This book is a welcome addition to the practice of psychological therapies with older people, as there is little doubt that mental health services will encounter increasing numbers of older people experiencing anxiety and/or depression in coming years. Psychological therapies such as cognitive-behaviour therapy (CBT) are recommended by the UK's National Institute for Health and Clinical Excellence (NICE) as integral to the treatment offered to all experiencing anxiety or depression. Furthermore, the efficacy of CBT for late-life anxiety and depression has been supported by controlled trials and recent meta-analyses. Despite the plethora of CBT guides and manuals now available for practising clinicians, few provide detailed and up-to-date guidance regarding the practice of CBT with older people.
The early chapters introduce the basic tenets that underpin cognitive therapy, such as recognising thinking biases; conducting a CBT assessment; and ending therapy. James argues cogently that CBT with older people requires specific adaptations to assessment, formulation and interventions in order to enhance its acceptability and outcome. He systematically describes what these adaptations should involve. For example, there is a helpful discussion of how changes in executive functioning affect the experience and presentation of psychological problems in late life, and the associated adjustments to therapy that this therefore requires. A running theme in the book is that to be effective, CBT needs to be conducted in a competent, careful way that is faithful to its core tenets, on the one hand, whilst responding to the specific needs of older people, on the other. Existing models and frameworks that can be used to aid psychological formulation of distress in late life are systematically synthesised. Some perspectives are generic and would apply to therapy with a person of any age, whilst others are specific to an understanding of older people. CBT approaches that can be useful with people of any age, such as the ‘continuum’ technique, are described particularly well.
There appear to be some gaps in James' selected emphases, and although he demonstrates well how generic CBT approaches are relevant to older people, more could be made of how problem complexity and chronicity in late-life depression requires wider-ranging approaches to formulation and intervention. Similarly, whilst the need to include gerontological factors in working with distress in late life is highlighted, the full range of important psycho-social and life-span development issues and their potential to inform CBT with older people are somewhat overlooked. Surprisingly, mindfulness and acceptance-based cognitive-behavioural approaches and their potential use with older people are not discussed in any great depth, and a notable absence is the recent work of Thomas Lynch and colleagues on the adaptation of Dialetical Behaviour Therapy with older people. The author's attempt in chapter 10 to provide a comprehensive approach to the practice of challenging behaviour in dementia runs the risk of over-inclusiveness where the remit of CBT may well have been broadened to include other approaches such as functional analytic interventions.
The later chapters are devoted to the wider application of CBT practice. Helping alleviate challenging behaviour in people with dementia is considered but other complex presentations, such as late-onset psychosis and suicidal behaviour, are not covered. Reflecting the author's background in CBT training, an excellent chapter is devoted to the issue of developing and maintaining clinical competence in CBT practice. The training manual for the revised Cognitive Therapy Rating Scale, which is essentially a guide to the ‘nuts and bolts’ of conducting CBT, is presented in depth as an appendix.
The more experienced practitioner might find the contrasting features of the book interesting. For example, models relevant to formulating distress in dementia, such as the author's Conceptualisation of Dementia Model, are discussed alongside existing more traditionally defined CBT approaches to depression and anxiety, such as the Comprehensive Conceptualisation Framework for Older People (Laidlaw et al. Reference Laidlaw, Thompson, Siskin-Dick and Gallagher-Thompson2003). Similarly, detailed descriptions of change methods in traditional CBT that are likely to be useful with older people are included alongside a chapter describing the ‘Newcastle’ CBT approach to formulating and intervening with challenging behaviour in dementia. This attempt at inclusiveness will appeal to clinicians working with older people in secondary care, where distress in dementia and co-morbidity with depression are commonly seen.
This book is both detailed and accessible. Case material is used well to illustrate the various CBT approaches that are described. Guidance is offered in an authoritative and empirically grounded manner and many of the key issues facing both experienced and trainee CBT therapists working with older people are covered. The book is therefore a useful resource for trainers, clinicians and therapists of all levels of experience. A timely addition to the text by Laidlaw et al. (Reference Laidlaw, Thompson, Siskin-Dick and Gallagher-Thompson2003), due to be updated later in 2011 (see Laidlaw, Thompson, and Gallagher-Thompson forthcoming), this book should be recommended reading for clinicians using CBT with older people, particularly those working in new Improving Access to Psychological Therapies (IAPT) services where training and supervision arrangements may not fully cover late-life presentations and issues of ageing.
