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rod-long-y0OAmd_COUM-unsplash.jpg ‘Once you’ve been initiated into the Elderly, the world doesn’t want you back. […]. We – by whom I mean anyone over sixty – commit two offenses just by existing. One is Lack of Velocity. We drive too slowly, walk too slowly, talk too slowly. The world will do business with dictators, perverts, and drug barons of all stripes, but being slowed down it cannot abide. Our second offense is being Everyman’s memento mori. The world can only get comfy in shiny-eyed denial if we are out of sight. […]. Us elderly are the modern lepers. That’s the truth of it.’
However caricatural and one-sided, this voice from one of the characters in Cloud Atlas (Mitchell, 2004) vividly conveys how it may feel to be marginalized in modern society. This voice comes to mind when observing the relative lack of older adults participating in clinical research projects, both within the field of psycho-trauma (Pless-Kaiser et al., 2019) and regarding other mental health disorders (Pettit et al., 2017). Due to this state of affairs, until recently, treatment evidence in this field was scarce (Dinnen et al., 2015). In turn, a lack of current treatment research may result in those older adults being under-treated. Despite many clinicians observing and reporting the beneficial influence of trauma-focused psychological treatment on symptoms of posttraumatic stress disorder (PTSD) in older adult patients, age seems to matter. The question is why.
Despite the existence of multiple guidelines for the treatment of PTSD (e.g., American Psychological Association, 2017; Forbes et al., 2020; Lang et al., 2024; Schnurr et al., 2024), gaining access to adequate treatment for trauma-related disorders has been proven difficult for older adults. Three barriers play a role: low recognition of PTSD in primary care settings, reluctance of older adults to use the service of mental health professionals to deal with their problems and persisting and biased assumptions about older adults being insufficiently flexible to benefit from psychotherapy. Due to these barriers older adults’ risk being under-recognized as needing PTSD treatment and being able to engage in adequate psychotherapy.
The first barrier may partly be caused by older adults’ tendency to underreport mental health issues. They can experience their complaints as shameful or as a normal part of aging. In addition, due to the overlapping symptoms in PTSD and other disorders, the problems presented are often misinterpreted as belonging to depression, anxiety, a somatic illness or age-related memory problems. Moreover, general practitioners are not always aware of traumatic backgrounds in the history of their older patients (Ehlers et al., 2009; Van Zelst et al., 2006). As a result, the suggested interventions are ineffective, patients keep complaining and the key symptoms may remain undetected for a long time.
The second barrier is associated with embarrassment to talk about personal problems outside the family and the fear of stigma involving mental health care. If an older patient hears it is considered helpful to meet someone like a psychiatrist, the following reply should not be surprising, “Me telling my worries to a shrink? Are you mad?”
The third barrier is found in a longstanding stereotype that older adults are like “old dogs not being able to learn new tricks”. In the early twentieth century, patients over the age of 40 were assumed to be too inflexible to benefit from psychoanalysis (Freud, 1905). Regarding trauma-related psychotherapy in later life, however, recent case studies, controlled trials and qualitative analyses reported encouraging results (Lely & Kleber, 2022). Unfortunately, the stereotypes, although ungrounded, are persistent and add to the phenomenon of ageism. This term was coined by Butler (1969) as a variation on racism and sexism. Just as racism and sexism, ageism acts like a self-fulfilling prophecy with negative consequences. The self-fulfillment may apply to psychotherapists expecting limited treatment results, but also to the patients’ expectations of what advancing age will bring them (Levy, 2009). Ageism is found to be associated with a higher prevalence of health conditions among older adults, leading to huge economic costs in the USA (Levy et al., 2020).   
A life course perspective allows for connecting childhood, adulthood and later life. Current views on brain development (Cohen, 2005) imply that emotional growth and mental resilience are possible from early youth into old age. This doesn’t alter the fact that specific processes (such as role changes and loss, death of important attachment figures, physical and cognitive changes) burden psychosocial adjustment in individuals. Experiences of disruption and powerlessness – as in PTSD symptoms or somatic crises – may disrupt individual autonomy and burden current resilience. Taken together, in an age of a growing population of older adults, those suffering from PTSD risk to receive less-than-optimally efficacious treatment, which may be considered a research gap as well as a clinical problem challenging both researchers and clinicians. Apparently, age matters.
The key to countering ageism can be found in a careful and flexible application of disorder-specific and age-appropriate interventions (Lely & Kleber, 2022). The individual balance of strength and vulnerability deserves to be considered as a unique constellation, variable over time and situations in each and every individual patient. Offering evidence-based interventions, age-appropriate adaptations can be selected (without impairing exposure), and addressing sensory difficulties, transport barriers or scheduling problems. Personalizing treatment is aimed at fostering self-reflection, the heart of psychotherapy. In all aspects, treatment decisions should be shared, and individual autonomy respected. Listening to the older patients’ (and their caregivers’) voice – their ‘first person perspective’ - may strongly counteract any stereotyping. To address cumulative traumatic memories or adverse experiences through different life stages, a life-span perspective is useful, such as in Narrative Exposure Therapy (Schauer et al, 2011). Finally, personal resilience should be addressed, as well as the social environment (Lely & Kleber, 2022).
The emerging body of evidence suggests that conducting treatment research with older adult trauma survivors may involve difficulties in recruiting participants. This is, however, not special for older adults. The risk of losing older participants due to drop-out is lower. This implies that longer follow-up intervals, just as for other adults, may be possible in treatment research with older adults. In order to develop more representative evidence, larger samples are needed with a larger percentage of older old (i.e., those over 75) adults (Pless Kaiser et al., 2019). In addition, expanding available knowledge on brain processes and the mind/body interplay in this age-group would help to better personalize trauma-focused treatment in later life. Expanding life expectancy implies that improved quality of life following treatment offers a perspective on more quality adjusted life years (QALYs) to one’s life. In addition, effective treatment might result in reduction of medical costs and social isolation and bring about better transgenerational legacies within families. Awareness of these aspects may offset ungrounded ageism and raise expectations regarding the benefits of trauma-focused treatment in later life.
The message from a recent publication (Bar-Tur, 2023) might counter-balance the opening quote. “I finally got rid of my shadow!’: Psychotherapy with an oldest old woman – a growth process for client and therapist.” Healing from trauma in older adulthood is possible, and even probable, with good support.
About the author

Jeannette Lely is a retired psychotherapist and researcher, affiliated with Arq Psychotrauma Expert Group/Centrum’45 in the Netherlands. As a clinician, she was involved in treating refugees and older patients with traumatic war experiences. Her PhD project focused on treating trauma-related disorders in later life and resulted in obtaining her PhD in 2019. Her doctoral thesis was shortlisted for the Pieter Boeke Award 2021, a Dutch distinction promoting scientific research on psychotherapy in clinical practice. Currently, Jeannette focuses on disseminating research findings regarding psychotraumatology in later life. In addition to chairing the Dutch Special Interest Group on Psychotrauma in Later Life, she is contact person of the Special Interest Group on Aging & Life Cycle in the ESTSS. Recently she joined the editorial board of the Clinical Gerontologist.

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