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Older adults with posttraumatic stress disorder (PTSD) do not often seek psychological support independent of a referral from a general health care practitioner. There are several reasons for this. One general observation is that people of the older generations often have great difficulty accepting the underlying concept of PTSD as a disordered psychological state. We know that many older people consider severe adversities in their early life to be "just part of life," implying very limited or neglected utilization of professional intervention (Hiskey & McPherson, 2013).

PTSD-specific avoidance is not the only explanation for the lack of help-seeking in this age group, nor is it sufficient. There are several contributing factors. One important influence may be a fatalistic attitude on the part of the older adult, where fatalism is defined as patience in the face of adversity and helplessness (Maercker et al., 2019). Another reason is the incomplete manifestation of PTSD symptoms. Studies have shown that sub-syndromal PTSD predominates in older age, meaning that not all symptoms, as required by the official classification systems (be it the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, or the International Classification of Diseases, 11th Revision), are present. For instance, older adults with PTSD typically experience or report fewer flashbacks or deliberate avoidance symptoms (Glaesmer et al., 2010).

These clinical aspects correspond well with the basic theoretical orientation for the treatment of older patients. Lifespan developmental psychology argues that to carry out effective interventions with older people, specific characteristics of the older age phase of life need to be considered (Birren, 2013). In other words: being in an old-age group is psychologically like belonging to another cultural group because of the wealth and otherness of their experience. Conse­quently, treatments for older people should include “culturally sensitive” modifications compared to mainstream approaches for adults, just as children and adolescents would not be treated psychotherapeutically like adults.

One key psychological characteristic of older people is the altered time horizon: Their own biographical past is much more extended than their own future. This has some implications for the nature of autobiographical memory, including disordered traumatic memories. As one of the pioneers of traumatic stress studies, Dr. Henry Krystal, put it, “In old age as in treatment, we come to the point where our past lies unfolded before us and the question is what should be done with it?” (Krystal, 1999, p. 96).

Forms of Life Review Therapies for Traumatized Patients

Life review methods were initially developed for depressive disorders and for mild to moderate dementia in older adults (Maercker, 2002; Maercker & Bachem, 2013). As short-term therapies of about 10 to 20 sessions, life review therapies stimulate and guide one’s recollections. Patients are encouraged to tell a coherent life story. Successful life review results in a decrease in depressive mood and an increase in well-being and self-efficacy. Common across the various forms of life review techniques adapted for PTSD is that traumatic experiences are built chronolo­gically into this life story in which they are narrated in a particularly detailed way. The therapist actively asks questions to stimulate memories and to encourage the expression of feelings, sensory impressions and evaluations that were or are still tied to the remembered experiences. The final phase aims at a general appraisal and inventory of one’s past life as well as integration and finding meaning. Through this therapeutic process, the patient is encouraged to make peace with or accept their biography.

The teams of Schauer, Elbert and Neuner (2011), who developed narrative exposure therapy, and of Knaevelsrud, Böttche et al. (2017) have combined this approach for PTSD clients with the “testimony treatment” approach. Here, the narrative account of the traumatic experience is transformed into a valuable written document—with this final stage of treatment designed in the form of a ritual. Rituals are particularly well accepted by people of traditional orientations—and many older people are among them. If the patient is provided with this written-up trauma report, they can share it with relatives or hand it over to a non-governmental organization that campaigns for the rights of traumatized groups. In this way, the document even takes on a “generative function” and provides personal meaning as described by Erik H. Erikson already fifty years ago.

Studies with controlled case series on this type of age-specific therapy have been published (see Maercker & Bachem, 2013). Furthermore, a randomized controlled trial (RCT) of life review groups was conducted in Germany with older people who were traumatized as children as war victims (Knaevelsrud et al., 2017). In addition, an international collaborative study with Holocaust survivors is currently underway in Israel as an RCT with the structured life review approach under the co-direction of Simon Forstmeier and Danny Brom. Narrative exposure therapy was originally developed for middle-aged adults and has become an evidence-based therapy. In addition to publishing case reports, there are smaller RCTs with elderly (60-87 years old) survivors of political persecution and torture in Romania and Cambodia, which have demonstrated the effectiveness of this method (e.g., Bichescu et al., 2007). 

Further “Culturally Sensitive” Modifications for Older People

The “culture” in which older people were raised often differs from those of younger adults, including different values, norms, traditional forms of expression, lifestyles and worldviews (see Maercker, Heim & Kirmayer, 2019). Two additional considerations should be mentioned: linguistic expression in the form of metaphors as well as worldview differences, to which familialism—the primary orientation towards family—and the above-mentioned fatalism belong.

Metaphors are particularly common in the field of traumatic stress. This applies to the perception of oneself as a "traumatized" person as well as to the communication between patient and therapist by means of metaphors. It already starts with the trauma metaphor, which is interpreted in many languages as "injury" following the Greek word origin. As our working group has shown, there are many other cultural metaphors in different regions of the world that are closer to the experiences of older clients than the "trauma"—or wound—metaphor (Rechsteiner et al., in press). Thus, especially among older people, there are prevailing religious metaphors such as "carrying the cross," "test of God" or "purgatory." In PTSD treatment, the proper time to use metaphors is often during the psychoeducational phase or the discussion of therapeutic rationale prior to the intensive phase of therapy. The culturally appropriate selection of linguistic metaphors will need to be appropriate for older people and must fit their life experiences and be easy for them to understand. 

Particularly relevant regarding cultural worldview differences are the basic orientations of familialism versus individualism (whereby familialism is closely related to the concept of collectivism). Many older people, not only from non-Western cultures, tend to have a strong familialistic orientation. In the therapeutic context for PTSD, this simply means that they do not want to talk about themselves, but about their family, their close relatives or their social group. Using the words “I” and “mine” in therapy is not in accordance with their own values and goals.

Together with a team from Beijing Normal University, we found in an intervention study with traumatized Chinese earthquake victims that the primary therapeutic goal of facilitation of mutual social or family support effectively reduced PTSD symptoms (Wang et al., 2016). To date there is no systematic review of whether a "we"-oriented PTSD intervention is as effective or even better than a traditional "me"-oriented intervention in older people.

Two countries with a particularly high number of traumatized people in old age due to their historical development are Israel and Cambodia. The Holocaust as well as the Khmer Rouge genocide have traumatized millions of people. In psychological anthropology, recent research indicates that mutual learning between the Israeli (i.e., Western) and Cambodian (i.e., non-Western) experience is productive and possible (Kidron, 2015). The author recommends testimony therapy for older Cambodians with their familialism and fatalistic mindsets. She emphasizes that the setting of treatment/public testimony transforms the individualistic focus of common psychotherapies into a collective focus, thereby blurring the boundaries between health-welfare services and the civic-moral-juridical act of bearing witness. The clients experience this as both relief and justice, for which they have often waited a lifetime. This in turn could also provide a perspective for older traumatized patients in Western countries. 

About the Author

Dr. Andreas Maercker is a professor and chair at the Department of Psychology at the University of Zurich, Switzerland. He completed his medical and psychological education in East- and subsequently in the re-united Germany. Professor Maercker is or has been principal and co-investigator in numerous national and international studies in traumatic stress research, clinical geropsychology and internet-assisted mental health—for example, studies on former political prisoners in East Germany. From 2011-2018, he chaired a workgroup at the World Health Organization for revising the International Classification of Diseases in the area of trauma- and stress-related disorders. He has authored or edited 14 scientific or therapeutic books.

References

Bichescu, D., Neuner, F., Schauer, M., & Elbert, T. (2007). Narrative exposure therapy for political imprisonment-related chronic posttraumatic stress disorder and depression. Behaviour Research and Therapy45(9), 2212-2220.

Birren, J. E. (Ed.). (2013). Handbook of the psychology of aging. Cambrigde, MA.: Academic Press.

Glaesmer, H., Gunzelmann, T., Braehler, E., Forstmeier, S., & Maercker, A. (2010). Traumatic experiences and post-traumatic stress disorder among elderly Germans: Results of a representative population-based survey. International Psychogeriatrics22(4), 661-670.

Kidron, C. A. (2015). Global Humanitarian Interventions: Managing Uncertain Trajectories of Cambodian Mental Health. In L. Samimian Darash & P. Rabinow, (eds,) Modes of uncertainty: anthropological cases. Chicago: Univ of Chicago Press, pp. 105-120.

Knaevelsrud, C., Böttche, M., Pietrzak, R. H., Freyberger, H. J., & Kuwert, P. (2017). Efficacy and feasibility of a therapist-guided internet-based intervention for older persons with childhood traumatization: a randomized controlled trial. American Journal of Geriatric Psychiatry25(8), 878-888.

Krystal, H. (1991). Integration and self-healing in post-traumatic states: A ten year retrospective. American Imago, 48(1), 93–118.

Maercker, A. (2002). Life-review technique in the treatment of PTSD in elderly patients: Rationale and three single case studies. Journal of Clinical Geropsychology8(3), 239-249.

Maercker, A., & Bachem, R. (2013). Life-review interventions as psychotherapeutic techniques in psychotraumatology. European Journal of Psychotraumatology4(1), 19720.

Maercker, A., Heim, E., & Kirmayer, L. J. (2018). Cultural Clinical Psychology and PTSD. Boston: Hogrefe.

Pachana, N. A., Mitchell, L. K., & Knight, B. G. (2015). Using the CALTAP lifespan developmental framework with older adults. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry28(2), 77.

Rechsteiner, K., Maercker, A., Heim, E. & Meili, I. (in press). Metaphors about trauma: A cross-cultural qualitative comparison across Brazil, India, Poland, and Switzerland. Journal of Traumatic Stress, in press.

Schauer, M., Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative exposure therapy: A short-term treatment for traumatic stress disorders. Boston: Hogrefe.

Wang, Z., Wang, J., & Maercker, A. (2013). Chinese My Trauma Recovery, a Web-based intervention for traumatized persons in two parallel samples: Randomized controlled trial. Journal of Medical Internet Research15(9), e213.