Case Conceptualization

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Disabilities and Older Adults Case Conceptualization

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Graduate School of Professional Psychology, University of St. Thomas

CPSY 680-01: Diversity Issues in Counseling

Dr. Gigi Giordano

May 10, 2022

Case Vignette: Counseling Older Adults - Sarah

Assessment/Conceptualization

Sarah’s presenting concerns are clear signs of depression and anxiety seemingly stemming from the demands of her caregiving responsibilities for her husband with Alzheimer’s. She describes her feelings as being overwhelmed, anxious, and very sad about the changes her husband has gone through. Sarah talks about getting angry in response to her husband expressing anger as well as getting upset when he is difficult to care for. Other notable aspects of Sarah’s presentation include that she becomes tearful when speaking about her husband, and she explains that she helps him with daily activities, dressing, bathing, on top of her taking care of all their home management and maintenance upkeep. She also describes not sleeping well at night due to her husband wandering around during the night and having her own health problems including being morbidly obese, with high blood pressure, high cholesterol, and peripheral vascular disease. The main sociohistorical contexts of Sarah’s identity that I am privy to now are the fact that she is an older adult, and caregiver to her spouse. I am unaware of her racial, ethnic, religious, or socioeconomic identities, and therefore cannot take these into account before meeting with her.

Current existing research suggests that given Sarah’s particular presenting concern, and the other aspects of Sarah that I know about, the evidence-based practices to implement when working with Sarah will be cognitive behavioral therapy (CBT), as well as relaxation training such as breathing exercises, progressive relaxation of the muscles, and visualization (U.S. Department of Health and Human Services, 2021). Ayers et al. (2007) conducted a review on evidence-based treatments for late-life anxiety and concluded that CBT and relaxation training had the most support for lessening symptoms of anxiety, whereas cognitive therapy and supportive therapy did not show lessened symptoms in older adults. Trevino et al. (2021) carried out a research study to test effectiveness of different anxiety interventions for older adults with cancer and their caregivers and concluded that a seven-session CBT-based psychotherapy intervention was associated with the greatest reduction in anxiety among the pairs of participants. Although Sarah’s husband has Alzheimer’s and not cancer, this study’s focus on an ill older adult and their caregiver further shows support for using CBT as the primary evidence-based practice in treating Sarah.

Sarah has many strengths and protective factors. A major strength and protective factor is that Sarah has two adult children who live locally and are both involved and supportive of their father’s care, which alludes to Sarah having a close relationship with her two children. Furthermore, she has seven grandchildren who bring her great joy as she states feeling connected to and very proud of. In a population where social isolation is a common stressor and predictor of mental and physical complaints, these close relationships that Sarah has with her children and grandchildren are very important. The case states as well that Sarah is down to earth and has a great sense of humor which both might be serve as protective factors in that her disposition towards others and herself might be light and playful which could lend to forming a therapeutic alliance well and easily with a clinician.

Before finalizing treatment, I would like to know some additional information about Sarah to relieve symptoms and implement intervention best. I would like to ask about Sarah’s involvement in the community, to see if she has support systems other than her family. Any other societal factors affecting her would be beneficial to know as well, such as “recent losses, financial stressors, and family issues” (Sue et al., 2015), and I would also ask about any history of mental health as well as physical health concerns in her family history. If Sarah has had any cognitive testing done through a medical doctor, these reports would be beneficial to see as well. Finally, in getting to know Sarah, I would like to ask about how other salient aspects of her identity come into plan in how she experiences her symptoms, how she views them, and how the people around her view them.

Intervention/Treatment Planning

The main approach I would take in providing mental health services working with Sarah would be a combination of CBT and relaxation techniques. As aforementioned, there are numerous studies showing that CBT is the most effective treatment for anxiety and depression in older adults, which is what leads me to conclude this will be the best option. Other literature states that relaxation techniques such as teaching the technique of progressive relaxation, visualization of calm places and feelings, and breathing exercises to focus on deep, slow breaths is helpful to reduce anxiety and depression. These relaxation trainings will be particularly important for Sarah because she mentions having trouble sleeping, and these techniques are shown to aid in falling and staying asleep. CBT and relaxation training will most likely take place in weekly sessions with Sarah.

In order to show cultural humility, I will make sure that I educate myself on the specific skills needed to work in counseling older adults and evaluate my own inner biases towards older adults. I will also need to make sure I am up to date on the signs of vulnerable adult abuse in case this would come up in working with Sarah. Through getting to know more about Sarah, there will of course be more specific ways to show cultural humility, such as racial and ethnic cultural competency and humility, but for now, I need to involve her in all decisions, and use multiple assessments to learn about her. Finally, I will need to remember how much value Sarah puts in taking care of her husband and be culturally humble when it comes to my own expectations about end-of-life care.

When working with Sarah, to develop rapport and establish a strong therapeutic alliance, I will make sure to show her respect, and give her as much autonomy as possible, because Sue et al. (2015) explains this is paramount to a great relationship with an older adult, regardless of the mental state of the adult and the issues that are being discussed. I will also establish rapport by not focusing the health concerns such on her husband, but making sure Sarah feels like an important and valued individual. I will also maintain a positive attitude and help Sarah to focus on positive emotions such as optimism and resilience (Sue et al., 2015).

Ethical Issues and Advocacy

Potential ethical concerns will be if I am competent to work with older clients, and if I have the opportunity to seek consultation and perhaps supervision if I find myself not confident and/or competent. Other ethical concerns will be making sure Sarah is not being taken advantage of due to her age in any aspect of her life, as she is an older adult. In terms of my own identities and implicit biases, I will need to make sure that I do not speak to Sarah in “elderspeak”, or talk as if she is not very intelligent, or not in the room. There will be a clear age difference, but I will need to not idolize my youth and look down upon her and her age, but rather always be respectful and take her concerns very seriously. And again, once I find out more about Sarah, I will need to check my implicit biases in terms of other aspects of her identity. I have close relationships with older adults, and I adore hearing about the “good ole days” and listening to the wisdom they have to impart on me; therefore, I believe I will be able to easily respect Sarah and see her as a competent, older adult.

Current events that might impact Sarah that I might want to be mindful of would be any research in Alzheimer’s in case she does not have access to her medical provider at a moment’s notice and might not see new information and studies on the caring for her husband. Other current events would be the continuation of the COVID pandemic, because due to her age and poor health, she might want to social distance more than others, and this could come into play with out therapeutic relationship.

I will advocate for Sarah and the issues she faces in helping her to cope with her emotions and stressors but also teach her how to ask for more help from her family members that are in town and help her to get involved (when she is ready) in organizations and groups outside of her home in order to reduce isolation. I will also advocate for possibly getting a nurse to come to her home and take over some of the caregiving duties, again only if she is ready, because her autonomy and decision making will come first. Overall, I will advocate for quality physical care for her husband and herself and do my best to establish rapport and implement intervention effectively.

References

Ayers CR, Sorrell JT, Thorp SR, et al. (2007). Evidence-based psychological treatments for late-life anxiety. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK74481/

Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2015). Counseling the Culturally Diverse: Theory and Practice. Wiley.

Trevino, K. M., Stern, A., Hershkowitz, R., Kim, S. Y., Li, Y., Lachs, M., & Prigerson, H. G. (2021). Managing Anxiety from Cancer (MAC): A pilot randomized controlled trial of an anxiety intervention for older adults with cancer and their caregivers. Palliative & supportive care, 19(2), 135–145. https://doi.org/10.1017/S1478951521000286

U.S. Department of Health and Human Services. (2021). Relaxation techniques for health. National Center for Complementary and Integrative Health. Retrieved May 9, 2022, from https://www.nccih.nih.gov/health/relaxation-techniques-what-you-need-to-know