of spirituality within CBT with older adults is the need for holistic care. Older adults often present complex concerns in therapy that require nonpsychological or problem-solving interventions. Spiritual resources, support systems, and communities represent three sources for providing holistic care. According to Kennedy (2000), “Religious institutions are the most common and widely accessible source of social support for older Americans” (p. 9). Faith communities often offer valuable resources to older adults needing holistic care. However, it is naïve to think that spiritual beliefs and faith communities only contribute positively to the lives of older adults. Such beliefs and communities may play a role in the older adult's harmful core beliefs, and therapists should be willing to holistically engage both the positive and negative aspects of spirituality that contribute to the older adults cognitions and behaviors.

Next, many of the issues and problems associated with older adulthood are inherently spiritual in nature. One's spiritual beliefs are not relegated to an hour on Sunday morning, or to a certain community of believers. Fischer (1998) addresses the pervasiveness of spirituality when she writes:

Spirituality means not just one compartment of life, but the deepest dimension of all life. The spiritual is the ultimate ground of all our questions, hopes, fears, and loves. It includes our efforts to deal creatively with retirement and to find a purpose for our lives after our family has been raised. It concerns our struggles with the loss of a spouse or a move from a home of many years; questions of self-worth and fear of reaching out to make new friendships; the discovery of new talents, deeper peace, wider boundaries of love. All these are spiritual concerns. (p. 13)

Therefore, losses, bereavement, role changes, physical disabilities, chronic illness, increased dependence, and various other aspects of aging are inherently spiritual concerns. By incorporating the spiritual nature of such challenges within CBT, the therapist is better able to provide holistic care and to constructively assist the older adult in developmental changes.

Finally, although the research is limited, there is empirical evidence suggesting the efficacy of spiritually based interventions for psychological well-being (Richards, Berrett, & Hardman, 2006; Dalmida, 2006). L. Rebecca Propst (1996) conducted a study comparing CBT, religiously oriented CBT, pastoral counseling, and a control group. In this study, therapists provided religiouslyoriented CBT “gave a Christian religious rationale for the procedures, used religious arguments to counter irrational thoughts, and used religious-imagery procedures” (Propst, 1996, p. 395). Her findings indicated that religiously oriented CBT administered by a nonreligious therapist proved the most effective intervention, indicating that “the inclusion of religious faith in the therapy process can enhance its therapeutic effects” (Propst, 1996, p. 399). However, in a day and age where more and more individuals identify as “spiritual” rather than “religious,” a treatment modality based upon doctrinal or biblical theologies may not resonate with a growing number of older adults. In contrast to religiously oriented CBT, spiritually based CBT is not limited to Christianity or particular religious doctrines and allows space for existential questioning and meaning-making. Unfortunately to date, research is nonexistent regarding the efficacy of spiritually based CBT (as opposed to religiously oriented CBT) interventions with older adults. Because the empirical efficacy of CBT is one of the benefits of this treatment approach, great need exists for clinical trials to examine the effectiveness of spiritually integrated CBT with older adults.

INTEGRATING SPIRITUALITY AND CBT WITH OLDER ADULTS

The following section aims to identify and then examine how the core components of the therapeutic process must be augmented to formulate a spiritually integrated CBT approach with older adults. To understand the necessary changes in the process and content of this approach, this article examines the following aspects of the therapeutic process: assessment, formulation, beginning therapy, cognitive restructuring, behavior exposures, and termination.

ASSESSMENT

First, in formulating an assessment for spiritually integrated CBT, the therapist must modify the assessment to consider the impact of the client's age and spiritual beliefs. First, the therapist must adapt the assessment toward the older adult client. The therapist engages the client regarding the client's demographics, presenting problem, family background, and personal history in order to arrive at a possible diagnosis and an initial explanation of the client's symptoms in CBT terms. In working with older adults, the therapist needs to engage the client regarding any physical disability or chronic illness. Because older adults often present depression through somatic symptoms, it is important to immediately begin assessing the client's physical as well as mental health. It is also more important to speak to other professionals if the therapist has questions about the physical illnesses of the client. In addition, the therapist needs to gauge the client's functional age in comparison to her chronological age. The therapist may even elicit such information from the client, by asking a question such as, “I understand from the information you provided that you are 72. Do you feel like a 72-year-old?” Incorporating a mental status exam, such as the one presented by Ledley, Marx, & Heimberg (2005), may also prove helpful. In working with older adults it may also be beneficial to speak to other family members, friends, or caregivers in the client's life. This helps the therapist to provide a system of care, and thus provide more holistic help. Finally, the therapist may wish to utilize assessment tools that are designed for older adults, such as the Geriatric Depression Scale (Brink et al., 1982).

Second, the assessment should also include a more in-depth spiritual review. The therapist should inquire about the client's faith/religious background, if any, and what role religion and spirituality play in the client's life at the present. In addition, it is helpful to begin examining what gives the client's life meaning and what activities and people the client finds meaningful. Although it is impossible for one's spirituality to be revealed in one assessment period, it is crucial to introduce the importance of spirituality early and how it will contribute to the therapeutic process. The therapist may choose to utilize spiritual/religious assessment tools, such as the Index of Core Spiritual Experiences (Kass, Friedman, Leserman, Zuttermeister, & Benson, 1991) or the Duke Religion Index (Koenig, Parkerson, & Meador, 1999). Such tools should not eclipse the importance of dialogue, but rather be used in a manner to enhance the client's internal dialogue and to strengthen the interchange between client and therapist. A general spiritual assessment of this kind will introduce the therapist to the client's spiritual beliefs and cognitions which will be instrumental in the application of CBT.

FORMULATION

Following assessment, the therapist works with the client to create a formulation—a theory and an approach to aid in the therapeutic process. Formulation is especially important in working with older adults because it reiterates the collaborative nature of CBT. Laidlaw et al. (2003) write, “Given that older adults may at times feel devalued and unwanted by the value placed upon youth in our societies, this experience can be a powerful agent for change” (p. 39). Because there is no final formulation, the therapist and the client work together toward refining and clarifying the client's problems and constructing helpful interventions. In addition, formulation has inherent spiritual connotations that are important for the therapist to note. Irrespective of belief in God, we are living, breathing, creating beings. Just as we are always changing, always in process, so too are our own problems and the problems of the world. Therefore, the dynamism of the formulation is like our own continual creation. It is important to continue revisiting and reformulating in collaboration toward a better end.

BEGINNING THERAPY

The next core component of CBT is introducing the process. Foremost, in working with older adults an increased amount of pscyhoeducation may be required. “More time is needed in the preliminaries of therapy to explain the rationale for the approach, and to ‘educate’ the patient concerning the process of therapy” (Morris & Morris, 1991, p. 407). Older adults may be unaware of the therapeutic process, and it is extremely important for the therapist to explain the goals and methods of CBT in clear and understandable language. In addition, it is necessary for the therapist to educate the client about the positive psychological approach of CBT, as opposed to a loss-deficit model. The older adult client may feel that the therapist will look for her inadequacies and then fix them, instead of working collaboratively to increase her positive functioning. Throughout psychoeducation it is important that the therapist dialogue with the client and avoid lecturing. Furthermore, at this point the therapist needs to explain homework and discuss the goals. In working with an older adult, the therapist must make it clear that the homework should be manageable, and is not meant to overwhelm or punish the client.

In the beginning, the therapist should also discuss with the client the inclusion of spiritual dimensions. In explaining the use of agendas, the therapist may ask the client if she would benefit from a time of prayer or meditation at the beginning or the end of the session. In addition, the therapist should educate the client on the spirituality of collaboration, one of the core features of CBT. We are a collaborative, communal people, who cannot exist in utter independence. Propst (1988) summarizes the importance theologian Karl Barth places on collaboration when she writes, “True humanity consists of rendering mutual assistance to each other gladly. We must place ourselves at the service of others” (p. 32). This means that both the therapist and the client are changed and affected by working together toward wholeness and healing. In addition, the therapist may emphasize the spiritual role of metacognition, the thinking about one's thoughts. Many spiritual and religious clients are versed in metacognition and may engage in prayer or meditation as a time to reflect on the relationship between a higher power and one's thoughts, beliefs, and actions. If the client engages in such internal dialogue, that may be a tool for the therapist to begin to explain the detection of automatic thoughts.

COGNITIVE RESTRUCTURING

The core techniques of CBT must also be nuanced when incorporating spirituality into therapy with older adults. The two core components of CBT are cognitive restructuring and behavior modification. First, cognitive restructuring with older adults requires education about the myths of cognition in older adulthood. Older adults may reflect the ageist attitudes of society and falsely believe that behaviors and beliefs cannot be changed in older adulthood. Laidlaw et al. (2003) write, “Since older adults may be so accustomed to thinking in certain ways, they may feel particularly unconfident in their ability to ‘change’ their ways of thinking” (p. 70). Laidlaw et al. (2003) contend that Dysfunctional Thought Records (DTR) are an effective tool in working with older adults. However, just as in CBT with children and adolescents, it may be important to spend additional time differentiating thoughts from feelings. In addition, older adults may believe that cognitive distortions are a result of aging. Due to society's normalization of depression in older adulthood, older adults may have internalized this cognitive distortion. Therapists must be aware of the pervasiveness of this cognitive distortion and empower the client to recognize the difference between the situation and her interpretation, her feelings and her behaviors.

Cognitive restructuring must also be reframed due to the integration of spirituality. One way to spiritually approach cognitive restructuring is by fostering a sense of hope. “Therapists are recommended to take a proactive, hope-engendering stance with patients in objectively difficult situations: only if the therapist can honestly convey the belief that things can change through CBT will it be successful” (Laidlaw et al., 2003, p. 72). Engendering hope is an inherently spiritual task. In addition to the effectiveness of modeling hope, the therapist must help the client restructure her cognitions toward choosing to be hopeful. Leahy (1996) explicates an exercise that he terms “Replacing Maladaptive Assumptions with Practical Assumptions” (p. 114). Although he does not employ theological language or the use of hope, this technique essentially helps the client to restructure despairing statements as hopeful statements. Leahy (1996) writes, “Maladaptive assumptions are rigid, demanding, moralistic, and almost impossible to live up to, since it is impossible to be perfect all the time or avoid rejection” (p. 114). Maladaptive statements are despairing precisely because they are impossible to fulfill. In contrast, pragmatic assumptions are based on the hopeful. Leahy (1996) writes

For example, “It would be useful to do a good job most of the time, but it is not disastrous to be imperfect” is pragmatic because it is realistic, adaptive because it still motivates the individual, and it is qualified by “most of the time.” (p. 114)

Pragmatic assumptions are inherently hopeful as they help the client form realistic thoughts and motivate the client to modify cognitive distortions. In addition, Christianity often mistakenly refers to hope only as a projection into the future. However, replacing maladaptive assumptions assists the client in recognizing that hope is in the present. Helping the client to engender hope for the present is a spiritually significant task, and an inherent part of CBT with older adults.

BEHAVIOR MODIFICATION

In addition to cognitive restructuring, behavior modification techniques must also be adapted for spiritually integrated CBT with older adults. “Often it is behavioral experiments that let patients see that change is possible and produce the necessary shifts in patients' conceptual thinking” (Laidlaw et al., 2003, p. 55). Therefore, two key considerations must be made when formulating behavioral experiments with older adults. First, the therapist must be vigilant of the client's physical and mental limitations. In preparing behavioral experiments, it is crucial that the therapist work collaboratively with the client and not ask the client to do anything beyond her physical and mental abilities. This may require consulting a physician if the therapist's knowledge is limited regarding the client's physical abilities.

A second aspect of behavior modification with older adults is the need for scheduling pleasurable activities. Many older adults are socially or physically isolated. Especially during depression, older adults may experience a decrease in pleasurable activities or any activity at all. Therefore, therapists must work with older adults to create an activity schedule that includes multiple pleasant events (PEs). Scheduling PEs with older adults is especially important due to the routines that many adults establish. Older adults may engage in what they think should be pleasurable events with regularity, especially due to increased time with retirement. However, Laidlaw et al. (2003) employ an example in which a woman considered knitting to be a pleasurable activity, and she knit every day. By scheduling knitting as a PE, and then monitoring her automatic thoughts, the woman discovered that knitting made her feel anxious and low because she frequently made mistakes. It is crucial in working with older adults that therapists pay special attention to the planning of pleasurable activities and work with the client to monitor her thoughts during such activities, even if the client is unable to keep a written log.

Integrating spirituality with CBT also impacts formulating behavior modifications. In planning behavioral experiments, the therapist may emphasize the integrative and holistic approach of modifying both one's thoughts and actions. For centuries Platonic thought as well as Christianity advocated a dualism of the body and mind, understanding the mind (or soul) as eternal and superior and the body as merely mortal. As body-mind dualism loses its hegemony over the Western mind-set, one's body and actions become as spiritually significant as one's mind and soul. Propst (1988) writes, “Wholeness is not merely thinking or feeling differently. Wholeness is also choosing, and acting on those choices” (p. 144). One's thoughts cannot change without affecting one's behavior. The therapist may remind the client that wholeness and health are not limited to cognitions, but transcend to behavior and action. Therefore, one way to facilitate the journey toward wholeness is through behavioral changes and experiments. Oftentimes clients experience anxiety regarding behavioral experiences. Such anxiety elevates the role of the mind above the role of the body. Reminding older adults of the integration of body and mind may help them to focus less on the roadblocks within their brains, and to focus more on their holistic abilities.

TERMINATION

Spiritually integrated CBT with older adults also impacts how the therapist and client should begin terminating therapy. According to Laidlaw et al. (2003), in CBT with older adults the therapist must be aware of the importance of the therapeutic relationship in the client's life, the client's other sources of social and emotional support, and the client's possible feelings of fear regarding future distress. To effectively address these concerns, Laidlaw et al. (2003) advocate placing more time, perhaps two weeks instead of just one, between the final three or four sessions. This encourages the client to be self-sufficient, and yet allows continued support. In addition, it is also more important with older adults to schedule multiple “booster sessions” following therapy. It allows the therapist to continue reinforcing the client's new skills, but also gives the client assurance that the therapeutic relationship is not entirely over. The therapist may also want to set aside time in the final few sessions to discuss the client's feelings and fears regarding the end of therapy. It may be affirming and helpful for the therapist to share with the client and recap how much the client has learned. This empowers the client and works to combat ageist myths.

In addition, the therapist and client should review the spiritual implications of terminating therapy. As previously mentioned, the client may despair over the end of such a significant relationship. This is true with clients of any age, but may be heightened when working with older adults if they are socially or physically isolated. The therapist may then want to engage the client regarding the concepts of healing and hope. According to Propst (1996), “Cognitive restructuring could be defined as a type of spiritual transformation of mind” with the end goal of healing and wholeness (p. 394). At the end of therapy, the client is likely to simultaneously experience hope and despair. One way to address the client's despair is to examine how such despair is rooted in unreality. Lester (1995) writes, “People become vulnerable to despair to the degree they separate themselves from reality by attaching their hoping process to fantasy and illusion rather than to reality” (p. 85). Therefore, despair is a form of cognitive distortion. Despair is not based on the experiential reality of the successes and the growth achieved through therapy. In contrast, the therapist may remind the client that hope often begins by witnessing that which is hoped for. Hope is rooted in reality. Capps (1995) writes, “Hope does not appear ex nihilo, it is not created from nothing. For it to occur there must be certain preconditions for it. In order to hope, we must first have experience of trust” (p. 145). The client is then prepared to hope based on the trust and experience of the therapeutic relationship. In approaching the final phases of therapy, it is critical that the therapist and client work together to identify despair as a negative automatic thought, and to then restructure such thoughts toward the hopeful.

CONCLUSION

Due to the increasing number of older adults in America today, it is now more important than ever that we tailor therapeutic approaches to address the specific needs and situations of this population. Spiritually integrated cognitive behavioral therapy with older adults is a holistic therapeutic approach that speaks to both the particularities of aging and the spiritual concerns of older adults. This article provided the basis for beginning to examine CBT with older adults, the rationale for including spirituality in such an approach, and the foundations of that therapeutic process. Although the fundamentals of CBT remain the same, therapists must be sensitive to the particularities inherent in working with older adults and in incorporating spiritual beliefs and values.