Definition of Depression

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2 Definition of Depression Depression is defined as having a low spirit and dejection that result in a decrease in force and activity; for the older adult, depression results in interference of activities of daily living (Bishop & Sweet, 2003).

3 Description of Group The psychoanalytic theory will be utilized while working with a group of geriatric adults who are currently residing in a long term care facility and have been diagnosed with depression.

4 Duration of Group Because psychoanalytic therapy is less concerned with short-term problem solving than it is with long-term personality reconstruction, the length of this group will be long term.

5 Intended Group Population Group populations that will be supported during the psychoanalytic therapy sessions are adults aged 65 or older who reside in a long-term care facility and have a current diagnosis of depression. Both male and female sexes as well as cultural and ethnically diverse group members will be included.

6 Developmental Needs of Population This stage of life involves crucial developments such as: Adjusting to the death of a spouse or friend Maintaining personal interests Adjusting to living in a long-term care setting Accepting physical and sensory losses Acceptance of past failures as well as successes (Corey, 2008 p. 144) Increased chance of co-morbidity of physical and mental health issues

7 Implications of Cultural Diversity It is imperative to remember that many cultural groups place a high priority on family history In some cultures, clients are reluctant to discuss their personal issues for fear of being perceived as being weak or disrespectful Some populations fear losing their own cultural world views and cultural identities It is also important to remember that body language can be interpreted in differing ways from culture-to culture (Corey, 2008 p.152)

8 Screening Procedure The screening process will include the integration and utilization of the Geriatric Depression and the Satisfaction with Life Scales. Potential group members will be excluded if they possess active psychosis and/or paranoia (Canete et al., 2000).

9 Rationale for Screening Procedures The Geriatric Depression Scale (GDS) is widely used in clinical and research settings to screen older adults for depression (Adams & Matto, 2004, p. 818). The Satisfaction with Life Scale is frequently used by mental health professionals to gage the levels of life satisfaction in adults (Osberg & McGinnis, 1987, p. 228).

10 Geriatric Depression Scale MOOD SCALE (Short Form) Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO

11 Satisfaction with Life Scale The Satisfaction with Life Scale By Ed Diener, Ph.D. DIRECTIONS: Below are five statements with which you may agree or disagree. Using the 1-7 scale below, indicate your agreement with each item by placing the appropriate number in the line preceding that item. Please be open and honest in your responding. 1 = Strongly Disagree 2 = Disagree 3 = Slightly Disagree 4 = Neither Agree or Disagree 5 = Slightly Agree 6 = Agree 7 = Strongly Agree 1. In most ways my life is close to my ideal. 2. The conditions of my life are excellent. 3. I am satisfied with life. 4. So far I have gotten the important things I want in life. 5. If I could live my life over, I would change almost nothing.

12 Size, Duration and Location It has been determined that the group will consist of 8-15 senior adults. The duration of the group will be approximately one hour, meeting twice per week. The location for the groups will be in a safe, comfortable environment located in a designated secluded location with enough room to accommodate the group.

13 Group Composition All members of this group are voluntary members who are capable of consenting and understanding the informed consent involved in the group development.

14 INFORMED CONSENT FORM Informed Consent I,, have been asked to participate in psychoanalytic group therapy for treatment of geriatric depression conducted by the Social Work Program at the University of Knoxville. Purpose: I understand that the purpose of this group is to reduce the levels of geriatric depression and increase the levels of life satisfaction among older adults residing in a long-term care setting. Duration and Location: I understand the group will be held in the facility that I reside. Further, I understand participating in this group will take approximately 60 minutes of my time two times per week for an undetermined amount of time. Procedures: I will be asked to actively participate in a psychoanalytic group therapy program.

15 Risks/Discomforts: It has been explained to me that a few of the questions may be sensitive in nature due to the politics of agency processes and social history. Benefits: I understand that the benefits from participating in this group may be a feeling of higher life satisfaction and a decrease in the levels of geriatric depression. Confidentiality: I understand that a no identifying information will be used to identify my responses from those of other participants and that my name, address, and other identifying information will not be directly associated with any information obtained from me. If results of this study are published, my name or other identifying information will not be used. In addition, I understand that my honest responses to the questions will in no way jeopardize my current status at the long-term care facility where I reside. Payments: I will receive no type of financial reimbursement for participating in this group..

16 Informed Consent Right to Withdraw: I understand that I do not have to take part in this group, and my refusal to participate will involve no penalty or loss of rights to which I am entitled. I may withdraw from the group process at any time. Signatures: I have read this entire consent form and completely understand my rights as a potential group member. I voluntarily consent to participate in this group. I have been informed that I will receive a copy of this consent. Signature of group member Signature of Witness Signature of leader Date Date Date

17 Therapy Goals The purpose and rationale for this group is to decrease the occurrence of geriatric depression in older adults residing in a longterm care setting. The further goal of group is to add an increased feeling of life satisfaction and fulfillment with the remainder of group member s life.

18 The Developmental Stages of Erik Erikson Stage Age Ego Development Outcome One Infancy (birth to 12 months) Basic trust vs. Mistrust Two Early Childhood (age 12 months to 3 years) Autonomy vs. Shame and Doubt Three Play Age (age 3 to 6 years) Initiative vs. Guilt Four School Age (age 6 to 12 years) Industry vs. Inferiority Five Adolescence (age 12 to 20 years) Identity Achievement vs. Diffusion Six Young Adulthood (age 20 to 35 years) Intimacy vs. Isolation Seven Middle Adulthood (age 35 to 65 years) Generativity vs. Stagnation Eight Later Adulthood (above 65 years) Integrity vs. Despair Figure 1.

19 Rationale for Group Older adults, over the age of 65, constitute 12.8 percent of the population and this population continues to grow; however, there is evidence that older adults are significantly under served with mental health services. Furthermore, there is evidence that older adults are significantly under served with mental health services (Bishop & Sweet, 2003).

20 Rationale Continued Clinical depression among older adults is estimated to be between 18 and 40 percent. Rates of geriatric depression are also shown to be higher in those individuals who reside in an acute care or nursing home setting (15 percent) compared to depression rates of older adults living in a community setting (two to eight percent) and older adults living in a primary health care setting (ten percent) (Bishop & Sweet, 2003).

21 Basic Assumptions It is assumed that group participants perception of life satisfaction will increase It is also assumed that the occurrence and levels of geriatric depression will decrease It is assumed that members will achieve a sense of accomplishment and integrity when completing the group process

22 Leadership Qualification Qualification for leadership include the following qualities: Objectivity Warm detachment Supportive Capable of helping members overcome resistances

23 Qualifications Continued Leaders should be competent in the group process. Leaders should ensure that groups are held in a safe environment. Leaders should understand and adhere to the NASW Code of Ethics. Leaders should be aware of their own limitations and biases. Leaders should be culturally competent. Leaders should be prepared to deal with unresolved issues from earlier stages of life.

24 Role and Functions of the The group leader should: Group Leader Maintain a therapeutic alliance Work out and work through transference reactions Pursue participants unconscious motivations; investigate the historical roots of these motivations through analysis of interpretation Give support Help members face and deal with resistances within themselves Assist members to gain awareness of subtle aspects of behavior (Corey, 2008, p. 131)

25 Role Continued Guides members towards full awareness and social integration Sees the group as a potentially powerful catalytic agent Employs the skills necessary to resolve conflict within the group Sets the tone of emotional freedom Watches for destructive alliances within the group Notices if any group member is becoming an isolate or is otherwise being harmed (Corey, 2008, p. 132)

26 Open Group Therapy The group will be formatted in an open group. This will provide a new stimulation to the group (Corey, 2008 p. 70). This format was chosen because of the long duration of this group, the fragile population supported and the necessity to replace existing members with new members due to deterioration in health or a decrease mental status.

27 Preparation of Group Members Prescreening for suitability for group To evaluate candidates and to determine what they want from the group experience Develop a feeling of confidence between leader and perspective members To determine the mental capabilities of participating in group and understand the informed consent To ensure the understanding of confidentiality The setting of group goals

28 Ground Rules for Group Arrive on time for group sessions Possess a willingness to self disclose Adhere to confidentiality principles of the group No use of inappropriate or impulsive behavior involving comments or gestures All information shared should be available to all group members No firearms or weapons allowed in group Cell phones must be turned off No illegal substances should be used in or before group sessions

29 Group Structure and Techniques Groups will be highly structured with clearly defined tasks. Common Techniques Include: Challenging Confronting Analysis of conflict Transference Counter transference Dream analysis Free association

30 Flexibility of Techniques Cultural competent leadership includes not only having knowledge of cultural differences but exhibiting ways to modify techniques to better support culturally diverse group members. Some members of various cultures are uncomfortable expressing emotions in public. A culturally encapsulated counselor will substitute stereotypes for the real world and disregard cultural variations among group members. Therefore the leader would not confront a member for not opening up in the beginning stages of the group (Corey, 2008, p.54).

31 Therapeutic Factors Dierick and Leitaer (2008, p.214) have described seven clusters of therapeutic factors (out of 28 total scales) that were found to be important not only in psychoanalytic groups, but also other group therapy modalities: 1. Group Cohesion 2. Interactional Confirmation 3. Cathartic Self-revelation 4. Self-Insight and Progress 5. Observational Experiences 6. Getting Directives 7. Interactional Confrontation

32 Psychoanalytic Framework The APsaA states that the psychoanalytic framework stresses the importance of understanding: That each individual is unique, That there are factors outside of a person s awareness which influence his or her thoughts and actions, That the past shapes the present ( /202/Default.aspx)

33 Consideration of Risks and Safeguarding Nature of Risks: Life changes that cause disruptions Hostile and destructive confrontations Scape-goating Harmful socialization among members It is imperative that the leader make all group members aware of the risks of participating in group therapy. The ACA Code of Ethics (ACA, 2005) state that counselors are required to take reasonable precautions to protect clients from physical, emotional or psychological trauma (Corey, 2008 p. 48).

34 Risk Safeguarding Leaders should also make clients aware of advantages and disadvantages of group therapy. Leaders should be aware of members limits, respecting their requests, and developing a invitational style instead of a aggressive style. Leaders should avoid abrasive confrontations and remain non judgmental. (Corey 2008, p. 50)

35 Substance Considerations Due to the fragile population of older adults living in long term care settings and the increase occurrence of co-morbidity of physical and mental issues, in the instance of members arriving under the influence of alcohol or dugs, leaders will consult with clinical nursing staff to determine if behavioral changes are due to side effect of medications. If members are experiencing unwanted side effects concessions will be made to allow members to still participate in group as long as members behavior does not detract from the therapeutic process.

36 Substance Considerations Continued If group members are under the influence of substances that are not deemed medically necessary members will be removed from group and evaluated for future participation in group.

37 Evaluation and Follow-up Evaluation should not be only utilized at the end of the group but should be a part of the group process throughout the duration of the group. Evaluation allow the leader to gauge the progress of the individuals as well as the effectiveness of the interventions being used. Members will be asked to write down the goals and concerns that they have about the group. Members are then encouraged to journal their experience in group and in every day life. Journaling will allow participants opportunities for self reflection and allow the leader to know what members liked and disliked about the group.

38 Follow-up and Topics Discussed Members will be asked to fill out a questionnaire during the post group meeting. Members will be allowed to evaluate the leaders techniques, the impact the group had on members and provide valuable data for evaluating the group process. During the final session a follow-up meeting will be scheduled to discuss the groups experience and to put it in to perspective. During this meeting, the leader will be given the opportunity to evaluate if the members outcomes were realized. (Corey, 2008 p )

39 Bibliography American Psychological Association. (2003). Guidelines for Psychological Practice with Older Adults. Retrieved February 23, 2009, fromhttp:// Bishop & Sweet. (2003). Mental health and the aging population: Implications for rehabilitation counselors. Journal of Rehabilitation, 69(2), l3-18. Bogutz, A. D. Special Considerations in Working with the Elderly. Retrieved February 24, 2009, from BOGUTZ_thumb.pdf. Boston Graduate School of Psychoanalysis (2008). Psychoanalytic Resources. Retrieved February 28, 2009, from Canete et al. (2000). Group-analytic psychotherapy with the elderly. British Journal of Psychotherapy, 17(1), p Corey, G. (2008). Theory and Practice of Group Counseling (7 th ed.). California: Brooks/Cole. Dierick & Lietaer. (2008). Client perception of therapeutic factors in group psychotherapy and growth groups: an empirically-based hierarchical model. International Journal of Group Psychotherapy, 58 (2), 214. Foundation Center (2009). Proposal Writing Short Course. Retrieved March 1, 2009 from Halgin, R. P. & Whitbourne, S. K. (2000). Abnormal Psychology (3 rd ed.). Massachusetts: McGraw/Hill. Leichsenring, F. (2008). Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data. The International Journal of Psychoanalysis, 86(3), MacKenzie, K. R. Professional Ethics and the Group Psychotherapist. American Group Psychotherapy Organization. Retrieved February 20, 2009, from Milton, J. (1996) Presenting the Case for Psychoanalytic Psychotherapy Services: An Annotated Bibliography. London: Tavistock Centre. Morgan, A.C, (2003, December). Practical Geriatrics: Psychodynamic Psychotherapy with Older Adults, Psychiatric Services, 54: Retrieved February 21, 2009, from North Carolina Psychoanalytic Foundation, Inc. About Psychoanalysis. Retrieved March 1, 2009 from Zastrow, C. (2004). Introduction to Social Work and Social Welfare (8 th ed.). Wisconsin: Brooks/Cole.