Why try to improve your life if the future is so brief?

Why try to improve your life if the future is so brief?

Young and middle-aged adults are often afraid of becoming old, so it is not surprising that they assume people who have already reached their late years are a depressed bunch. Nevertheless, there is no truth to this assumption. Yes, older adults have most likely experienced losses: loss of loved ones, loss of some degree of independence, and loss of the ability to do some of the things they have enjoyed in the past. But as we've said before, there is no great personality change waiting for us in old age. Life circumstances may change, but we do not necessarily change appreciably. However, the fact that personality tends to be stable in important respects does not mean that older people are “set in their ways.” Some people are set in their ways from a young age and stay that way. Yet, many older people think of the future as holding possibilities, just as people in other age groups do. That's why psychotherapy is a valuable option for older people, as it is for younger ones: it can make the future better than the present.

Myth #22 Older adults have given up any hopes and dreams

Having no hopes and dreams for the future implies having no positive expectations and perhaps no vision for a future at all. But before we consider whether older adults have any hopes or dreams beyond the present, let's first look at what social scientists have to say about how people see themselves.

Self-concept is the term that social scientists use to refer to ideas that people have about themselves, or what people think they themselves are like. Although personality traits may remain relatively stable over time (McCrae & Costa, 1997), people can and do modify their self-concepts when they perceive that changes are occurring as they navigate the adult years. A self-concept is not just a general idea about what an individual thinks of himself or herself; rather, a self-concept has numerous components (schemas) that relate to domains as diverse as physical capability, appearance, cognitive/intellectual abilities, creative abilities, social roles, and social abilities. For example, a person can have a schema that he or she is very good at playing a musical instrument and good at making people laugh, but not very good at sports. Over the course of their adult years, individuals maintain an accurate picture of themselves by reassessing, and possibly revising, their schemas as well as reevaluating the relative importance, or priorities, of the schemas that make up their self-concept (Markus & Herzog, 1991).

It is safe to say that we have a variety of schemas when it comes to thinking about ourselves in the past (e.g., I was an excellent athlete when I was younger). We also have schemas about what we are like at the present time (e.g., I am a better athlete than most people my age). Furthermore, we have schemas about what we think we will be like in the future (e.g., I may not be as good at sports as I am now, but I will continue to be an active person as long as I can – so I'll probably be a better athlete than you). Future self-concepts have been termed possible selves (Cross & Markus, 1991), and they consist of schemas about what we hope we will be like (hoped-for selves) and perhaps also about what we are afraid of becoming (feared selves) in the future.

What about possible selves in late life? Do possible selves just disappear when the future seems foreshortened? Smith and Freund (2002) studied transcripts of interviews conducted over four years in which individuals aged 70 to 103 expressed their personal hopes and fears for the future. Even the oldest individuals showed evidence of dynamic possible selves, with schemas added and deleted over the four-year time period. However, in contrast to the possible selves of young adults, those of people over the age of 60 often have less to do with occupation and career and more to do with health, physical functioning, and leisure pursuits (Cross & Markus, 1991). For older adults, a hoped-for possible self might be the independent self and the healthy self; a feared possible self might be the dependent self or the unhealthy self.

Possible selves motivate individuals to do things that they think will bring them closer to their desired goal. But once again, possible selves include not only what people would like to become but also what they are afraid of becoming. For example, as a young or middle-aged adult, you might hope to be successful, rich, and loved. Therefore you will likely engage in activities and interactions that you think will improve your chances of achieving these goals. You might even have a specific hope, such as becoming a famous chef, in which case you will be motivated to work long hours perfecting your skills. Perhaps you will even be willing to spend the time and bear the expense of attending culinary school in order to realize this goal. With regard to feared possible selves, you might be afraid of becoming homeless, incompetent, or alone, in which case you are likely to engage in activities that will minimize these possibilities.

Older adults are no different from any other age group – they also envision possible selves. They too hope for success, but this hope is more likely to be associated with being healthy and maintaining independence or possibly continuing to enjoy a specific activity. Once again, hopes motivate behavior. For example, older adults who want to realize a hope of maintaining their independence by continuing to drive might take senior driving classes to maintain their driving skills (and lower insurance rates at the same time!). To realize the hope of maintaining physical mobility, they might take an exercise class. To realize the hope of maintaining cognitive skills and/or a social network, they might participate in playing bingo or chess. By working to realize these hopes, they will also be maximizing the chances that feared possible selves will be held at bay.

In sum, can we say that older people have no hopes or dreams for the future? Absolutely not! If they did not have hopes and dreams, how could they hold possible selves in their consciousness? Why would they engage in behaviors that they think will help them realize their hoped-for possible selves and minimize their feared possible selves? We cannot help but believe that older people are as conscious as anyone else that the future is coming, that they will be there to see it, and that they hope it will turn out well.

Myth #23 Older people are set in their ways

We frequently read or hear that older people are set in their ways. For example, on a website meant for people about to become caregivers for older adults, we found the following bit of advice for adult children who may be planning to move back in with their parents:

Will you be happy as “second fiddle” when it comes to managing the house? This will be their home, not yours. Many seniors become more stuck in their ways with every passing year. If moving an ottoman to prevent a fall will involve major warfare, what do you predict will happen when serious decisions need to be made? Will you have an equal voice? (http://www.eldercareteam.com/public/579.cfm)

Even advice for professionals reflects the existence this myth. According to the American Psychological Association (2013), Guidelines for Psychological Practice with Older Adults, those who deliver psychological services are reminded to be aware of the inaccuracy of negative stereotypes such as “older adults are inflexible and stubborn.” Apparently, the authors of this APA advice presume that even some professionals hold the stereotype of older people being set in their ways.

Let's begin by approaching this myth in the context of McCrae and Costa's (1987) Five-Factor Model, which was introduced in Myth #17, “Older people are hypochondriacs” (see Table 3.1). The factor directly relevant to the present myth is O, openness to experience. Being high on O would mean possessing traits such as being open to fantasy (e.g., having a vivid imagination), being open to aesthetics (e.g., appreciating art and beauty), being open to actions (i.e., willingness to try something new, being open to variety), and being open to ideas (e.g., valuing new knowledge, having curiosity, and having a broad range of interests). Recall that based on the FFM, we don't expect much change in these traits over an individual's lifespan; if so, older adults should be no less open to experience overall compared with younger adults.

Nevertheless, it is important to consider that beyond young adulthood there are probably fewer choices a person can make – there may be reduced opportunities to go down an entirely new path. Increased responsibilities, declining employment opportunities, and commitment to long-term relationships could well limit the array of options that are readily available. Thus, it follows that, as with extraversion, openness to experience may show some degree of absolute decline once individuals move beyond their younger years.

If “set in their ways” means being unwilling to try new things, there is certainly considerable evidence to the contrary for older adults. Huge numbers of older adults take advantage of extensive travel offerings, both national and international, which are sponsored by the AARP and other organizations. In addition, there is a high demand among the older population for educational programs sponsored by organizations such as Road Scholar. In 2010 alone, nearly 100,000 older adults participated in Road Scholar programs. That organization did a survey, and 90% of participants reported that they learned something new, 85% met interesting fellow participants, 45% were revitalized by their program experience, 25% stepped outside their comfort zone, 20% had their perspective on the world changed, and 15% fulfilled a lifelong dream (Elderhostel, 2010). Osher Lifelong Learning Institutes (OLLI) sponsor courses for older adults who, after years of long hours spent in the workplace, are grateful to finally have time to satisfy their curiosity for learning about new things and meeting new people.

When people think about older adults as “set in their ways,” they may have in mind a tendency for older adults to prefer to accomplish tasks using a method they are accustomed to. This could mean wanting things to be done “just so” around the house. It is possible that openness doesn't change in a basic sense, but perhaps life is a bit easier if routines are observed. After all, being open to new experience doesn't mean being open to flagrant disruption. When physical strength is waning, it might be a relief to get the house back in order after the grandchildren return home. After traveling to sightsee or visit, it might be a relief to come home and find one's favorite soap and shampoo where they belong. This is a matter of conserving one's resources, although it might look a bit like being resistant to change. Likewise, after preparing pot roast the same way for years, and noticing that everyone seems to love it, many people just might not be interested in trying a new recipe. After all, if it doesn't itch, why scratch? The same can be said for sticking with a favorite restaurant that offers good-quality food on a reliable basis. Especially if one is on a budget, the guarantee of a satisfying meal, as opposed to a disappointing one at a new eatery, could be particularly appealing. Furthermore, it is important to consider that older adults have likely been doing things a certain way for a much longer time than younger or even middle-aged adults have. Thus, switching to something new amounts to reversing a longer history of certain preferences or ways of doing things.

What about being easily persuaded? Strictly speaking, people who are set in their ways should be difficult to persuade. In contrast to what might be expected, Eaton, Visser, Krosnick, and Anand (2009) found that older adults are actually more open to persuasion than are middle-aged adults. This finding runs counter to the idea that older people are more set in their ways. Attitude strength is another aspect that could be viewed in light of being set in one's ways. Attitude strength is the extent to which an attitude is durable and impactful. Strong attitudes would seem to be a hallmark of individuals who are set in their ways. Even so, Eaton et al. found that attitudes seem to be strongest in middle age, as is resistance to attitude change. Eaton et al. suggest that social roles could be a partial explanation for this phenomenon; midlife is the time when people occupy powerful roles at work and in the community. Middle-agers make many of the decisions, and they are influential in defining social norms. As those who are in power, they are expected to be resolute, to hold firmly to their views. Eaton et al. point out that managers are more likely than subordinates to endorse having definite opinions. They would rather be stubborn than wishy-washy. As well, individuals like to see resoluteness demonstrated by individuals who are in power. People are encouraged to vote against politicians who flip-flop on issues: “He was for it until he was against it.”

Before leaving our discussion of the myth that older adults are set in their ways, we are obliged to consider the following reality: events that occur with increasing frequency in older adulthood often require a change in perspective and in many cases drastic life changes. Retirement from the workforce requires a revamping of daily life and possibly developing a new identity. Widowhood necessitates radical changes, especially after decades of living as half of a couple. The loss of good friends and relatives, either through death or through their or one's own relocation to a new community or new living arrangement, can also represent a dramatic change in an older adult's social network. Finally, health issues can necessitate major revisions in lifestyle (e.g., necessary changes in diet and changes in the ease of mobility). If they were so set in their ways, how would it be possible for older adults to deal with all the changes they face? As far being able to adapt to major life events that require unfamiliar ways of thinking and living, older adults are probably at the head of the class!

Myth #24 Growing old is depressing; no wonder older people are more depressed than younger people

Depression is a word that is used in more than one way. Lay people tend to use it freely to refer to everything ranging from having a mild case of the blues to harboring suicidal thoughts. In a study carried out in 26 countries (Chan et al., 2012), 3,323 participants rated old persons as being more depressed than any other age group. It seems clear that the perception people have that older adults are depressed is widespread.

When mental health professionals use the term, they distinguish between major depression and other depressive conditions. Major depression interferes with a person's ability to function normally. The person with this disorder can't work or study, sleep or eat as usual, or take pleasure in activities that were previously enjoyable. Most other depressive conditions are less severe, and though they can have a negative effect on quality of life, they are not disabling.

According to recent statistics from the Centers for Disease Control and Prevention (CDC, 2010), at a given moment in time, 4.1% of the U.S. population suffers from major depression and 5.1% from other depressive conditions. However, the statistics for the age 65+ group are lower than that, 2.1% and 4.8%, respectively. The group with the highest prevalence of any type of depression is aged 18 to 24, and for major depression it is those aged 45 to 64.

Mojtabai and Olfson (2004) examined the 12-month prevalence (rather than at a given moment) of major depression in nearly 1,000 community-dwelling adults who were aged 50 and over. These individuals were part of the U.S. Health and Retirement Study sponsored by the National Institute on Aging. Among these people, the rate of depression declined with age: 9.2% for ages 50 to 54, 7.7% for ages 55 to 59, 5.6% for ages 60 to 64, and 4.0% for 65+. The prevalence was somewhat higher than the CDC (2010) estimates, but that can be accounted for by the fact that over a period of one year there is more diagnosis of depression than there is at a single point during that year. Also, different diagnostic instruments can affect estimates of prevalence. Regardless, it appears that the diagnosis of major depression declines in community-living adults aged 50 and older.

We admit that it is surprising that older adults are not more depressed than they are. Their lives seem to have more depressing elements than those of younger people. Even researchers can be surprised: Mojtabai and Olfson (2004), who studied depression in that national sample we just mentioned, state that “in view of the personal losses, physical illnesses, and functional disabilities that commonly befall older age groups, it is surprising that major depression tends to decline rather than increase with advancing age” (p. 630). These authors also found that some correlates of major depression (factors that co-occur with depression but cannot be said to cause it) are similar across the age groups: depression affects predominantly women; people with less formal education; the unemployed; individuals who are separated, widowed, or divorced; and those with lower incomes.

So it seems that the myth that older people are more depressed than younger people is easily busted, at least for the community-dwelling older adults. But is this also the case for those who reside in assisted living facilities or nursing homes? Watson and colleagues (2006) studied 196 residents in 22 randomly selected large and small assisted living facilities in central Maryland. Residents' average age was 86, and most were over 80. Depression in this sample was pretty high: 24% were depressed and 8% were seriously depressed. Unfortunately, only 43% of the residents with depression were receiving treatment for it. People who were depressed were more likely to need help with activities of daily living (ADLs), such as bathing, dressing, and eating. It is not possible to say whether ADL dependency is a cause or a result of depression. These authors note that it has been argued that the two are mutually reinforcing.

What about nursing homes? Levin et al. (2007) studied documented depression in 921 nursing homes in Ohio (76,735 residents). In this group, 48% had an active diagnosis of depression. As in the assisted living sample just described, these folks were undertreated – 23% received no treatment at all. And the situation might even be worse than it sounds: disadvantaged nursing home residents, such as African Americans and those with physical and cognitive impairments, were less likely to be diagnosed, let alone treated. Thus, unless Ohio is especially depressing, nursing homes are where the depressed elderly are living.

In sum, the rate of depression in community-living older adults (who, by the way, are the majority in the older age group) is no higher and may even be lower than it is in younger adults. Thus, growing older is not, in and of itself, associated with depression. Unfortunately, however, those who reside in assisted living facilities and nursing homes are an exception. Perhaps the physical and cognitive disabilities of these older adults, which most likely lead them to reside in assisted living facilities and nursing homes in the first place, give them more reason to be depressed.

Myth #25 Older adults do not benefit significantly from therapy

When people think about psychotherapy, why don't they immediately envision older adults as typical clients? After all, older adults do have myriad issues that would seem to be amenable to therapy – loss, grief, adjustment to new living situations, adapting to physical changes, and so on. Yet there is a myth that older adults don't benefit from therapy. A belief that lurks behind this myth is that older adults are too rigid and set in their ways to be open to change. Yet, as described under Myth #23, “Older people are set in their ways,” there is little reason to assume that older adults are any less open to change than are other age groups. Another aspect of this myth is that mental health care is a limited resource, so therapy should be aimed at younger people, who will have more time to benefit from it.

But is mental health care a limited resource? In actuality, there is no longer any dearth of clinical psychologists or other mental health professionals, so resources are considerably less limited now than they were in the past. Careers in the mental health field are very popular, and many universities have initiated graduate programs or expanded those already offered. Each year, large numbers of students graduate with master's and doctoral degrees in clinical social work, counseling, and clinical psychology. These newly minted professionals are poised to enter the field, but they are vying for fewer jobs, especially those focusing on clients in younger age groups. At the same time, there is increasing realization that the American population is aging – and that mental health practitioners will of necessity have to adjust their views about who will require their services.

Mental health professionals, such as psychologists, counselors, and psychiatrists, all have the option to specialize in working with older people. There are workshops and other training programs that enable mental health professionals with limited experience in this area to gain competence in providing effective services for older adults. Contributing to the greater acceptance of older adults' need for mental health services and the willingness of professionals to treat the problems older adults face is the fact that Medicare, the primary source of health insurance for adults aged 65 and older, now reimburses providers for mental health services more extensively than it used to.

Professionals with expertise in working with older adults have been making efforts to broadcast the mental health needs of this age group (e.g., Cohen & Eisdorfer, 2011). According to Karel, Gatz, and Smyer (2012), approximately one in five adults aged 65 and older, including those who live in the community and in institutions such as nursing homes, meet the criteria for mental disorder, assuming both emotional dysfunction and cognitive impairment are included. It may surprise some people to learn that this figure (one in five) is about the same for younger adults. Although the proportion of the population meeting the criteria for mental disorders does not vary greatly with age, different disorders predominate at different points in the lifespan, with a higher rate of cognitive disorders such as dementia (which we described in Chapter 2) in the older group. Thus, therapists are likely to need specialized training if they work with the older population.

In all fairness, older adults may have received less attention than other age groups in the area of mental health not solely because of the attitudes of the mental health establishment. Older cohorts were not socialized to accept or seek psychotherapy. Unfortunately, some older adults have memories of people they once knew being “locked up” in “loony bins,” and they want no part of it. Many in the older generation assume that only people who are “crazy” need therapy, or that needing therapy is a sign of weakness or shame. For those in the very old group, it can feel unseemly to tell your problems to a stranger, and downright profligate to pay someone to listen.

Thanks to education and general exposure, individuals who are now moving into the older adult age range are more open to the benefits of therapy. In the not so distant future, the idea of “loony bins” (an image fostered so vividly by Jack Nicholson in the classic 1975 movie One Flew Over the Cuckoo's Nest) will no longer be the first thing people associate with mental health practitioners and therapy. Also, baby boomers will not think it is wasteful or embarrassing to tell their problems to a mental health professional rather than just confiding in friends.

A recent article published in the New York Times (Ellin, 2013, April 22) exemplifies the change in older adults' attitudes about therapy. The article describes an 83-year-old retired man who was not clinically depressed but felt he had “emotional issues,” which he wanted to explore with a therapist. For years he had suffered with migraine headaches, and he had experienced the sudden death of his first wife and the loss of a long-term business partnership. He had never considered seeking psychological help when he was younger. But now that he was in his later years, he was finding monthly visits with a professor of clinical psychiatry to be extremely beneficial in helping him improve his relationship with his current wife and with his adult children and grandchildren. He claimed his only regret was that he did not seek counseling earlier in life. This case highlights another reason it can be short-sighted to assume therapy is wasted on older adults – older adults are usually members of a family system. They may not live under the same roof with all their family members, but the state of their health (physical, cognitive, and emotional) does affect other family members. In short, it's never too late for therapy to have beneficial effects not only for someone in advanced old age but also for the larger number of people who are in that person's social network.

What are some problems older adults experience that may warrant treatment by mental health professionals? Older adults may be dealing with unresolved issues from the past, in which case reminiscence therapy could be an effective intervention (Bohlmeijer, Westerhof, & Emmerik-de Jong, 2008; Korte, Bohlmeijer, Westerhof, & Pot, 2011). Reminiscence therapy is an approach whereby older adults are encouraged to review and both re-evaluate and integrate facets of their earlier experiences. If properly conducted by a professionally trained therapist, this process may be helpful in alleviating feelings of depression and sadness not only in community-living older adults but also for nursing home residents (Haight, Michel, & Hendrix, 1998). In addition to unresolved issues from the past, older adults may also be experiencing immediate stressors such as health problems, spousal caregiving, financial problems, loss of loved ones, and having to adjust to new living arrangements. Under such circumstances, properly designed therapy can be highly effective in helping them deal with circumstances that might otherwise seem overwhelming.

In Myth #24 we discussed “Growing old is depressing; no wonder older people are more depressed than younger people.” As we explained there, although older adults do not suffer from depression at any higher rate than younger adults do, it is still the case that depression is probably the most common disorder affecting all adult age groups. Medications are available for this mood disorder, though these can have side effects, especially for older adults who suffer from other health issues and may not do well when additional items are added to an already full medicine chest. Psychotherapy, either alone or in conjunction with antidepressant medication, can be extremely beneficial (Knight, 2004). Even for severe depression, cognitive behavior therapy (CBT) can be highly effective for patients who cannot or do not want to take antidepressant medications but are dealing with stressful circumstances that could well be alleviated with therapy (see Cohen & Eisdorfer, 2011).

Cuijpers, van Straten, Smit, and Andersson (2009) investigated the effectiveness of psychotherapeutic intervention for young versus older adults who suffered from a mild to moderate level of depression. In searching the literature, they found 112 studies (20 of which focused on older adults) that compared people who received psychotherapy with people in a wait-list control group. Overall, psychotherapy was neither more nor less effective for the older adults than it was for younger adults. However, very few of the participants in any of these studies were over the age of 70, so Cuijpers et al. were unable to make a definitive statement about whether therapy would be equally effective for people in an even older age group.

We've heard a lot lately about the benefits of physical exercise for improving mood. Can't older adults just become more active instead of embarking on a costly and time-consuming course of therapy? Pinquart, Duberstein, and Lyness (2007) conducted a meta-analysis on the results of 57 studies that tested the effectiveness of therapy for older adults with depression. Overall, they found that CBT and other non-pharmacological treatments achieved better outcomes with regard to alleviating symptoms than did physical exercise alone, especially for individuals with milder forms of depression. They concluded that psychological interventions seem to be just as effective with people aged 60 to 80 as they are with younger adults.

Despite the growing evidence that psychotherapy can be helpful in treating depression, it is probably not used as often as it could be. Wei, Sambamoorthi, Olfson, Walkup, and Crystal (2005) analyzed Medicare claims from 1992 to 1999 that were filed for older adults diagnosed with depression. They found that the majority of the claims were for pharmacological antidepressants, but only 25% of the claims included psychotherapy. Also, as we noted in our discussion of Myth #24 above, people who reside in assisted living facilities and in nursing homes are vastly undertreated for depression (Levin et al., 2007; Watson et al., 2006).

Anxiety disorders and anxiety symptoms are another problem among older adults that accounts for a sizeable number of Medicare claims related to mental health. Sometimes, though not always, anxiety is comorbid with depression (that is, anxiety exists simultaneously with depression), but in some cases untreated anxiety can precede late-life depression (Ayers, Sorrell, Thorp, & Wetherell, 2007). According to Ayers et al., approximately 10% of community-living older adults suffer from diagnosable anxiety disorders, though the rate could be as high as 20% if those with anxiety symptoms but no specifically diagnosed anxiety disorder are counted. And this rate can escalate among older adults who have physical illnesses. Not only does anxiety have a negative impact on general feelings of well-being, but also it can have negative consequences for physical health (e.g., coronary heart disease) or even the ability to function in daily life. Furthermore, individuals suffering from anxiety often overuse medical services.

Unfortunately, it is not uncommon for anxiety to be treated solely with pharmacological interventions, but these can have a downside – there can be negative effects on cognitive functioning as well as physical functioning, such as causing falls. Thus, it is important to determine whether evidence-based psychological treatments could alleviate anxiety without such negative side effects and at the same time teach older adults skills they can employ on their own. There is less published research on late-life anxiety than there is on late-life depression, but Ayers et al. were able to locate 17 studies on the effectiveness of several types of psychological treatment for older adults with anxiety. The results of these studies indicated that relaxation training and CBT are especially helpful in treating anxiety.

Clearly, therapy for older adults must be tailored to their needs and capabilities. For example, for older adults still in the early stages of Alzheimer's disease, individual counseling can help with their anxiety, depression, and grief. Group therapy may also be beneficial – common problems and struggles can be shared in a discussion guided by a trained mental health professional. In the case of AD, however, older adults beyond the early stage may not be able to benefit from therapy that requires a great deal of cognitive processing (e.g., CBT). In such instances, behavioral therapy may be appropriate and also highly effective. With this type of therapy, attempts are made to manipulate environmental cues so that the individual receives positive reinforcement for engaging in desired behaviors such as feeding and toileting.

In sum, there is every reason to believe that making therapy available to the older adult population is a wise use of resources. Therapy can be effective in helping older adults to maximize their quality of life without the side effects of medications. And there are added benefits – the lives of family members and others in older adults' social network are often improved when older family members and friends are helped.