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The Elder Interview

The power of psychotherapy in later life: An interview with Dr Liz Forbat and Lorraine-Davies Smith

Getting the support and assistance of a professional family therapist can be an extremely effective way of bringing the family together to talk and listen to each other’s thoughts and feelings. It can be an extremely useful tool when coming to the realisation that a loved one in the family needs the support of a carer. Helping to overcome feelings of reluctance, so everyone is agreed on the next steps.

In this interview, we speak with two leading experts of family therapy, both key members of the Association of Family Therapy, Dr Liz Forbat, Associate Professor of Ageing at the University of Stirling, and Lorraine-Davies Smith, Consultant Systemic and Family Psychotherapist.

Throughout this intriguing discussing, we discuss the principles of family therapy, the impact of ageing on mental health and how to raise the issue of care.

Can you please introduce yourselves and tell us briefly about your roles?

Liz: I’m Liz Forbat, and I’m an Associate Professor of ageing at the University of Stirling, so most of my background is as an academic, as a psychologist and then a research psychologist.

A lot of my focus is around ageing and serious ill-health problems so I’ve done a lot of work in cancer and palliative care but, alongside the academic work, I’ve trained as a family systemic psychotherapist.

I’m really driven by a passion to understand more about people’s difficulties and to find a way of much more quickly kind of intervening and supporting people. Academic research can take 20 years to get evidence and then get it into practice but sitting in a room with a family that’s in distress and having difficulties you can really feel like you can support them to make a difference within 50 minutes or an hour.

So that’s the balance of my interest in them and that’s why I run the two alongside each other. My clinical work is focussed largely around people with serious ill-health problems so that might be things like cancer, it might be other conditions that lead to the need for palliative care.

Lorraine: My name’s Lorraine Davis-Smith, I’ve recently retired from the English NHS where I’d worked for many years as a systemic psychotherapist based in adult mental health, which is kind of unusual because a lot of systemic psychotherapists work in CAMS, in child and adolescent mental health services, but it’s something I really enjoyed.

Across the years, I’ve worked across primary care – what we now call IAPT – which is improving access to psychological therapies through to severe and enduring mental health issues – including personality disorders and schizophrenia, bipolar, and working with families.

Over time, during my career moving from being, well always remaining, a therapist, but also becoming a lead for teams and lead for services and helping to develop new services.

You need some of the humour to engage with people. The relationship you build is so important – both within the family that you’re supporting, but also the relationship between therapists and family.

Dr Liz Forbat, Associate Professor of Ageing, University of Stirling

Tell us a bit more about the work that the Association of Family Therapy (AFT) does.

Liz: So AFT is the association of family therapy, it’s a UK-wide organisation and it provides a number of different things for practitioners and for the public. For practitioners, it provides an infrastructure to set the standards for training for family therapists and systemic practitioners.

It promotes and develops research and supports the professional journal, The Journal of Family Therapy. So very much thinking about standards and how we all practice. Then, for members of the public, it also provides – the website provides – a ‘find a therapist’ function so that members of the public can go in and look for somebody in their local area that can provide a service.

What are the principles of family therapy using systemic practice?

Lorraine: It begins to think about an individual within a network of relationships and these networks are commonly referred to as ‘systems’. That can be a family system, a friendship system, it could be a religious system, a professional system and each system that we’re a member of.

We’re often members of many systems simultaneously. Each system we’re a member of we influence that system by being part of it, but we are also influenced by the system.

So, for instance, in a professional working system, there might be certain expectations of you within that system but equally you’re feeding in sometimes to change the system if things aren’t working through the feedback process.

You’re trying to get to understand where each individual is in the system, where their beliefs and meanings are coming from, and then how they interact with each other member of the system, and that’s how you hope to induce some kind of change – by better understanding each person’s position and beliefs and meanings that they bring. 

At the core of it is this idea of being a non-blaming, non-pathologising type of stance. If somebody or a family comes in distress – there’s a sort of story the family’s built up about somebody being the problem, somebody’s behaviour is the issue. Actually, what we’re trying to look at is the system overall and the interaction between the constituent parts of that system so we’re not looking to blame any one person. That’s something we hold dear.

And the other thing that we hold dear is something called context. Context is about what’s also referred to as the social graces, we’re very keen on thinking about things like gender, ethnicity, age, ability, class, religion, sexuality, and how all those kinds of contextual issues come together and both influence the system that someone’s a part of and the individuals within the system. Without context, someone’s behaviour maybe doesn’t seem as logical as it might then seem once you add context to it.

Liz: For me, systemic practice is a very active form of therapy. I think people sometimes think of counselling or therapy as being a practitioner sitting and doing a lot of nodding and I guess what I see – both for myself and other practitioners –is very dynamic, very interactive, often quite lively, often quite funny like there’s a lot of humour that people bring in.

You need some of the humour to engage with people. The relationship you build is so important – both within the family that you’re supporting, but also the relationship between therapists and family. Also because it’s a very dialogical approach that is very much based on the dialogue and the conversation that you’re having with clients.

How might ageing affect mental health?

Liz: Thinking about older people and mental health problems that might be likely to crop up and warrant the kind of support that a family therapist might offer, I think depression is something that affects people across all age ranges and is often under-diagnosed in older people.

The fact the statistics don’t show lots of lots of older people being diagnosed with depression is more a problem with how diagnoses are managed rather than whether or not there’s a problem there.

Suicide rates actually are higher in older people than they are in younger. I think the kind of messaging that we get about suicide is that it’s a problem for primarily young men but actually the relationship between depression and suicide is a real concern for older people.

The impact of isolation on mental health as people get older, some of the changes in daily living that people have as they grow older, and perhaps are impacted by physical health problems and all of those things can really impact and make worse people’s mental health and well-being in a way that isn’t so much for concern for other age groups.

The stress of caring can sometimes lead to tension within families. How can therapy help?

Lorraine: They’re going to have had a lifetime of being connected to one another and having ideas about one another and beliefs about one another. As sometimes happens in families, sometimes there is a family member who is the one that you know when we’re in trouble we go to ‘x’ and ‘x’ is always really helpful and somebody else gets the reputation of being perhaps not quite so reliable, always busy with their own life.

Of course, those things can come into sharp relief at the time when somebody’s really ill with a disease where they need to be cared for. And, depending on how able people are to talk about it and say ‘this isn’t okay now I don’t want to be that person that’s relied on, I want some help, I need some help’, that’s when it can go underground and fester.

I think that’s where systemic psychotherapy can be really helpful – in a non-judgmental way to track ‘how do you normally come together around issues?’ ‘How do you normally come together around crises? ‘Is that okay for you all?’ ‘Does it work for you all or do you want it to be different? ‘If it were to be different what room for manoeuvre is there?’

So you’re beginning to get the family system, to reflect on their own processes and think about how they’ve organised themselves up to now and whether it’s the way to go forward or whether a reorganisation is required.

We’re often members of many systems simultaneously. Each system we’re a member of we influence that system by being part of it, but we are also influenced by the system.

Lorraine Davis-Smith, Systemic Psychotherapist

How might dementia impact on the therapeutic needs of families?

Lorraine: In a way, it’s always the issue that brings people together. In this case, let’s say dementia. While there are things specific to that issue that the families might need around understanding some psychoeducation of what’s going to happen, and what’s likely to happen, I think alongside that, again, are still the same kind of processes.

How do we talk about this, as a care system? Whether it’s the family or the families and the professionals. How do we organise ourselves? What are our own internal beliefs about how things should be done? How does that fit with the other members of the care system who might have other ideas?

That’s sometimes where I think in families it can get a little tricky because people are coming at it with different beliefs about the best way forward. How do we communicate our fears in a way that’s okay for me to be vulnerable and say this is what I worry about for the future, and know that people are going to hear that in a gentle and kind way?

While dementia might be the thing that brings people together around something, I think some of the issues that come up would be similar whatever the issue was in a way, albeit I think there are some specific things around dementia that people might need in terms of information and psychoeducation.

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Think your family may need the help a professional therapist?

Visit the Association of Family Therapy. It’s the UK’s leading organisation for family and systemic psychotherapists and practitioners. They support family therapy training and practice standards, promote research, and provides a wealth of information and resources for students, professionals and members of the public.

Liz: If I can add to that, one of the elements Lorraine touched on was the idea of psychoeducation for families. Not all therapists actually are aware of what it means to be working with families affected by dementia.

There is something about therapists actually having their own psychoeducation and understanding what the neurodevelopmental changes are for the individual – and how that might impact the wider family system. Not all dementias are the same.

If we understand dementia to be an umbrella diagnosis under which several other kinds of conditions come, Alzheimer’s and Vascular Dementia being the main two,  then it’s about actually understanding what that means for the family as the condition progresses.

With Alzheimer’s disease what you tend to get is a fairly kind of continuous and it goes on for quite a long time you know people can live with Alzheimer’s Disease for a decade.

With Vascular Dementia what you’d expect to see is more peaks and troughs, with a gradual decline too – as people perhaps have mini-strokes the function would decline over time. And why’s that important and why is the psychoeducation around that important? Because the therapist and the family then need to understand how that’s going to impact on how people.

With somebody with a very steady, long trajectory and change over time it’s going to be really different to somebody who’s been very functionally fit and active and then suddenly has some other kind of catastrophic event to do with aging, so maybe they have one large stroke.

That’s going to change the needs and demands on caregivers and other members of the family and it may well change how the individual living with the diagnosis is able to communicate their own point of view.

There’s a lot of mix up between the bio-psychosocial – the biological, the psychological and the social elements – that really need to be unpicked by people that can hold the distress around what is known and also what’s not known.

Read more on dementia

What has been your professional experience of treating people who have a limited time left, and their families?

Liz: The context of palliative care really chimes with all sorts of other times in which people seek therapy. That could be people struggling with relationships or communication, depression, other kinds of mental health problems.

The thing that makes palliative care a bit different is that people tend to recognise that they have a very limited time to get this right. I think with other therapeutic contexts, there’s a sense that you could probably put it off a bit and if now doesn’t feel quite right then maybe it will feel better in a year’s time to seek help.

Whereas when people are receiving palliative care services – which tends to be in the last months or maybe years of life – people are aware that really they’ve got a very limited time now to try and repair the relational fault lines that have cropped up to date.

That’s a core thing – that sense that there’s no kind of do-overs. You can’t just return to it at another point in time. Another similarity with other areas is this idea that you’re looking at the next generation, with a limited time to fix things or to attend to whatever’s going on in the here and now. 

There’s also the dying person’s sense that they want to leave a legacy of having managed and sorted out whatever’s happening.I say that’s the dying person but actually the surviving people might also have that as their frame of reference.

If a family member struggles to accept they need care or help, how can families best approach that?

Lorraine: First of all, who’s the person that’s making the decision a person needs help? It’s really hard to be told that you need help if you haven’t arrived there and, sometimes, people don’t arrive there because maybe there’s a cognitive issue – such as dementia – where they really struggle to see themselves in that way. 

Maybe they haven’t arrived there because of their self-identity. I can remember my friend’s mum saying to me when I was about 19 she says ‘the strange thing about ageing is you know inside I’m still 19 just like you are but then I look in the mirror and somebody else looks back at me’.

There’s this internal identity that we have. Even though physically things may be changing, maybe who we experience ourselves as doesn’t change quite as quickly.

That leads me to think about who this person was in their younger life. You know, were they the go-to person to help others? It takes a huge shift then to suddenly become the person that’s accepting the help in terms of your self-identity.

What’s the meaning of accepting help? Do they have something from their history, where a favourite auntie, a parent, got to the point where they needed help and they died very quickly after that and so is there a fear underneath accepting help which says if i go down this road i know what might be next and i’m not ready for that?

Again, for me, it’s always unpacking trying to understand what’s underneath the behaviour. What are the beliefs that are informing the behaviour, what’s the meaning given to the behaviour?

Rather than taking a position of – you’re just being really awkward, you need help and you won’t accept it and I’m getting really irritated now. That doesn’t actually help anyone. For me, it’s always looking for what’s behind the behaviour, what’s feeding the behaviour, rather than seeing the behaviour as wrong.

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Mental and health and loneliness in later life

  • Depression affects around 22% of men and 28% of women aged 65 years and over, yet it is estimated that 85% of older people with depression receive no help at all from the NHS.
  • 17% of older people have contact with those close them less than once a week. 11% report this contact is as infrequent as less than once a month (Age UK, 2015).
  • 24% of people aged 50+ living in England feel lonely some of the time. 7% – 1.4 million people –feel lonely often (Age UK, 2018a).
  • 2 million people aged 50 and over in England are projected to be lonely before the end of the 2020s if efforts to tackle loneliness are not made (Age UK, 2018a).

Liz: I suppose the only other element is about reciprocity. I think there’s sometimes a danger that, socially, we get into this idea that older people need stuff and they receive and younger generations give stuff. Actually, relationships don’t really work like that and over the history of a relationship and in almost any given sort of year or month, there is a back and forth and there is a reciprocal exchange.

I think that there is that part of working with families to think about what’s still being given and received rather than just seeing it as a one direction transaction. 

What’s the importance of home for people, especially as they contemplate care?  

Lorraine: What came to my mind, Liz, was that very basic principle of Maslow’s Hierarchy of Needs. I don’t know if your readers or yourself are familiar with this but it’s the idea that first of all you’ve got to have your very basic survival needs met: food, water, warmth, shelter. Then you need your safety needs met. Then your belongingness needs met.

For many people, their home gives you those basic things. It’s where I’m safe, it’s where I’m familiar, I’ve got all my memories here of my life and what went before. So, it’s a real emotional wrench as well as.

I think of fear coming in and I think any time we activate fear people lose the ability to, whatever your age, not just elderly people, to think logically because you’re driven by the emotion of fear and loss and almost trauma at that stage.

For me, before you foist something on somebody, it’s about really taking time to understand with them what would they need to take with them to help them remain connected and feel safe.

What would need to be in place to help that move? Maybe if we waited three months would it be easier than doing it right now? Is it safe to do that? If they’re not well maybe it’s not safe to do that? Those are the kinds of ideas that come up for me.

There’s often a lot of emphasis on talking and not so much emphasis on listening and often what happens in therapy is we learn the skill of really listening to each other.

Lorraine Davis-Smith, Systemic Psychotherapist

Liz: There’s something about loss tied in all of this. If you’re thinking about somebody transitioning from their own home into a care facility. Even if it’s supported living but they’ve had to go from a three-bedroomed house to a one-bedroom apartment, there’s a huge amount of loss tied up in the bricks and mortar, maybe the garden, how you hang your things around the house.

People will be watching this video thinking about and interpreting what they can see behind the video in each of us. Interpreting things about people’s identity and importance in relation to that.

Even though we don’t often consciously think about how we look, or the things that are around us, when you start picking somebody up and putting them into a new environment, all of those losses which are also tied up in overall loss, the ultimate loss of your own death, it just becomes amplified.

I think that’s some of the stress that people get hung up on – the idea that maybe a photo or two in the care home will link you back to your family and the people you love. When, actually it’s not really just about that.

Lorraine: I was thinking about this in relation to my mother, who a number of years ago, through her own free will, decided to sell her house move into supported accommodation.

She’s got a flat of her own that’s within a block and there’s a warden who lives in there. There was something about that transition, because she did it voluntarily, that she’s really at peace with. It made me think about what happens when you’re asked to do any kind of transition and you’re not ready for it and it’s not voluntary.

If somebody came to any of us tomorrow and said ‘oh and by the way in three months time you’re moving by the way and you’ve got no choice in this’ I guess we’d have quite a difficult reaction to that. Why would we expect somebody, just because they’re a few years older, to have a different reaction? You know it’s a big thing isn’t it?

Albeit I know it’s done for very good reasons sometimes and for people’s safety. There’s something about walking in someone else’s shoes through the process and understanding it from their perspective.

Read more from the Elder Magazine

What are some key signs for families, that it might be time to access therapy or outside help? 

Lorraine: Every family will have a different level of tolerance to conflict. Some family members, some families, work in a way that everything’s always incredibly polite but actually underneath that there’s a lot of unsaid stuff.

It means they don’t come into therapy when there’s a conflict, they often come into therapy when somebody might be showing some kind of physical symptom because the stress is too much but it’s not getting spoken about.

For other families, they’re much more out there but the conflict can then rise quite high. Different families will have different ways of knowing whether when they’ve reached their limit of what they can do without a neutral person to help. Help them to get a better understanding and to talk about things more openly.

There’s often a lot of emphasis on talking and not so much emphasis on listening and often what happens in therapy is we learn the skill of really listening to each other.

When we really listen to the other people we get a better understanding of why they’re behaving in the way they’re behaving, or how they’ve arrived at the opinion they’ve arrived at or the position they’ve arrived at.

Once we have some understanding that often makes us more open to being able to find solutions because suddenly it’s moved from a position of obstructiveness to a position of ‘oh I get it now, I understand that now, oh well let’s see what we can do about that’. Listening is probably the greatest gift that therapy gives people sometimes.

One of the most important things that older people, or families that are worried about older people, can do is to think about what kind of connectedness they can have in place for the older person.

Dr Liz Forbat, Associate Professor of Ageing, University of Stirling

Liz: Different people will need different things. Most people won’t need a highly specialist psychotherapist to support them. The vast majority of the population manage on their own.

The majority are going to support themselves and each other they’re going to track along okay. A smaller proportion of people are going to probably need some low-level kind of support – may be peer support, other caregiver groups, maybe other groups for people supporting those with certain conditions, that kind of thing.

And then there are likely to be the people that would most benefit from highly specialist therapists. Those people, as Lorraine’s indicated, are most likely to be the ones that engage in conversation in more of a kind of overtly distressed way, where there’s maybe hostility or a pattern of kind of sullenness that gets in the way of full communication.

There have been some research studies done in palliative care to look at triaging and prioritising people and to understand what proportion fit in each group. For family therapy support but also for bereavement support, you’re really looking at 5% of people. So, I guess if readers, listeners are wondering if they fit in that group then it’s about whether or not they’ve tried any of the kind of informal peer support type stuff.

If that’s not really met their needs, then they should refer themselves, speak to the GP, perhaps to look at escalating that to get more sophisticated support. 

Lorraine: And Liz, you’re based in Scotland I’m in England. I know from experience that actually accessing that kind of support is very very limited in England, I don’t know if it’s different in Scotland?

We’ve been set up with the NHS which is fantastic and marvellous, they’re interested in diagnosis and families in distress is not – at this moment in time a medical diagnosis. 

What happens in my experiences is if families are in enough distress, some members of the family, at least one maybe sometimes more than one, will develop some kind of diagnosis whether it’s  stress or depression or anxiety or something of that nature. 

Actually being able to intervene before people get to that point I think would be much more desirable. I don’t know if the system is actually set up to do that so well at the moment. You do get people who, as you say, might go to the AFT website to find a therapist and they pay privately because they feel they don’t want their family to break down in some way or to grow apart in some way.

But I would really want and love to see that kind of help available through the NHS. We’re not quite there yet or or it’s very patchy and very little what is available certainly.  

As people age, how can they best look after their mental health?

Liz: It’s a lot of the same as keeping well at any other age. So – diet, exercise, not consuming tobacco, those kinds of things. But specific to aging, I guess some of the real concerns that you see in the research evidence is around the impact of isolation and loneliness.

One of the most important things that older people, or families that are worried about older people, can do is to think about what kind of connectedness they can have in place for the older person.

So things like lunch clubs or letter writing, or whatever fits with the social context. We’re recording this in July 2020 and COVID-19 is rampant and has really impacted lots of people’s social connections and there’s real concern, a very clear and strong evidence base, that people with reduced social connectivity and increased isolation are at much higher risk of mental health problems, like depression and anxiety.

Above and beyond anything else older people need to be supported to grow and maintain – maybe even increase their social networks. There’s a real paucity, a real thinness of relationships as people grow older and the relationships shrink and shrink and shrink over time. There’s a real need, as individuals, as families and as a community to find ways to support the enhancement and growth of relationships.

Lorraine: I would echo that. Something about those relationships is being across the age range that you know old people don’t just want to talk to other old people as much as that might be enjoyable.

It’s lovely to be around people of all sorts of ages, and especially young people I think. The way grandparents have been cut off from grandchildren at the moment is a real detriment, because of COVID-19, it’s been very detrimental to both age ranges actually.

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