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Introduction to Evidence-Based
Psychological Treatments
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for Older Adults

Forrest Scogin and Avani Shah

Evidence-based practice (EBP) is here to stay. We make this proclama-

tion despite the controversy that has attended this concept. Psychology is,
after all, an evidence-based discipline, and we should expect nothing less
from the applied arms of our field. In this book, we undertake the daunting
task of summarizing the evidence base for psychological treatments as used
with a particular segment of the population: older adults. Older adults com-
prise a substantial and rising portion of the populace, and thus it is important
that we bring the best available knowledge to bear on the often complex
health and behavioral problems presented by older people.
This book is a continuation of efforts undertaken by the Society of Clini-
cal Geropsychology of the American Psychological Association (APA) to
provide scholars, practitioners, consumers, and policymakers information
on practices that have been systematically evaluated. This information was
first published as a Special Section in the APA journal Psychology and Aging,
in which reviews were undertaken of psychological treatments for anxiety,
depression, insomnia, caregiver distress, and behavioral disturbances associ-
ated with dementia. In this book, we want to go beyond the information pro-
vided in these reviews by sharing perspectives on the implementation of these
evidence-based treatments (EBTs). The authors of those aforementioned

http://dx.doi.org/10.1037/13753-001
Making Evidence-Based Psychological Treatments Work With Older Adults, edited by
F. Scogin and A. Shah
Copyright © 2012 American Psychological Association. All rights reserved.
 reviews are passionate about promoting the best for older adults, and it is with
this intent that we agreed to create this book.
To make the content of these chapters even more valuable to practitio-
ners, we have enlisted as coauthors persons who are actually in the business of
implementing EBTs with older adults. These individuals will tell us about the
challenges and rewards of using EBTs in applied settings. Thus, we hope to
combine that which is at the heart of psychology: the marriage of hardnosed
scholarly evaluation of the evidence base with the realities of using these
interventions with the exigencies that exist in the health care world. You
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may recognize that this is essentially the APA definition of EBP: the synergy
of the best available scientific information with the skills of expert clinicians
in the context of the patient’s values and preferences. Our book is an effort
to dilate this aspirational synergy.
This book is an effort to provide information on EBTs to practitioners
who work with older adults. We would like to provide an overview of the
methods the original task force used to identify EBTs so that this informa-
tion will not need to be repeated in each of the chapters that follow. Five
teams were assembled to review the literature on psychological treatments
for anxiety, depression, insomnia, memory, disruptive behaviors in dementia,
and caregiver distress. These areas were considered the most likely to have
received sufficient scientific attention to warrant review; moreover, these are
problems that are of significance to older adults and those who serve them.
Review teams used a coding manual developed by Weisz and Hawley (2001)
for a wider effort to identify EBTs by APA’s Society of Clinical Psychology.
This manual provided guidance on determining what articles to include in
the reviews and decisional rules on whether a treatment should be considered
beneficial. In a nutshell, for a treatment to be considered evidence based
there needed to be two controlled studies in which the treatment was shown
to be significantly better than a control condition.
Though this task may seem relatively elementary, it was, simply put, a
huge undertaking. Review teams looked over hundreds of articles and provided
detailed coding on about 30 articles on average per team. Many decisions had
to be made along the way, and this is where the collective wisdom of the com-
mittee was invaluable. For example, deciding what was indeed a psychological
treatment was not always easy—for example, whether to include interven-
tions that focus on exercise and respite care (we decided these were not psy-
chological treatments). In the end, it was gratifying to find that a number of
psychological treatments were indeed found to be evidence based across these
disorders and problems, despite our use of a rigorous set of criteria for inclu-
sion. In these chapters, the authors have updated these reviews with studies
that have been published since the 2007 review. Not surprisingly, this did not
change to any substantial extent the status of the earlier established EBTs.

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 In this book, we hope to provide you with information on treatments
that have a substantial evidence base, but more importantly, we hope to
stimulate your thinking about implementing EBTs in your work. To this end,
each chapter has sections prepared by providers on the challenges and ben-
efits of using EBTs. It is rarely so easy as to pull a treatment manual off of
the shelf and apply an EBT from start to finish with unfettered fidelity (and
contrary to popular belief, even in clinical trials). Moreover, we have yet
to see “cookbook” protocols; at best, most provide an outline that must be
filled in by the provider. Patients present with disparate conditions including
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wide variation in cognitive status, complicated medical comorbidities, and

tremendous cultural diversity. As such, clinician expertise and flexibility are
vital. At the risk of repetitiveness, this expertise coupled with the best avail-
able treatment protocols is at the heart of EBP. However, the evidence base
for psychological treatments for older adults is neither deep nor broad. Clini-
cal geropsychology is still an emerging specialty only recently recognized as
such by APA, and the number of investigations that support the efficacy of
our work is fragile. On at least two occasions over the past several years I (FS)
have tried to help colleagues find controlled efficacy data on particular well-
known treatments for common disorders, only to find that we had assumed
such data existed but did not. Thus, we are not naïve in our advocacy for EBP,
knowing that in many circumstances one must work with minimal direction
from the scientific literature. Such shortcomings do not, however, justify a
renunciation of attention to the best available information.
In any discussion of the use of EBTs the following question arises: How
does an individual clinician implement specific interventions with a particu-
lar client, remaining true to evidence-based principles of care while at the
same time tailoring the intervention to the needs of the client? There is no
simple or entirely satisfying answer to this question. Certainly, a first step in
an evidence-based approach is to be knowledgeable of the scientific litera-
ture in a particular area. Accessing this information can be a daunting task
even in a relatively small subarea such as geropsychology. Systematic reviews
and extended presentations such as those contained in this book are helpful.
Another key component we believe is important to addressing this overarch-
ing question is a commitment to an EBP perspective. This means there must
be a willingness to obtain and follow protocols that may not be familiar or
in some cases entirely compatible with one’s predilections. Implementing an
EBT then becomes the challenge.
What principles guide a clinician when faced with implementing an
intervention for an individual older adult within an EBP orientation? One
guiding principle is sagely stated by our clinician coauthor, Mark Floyd, in
Chapter 4; to paraphrase, give the EBT a chance to work and modify when
needed. For example, in using cognitive behavioral therapy (CBT) with

introduction    5
 depressed older adults we sometimes find that clients struggle with the cogni-
tive assignments, such as monitoring thoughts. For others, this is easy and
often very productive. For those that struggle, modification of the protocol
to emphasize behavioral activation and supportive psychotherapy is often a
course of action. We know that both behavioral activation and supportive
psychotherapy are beneficial interventions, and in this way the clinician has
stayed loyal to an EBP perspective.
Other vexing questions arise when engaging in EBP. For most of the
more common presenting problems, there are two or more EBTs. Which one
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should be selected? The quick-and-dirty answer is that it probably doesn’t

matter as long as whatever is chosen is implemented skillfully. The prevail-
ing belief among leading psychotherapy scholars (Chambless et al., 2006) is
that there are small differences in efficacy among various EBTs for similar
problems but that skillful implementation of any particular EBT has large
consequences.
Not to be ignored in this discussion of the use of EBTs is the preference
of the client. Having several EBTs available for a particular presenting prob-
lem allows a presentation of options from which the client can state a prefer-
ence. Of course, presenting options assumes the clinician has the background
to skillfully deliver each treatment. A frequent concern for those implement-
ing EBTs is how to adapt such standardized treatments to the unique clients
that often seek treatment. Tailoring interventions to client characteristics
can lead to better outcomes, but until recently there has been little guidance
on ways of accomplishing this while maintaining the integrity of the treat-
ment. For further information on this topic, we suggest reviewing the work
conducted by an interdivisional APA taskforce (Norcross & Wampold, 2011)
that identified empirically supported methods of adapting psychotherapies
based on various client factors (e.g., patient reactance–resistance, spirituality,
culture).
The chapter authors in this volume share a passion for advancing the
field of mental health and aging. We also have a deep conviction that psy-
chological treatments can provide real benefit to the quality of life of older
adults. In each of the chapters that we briefly overview below, we also provide
information on treatment resources, including training materials and mea-
sures used in conjunction with the EBTs.
In Chapter 2 of this book, Shiva G. Ghaed, Catherine R. Ayers, and
Julie Loebach Wetherell present an overview of EBTs for geriatric anxiety:
relaxation training, CBT, supportive therapy, and cognitive therapy. Clini-
cian coauthors Ghaed and Wetherell discuss their experiences with imple-
menting CBT with older adults in the Veterans Affairs health care system.
Their presentation of “Helen” demonstrates the use of relaxation training
and cognitive therapy techniques in the treatment of generalized anxiety

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 disorder symptoms, such as worry and tension. Anxiety is one the most com-
mon problems seen in community-dwelling older adults, and it is important
that we have solid choices for EBT implementation.
Chapter 3 is a presentation by Haley R. Dillon, Ryan G. Wetzler, and
Kenneth L. Lichstein of EBTs for geriatric insomnia. The previous review
identified two treatments: sleep restriction–sleep compression and multi-
component CBT. Clinician contributor Ryan Wetzler discusses his experi-
ences in using EBTs to treat sleep problems in older patients. Challenges
identified include limited community understanding of EBTs, difficulty
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establishing consistent referral sources, reimbursement challenges, and diffi-

culty applying a research model of treatment to complex clinical populations.
These challenges should resonate with all psychological treatment providers,
and the authors of this chapter provide us with some creative ideas to miti-
gate these difficulties.
Chapter 4 summarizes EBTs for depression among the older popula-
tion. Avani Shah, Forrest Scogin, and Mark Floyd provide information on the
six treatments identified in our review: behavior therapy, CBT, cognitive
bibliotherapy, problem-solving therapy, brief psychodynamic therapy, and
reminiscence therapy. Our clinician collaborator, Mark Floyd, shares his
experiences in implementing EBTs in the home-based primary care system
of the VA. This unique setting provides many challenges and rewards for
EBP, as medical comorbidity becomes extreme and the home environment
forces clinician creativity. Floyd’s commonsense suggestions will be appreci-
ated by clinicians who are interested in working with older adults experienc-
ing depressive symptoms.
Chapter 5 summarizes the evidence base for memory and cognitive
training programs for older adults. George W. Rebok and colleagues present
information on eight memory training approaches to meet evidence-based
criteria. These include association, visual imagery, method of loci, self-
guided training, and relaxation training. Concerns about memory function-
ing are frequent among older adults, and clinicians should be equipped to
provide the best available interventions for the oftentimes very motivated
older adults who are seeking assistance. At the same time, one would likely
encounter questions about recent commercially available technology to
improve memory, which is briefly overviewed in the resource section of this
chapter. As this is an emerging field with few sole clinical providers of cogni-
tive interventions, Rebok shares his clinical experiences in providing cogni-
tive interventions to older adults.
Chapter 6 reviews the evidence for psychological treatments aimed to
reduce behavior disturbances of dementia. This chapter is authored by Kim
J. Curyto, Kelly M. Trevino, Suzann Ogland-Hand, and Peter Lichtenberg.
The clinician perspective is supplied by Curyto, Trevino, and Ogland-Hand.

introduction    7
 Three interventions were determined to meet EBT criteria: progressively
lowered stress threshold, pleasant event scheduling, and simulated presence
therapy. These authors note that the implementation of EBTs for behav-
ioral disturbances are often challenged by level of staff–family support, the
resources available for the significant effort involved in the use of these EBTs,
and the wide variance in the environments in which they are used.
Chapter 7, the final chapter, summarizes EBTs for caregiver distress.
David W. Coon and Dolores Gallagher-Thompson infuse the chapter with
considerable research experience in the area of caregiving while highlighting
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unique clinical experiences within a cultural framework of three clinician

coauthors: Maureen Keaveny, Irene Rivera Valverde, and Shukofeh Dadvar.
They note that caregivers come from diverse cultures, and awareness of their
needs is critical to EBP. The case examples provided in this chapter highlight
the need for cultural consciousness.
These chapters cover a broad range of the problems experienced by
older adult consumers of psychological services. However, there are other
areas that need attention, among them, substance abuse, posttraumatic stress
disorder, and serious mental disorders. Even in those areas with established
EBTs, the need for evidence on a broader range of older adults is a recurrent
theme in this book and many related scholarly pieces. Many talented clini-
cians and researchers continue to advance our field, and it is undoubtedly the
case that future efforts of the sort presented in this book will provide a broader
and deeper evidence base on which clinical practice can draw. In the mean-
time, we can draw some comfort from the fact that our field has advanced
to the point that an array of evidence-based interventions are available for
consideration as we serve our older adult clients.

References

Chambless, D. L., Crits-Christoph, P., Wampold, B. E., Norcross, J. C., Lambert,

M. J., Bohart, A. C., & Johannsen, B. E. (2006). What should be validated? In J. C.
Norcross, L. E. Beutler, & R. F. Levant (Eds.), Evidence-based practices in mental
health: Debate and dialogue on the fundamental questions (pp. 191–256). Washing-
ton, DC: American Psychological Association. doi:10.1037/11265-005
Norcross, J. C., & Wampold, B. E. (2011). What works for whom: Tailoring psycho-
therapy to the person. Journal of Clinical Psychology, 67, 127–132. doi:10.1002/
jclp.20764
Weisz, J. R., & Hawley, K. M. (2001). Procedural and coding manual for identification
of evidence-based treatments. Unpublished manual, University of California, Los
Angeles.

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