Older adults significantly underutilize mental health services relative to their numbers in the population. Barriers that impede their access include physical, financial, cognitive, emotional, and attitudinal issues. This article discusses strategies for overcoming these barriers, including physical adaptations such as in-home psychotherapy and telephone sessions, use of support groups, strong community outreach, and liaisons with other professionals. Adaptations that help to increase older adults' use of mental health services are discussed, including education about treatment, nontraditional "pursuit" of clients, and use of alternative terminology. Informed consent is discussed as a special issue.

Older adults underutilize mental health ser­vices. Whereas approximately 13% of the U.S. population is over age 65, only 2 to 4% of patients in mental health outpatient clinics axe over 65 (Eisdorfer & Stotsky, 1977). This is so, despite the fact that overall rates of mental disorders do not seem to decrease in older age. Providing appropriate mental health services to these elders can increase their quality of life, help prevent premature institutionalization, and reduce over utilization of medical services. Drawing on their experience directing the Center for Aging Resources in Pasadena, California, these authors will discuss obstacles elders face in accessing mental health services and strategies to surmount these obstacles. The Center for Aging Resources is a community-based mental health clinic for seniors, with special programs designed to help them overcome the financial, physical, linguistic, cognitive, cultural, and psychological difficulties faced by older adults.

Barriers to Access

Older adults in today's cohort of elders demonstrate many difficulties accessing mental health services, including physical, financial, linguistic, cognitive, and psychological (emotional and attitudinal) barriers (Newton & Lazarus, 1992). First of all, for many elders, physical condition prohibits them from traveling to a mental health clinic or practitioner's office. Between 12 and 30% of elders have chronic medical problems causing mobility impairments (Centers for Disease Control, 1992; Parnes et al., 1993). An even greater percentage, though able to walk or drive, may find that keeping an appointment takes too much energy or causes too much physical pain to be worthwhile.

Second, many elders live on a low income. Approximately 13% of adults over age 65 live below the poverty line. Although some elderly people have insurance that covers mental health services, increasing numbers of elders are joining health maintenance organizations (HMOs), that tend to restrict access to mental health treatment. In addition, many elders who may have financial resources will hesitate to spend them to "just talk."

Third, approximately 5% of adults over age 65 and 15-45% of adults over age 85 are diagnosed with dementia (Evans et al., 1989; Regier et al., 1988). While there is ongoing debate about the benefit of psychotherapy for moderately to severely demented individuals, certainly cognitive impairment presents some difficulties in accessing psychotherapy and requires new approaches to service provision. Fourth, at least four further psychological (emotional and attitudinal) issues interfere with accessing services. Mental health treatment carries great stigma for the elders of this cohort (e.g., Lazarus, Sadavoy, & Langsley, 1991). Today's elders developed their attitudes in the 1920s, '30s, and '40s, when being mentally ill usually meant being psychotic or suicidal. People who received psychiatric care were usually hospitalized and may have received electroshock treatments; psychotherapy as a treatment was not widely available. Many of these elders were taught by their families that negative feelings of sadness, fear, depression, or anger were either bad or weak, and that talking about them would be shameful.

A second internal dynamic for today's elders is simply a lack of education about the effectiveness of psychotherapy. Having grown up in an era in which psychotherapy was not prevalent, they are often unaware that psychotherapy is an effective treatment for psychological problems.

A third internal dynamic is the emphasis placed on independence, being able to take care of oneself. With many areas of declining independence and increasing needs for help from others, many elders fear that accepting one more service, particularly mental health, will lead to further loss of independence and ultimately to institutionalization. This is not completely unfounded, in that once an elder enters the social service system, he or she may actually be pressured to move to a higher level of care.

A fourth internal dynamic is a generalized sense of fearfulness experienced by elderly people who have become vulnerable. This applies particularly strongly to victims of elder abuse and other crimes. Such elder victims maybe especially hesitant to agree to anything new for fear that the unknown may bring violation of themselves or their property. This fearfulness may include a fear of signing any papers, which can interfere with standard mental health treatment procedures.

Strategies for Overcoming Barriers

A number of adaptations to traditional service delivery are necessary to address adequately older adults' needs. One of the most needed physical adaptations of outreach and treatment is to provide treatment in clients' homes. Because of the numerous and complex issues that arise in providing psychotherapy in clients' homes, we will devote a section to addressing this need later in the article when alternative modes of treatment are discussed.

Because of the financial bathers mentioned, providers of psychotherapy to older adults must be willing to accept Medicaid and Medicare insurance, or work to find other sources of government and foundation funding to underwrite the cost of services to individuals who lack adequate insurance.

A discussion of providing psychotherapy to cognitively impaired persons is beyond the scope of this article. Research has begun on the effectiveness of psychotherapy with demented patients at various levels of impairment. The authors have seen significant improvement in the psychological and behavioral status of demented individuals through psychotherapy. In addition to facilitating behavioral interventions by the caregivers, we have found verbal psychotherapy with the cognitively impaired to be effective. An appropriate approach is validation therapy developed by Naomi Fell (1982), which is poignantly illustrated in her videotape called Looking for Yesterday. This tape demonstrates Ms. Feil's approach to connecting with, understanding, and validating the internal world of the demented person.

A number of adaptations to the traditional approach to providing services must be made in order to break through the psychological fears and hesitations of many older adults. These can include community outreach, liaisons with community gatekeepers, "pursuit" of a client, change in terminology, educational interventions, rapport­building techniques, altered informed consent procedures, and alternative modes of treatment delivery.

Community outreach: Aggressive outreach may be necessary to enable this population to accept services. Many seniors, particularly in first-generation immigrant communities, will initially reject the possibility of talking with a clinician or even a social worker. One strategy to overcome this is to send a nonprofessional out­reach worker into senior gathering sites, such as senior residences, senior centers, community centers, and churches. Such an individual can spend time informally with the seniors and gradually develop relationships with them. By developing trusting relationships, an outreach worker can encourage these seniors to begin to verbalize their needs. The authors have found that sometimes older adults may initially identify case management needs, or needs of their friends, rather than their own psychological needs. The outreach worker can then work as a bridge to the needed services, whether they are practical (e.g., legal, social, medical) or psychological. He or she will often go with them to their first appointments, will sometimes help with difficult paper work, and so on. Often, the seniors are first willing to receive offers of concrete help through the case management agency and later are willing to receive our mental health service.

Liaisons with community gatekeepers: Another aspect of community outreach that will facilitate access to services is working closely with community gatekeepers. These may include social workers, physicians, pastors, senior center staff, police officers, attorneys, home health nurses and aides, and senior residence managers. Maintaining ongoing, active relationships with these agencies and individuals, both informally and through community networking meetings, provides a forum in which the mental health provider can encourage the gatekeepers to identify elderly persons who are in need of mental health interventions. Where these gatekeepers have already developed trusting relationships with their clients, the mental health provider can work with those individuals to demystify the psychotherapeutic process and help them to educate their clients to the benefits of psychotherapy. A joint first meeting to see the client can help to concretize the bridge from the trusted relationship with the gate­keeper to the mental health provider.

Consultation with the gatekeeper can also aid the older adult. When, despite significant efforts, a senior is still unwilling to receive psychological services, the gatekeeper can be taught strategies to manage the mental health problem. These strategies are based on research suggesting that social contact, physical health, and religious connection are three of the highest correlates with mental health and lack of depression (Gelman & Pederson, 1993; Lin, Hunter, & Harris, 1980; Phifer & Murrel, 1986). Some of these strategies are to:

Educate the gatekeeper about the positive benefit to the senior of maintaining an ongoing relationship.

Encourage the gatekeeper to help the senior increase and strengthen connections within social and family networks.

Encourage the gatekeeper to help the senior find good medical attention.

Encourage the gatekeeper to help the senior connect or reconnect with religious faith.

Pursuing a client: Once a senior has been identified to be in need of mental health services, it often becomes necessary to determine to what extent to pursue the older adult. In a traditional mental health approach, professionals are trained not to call a patient directly, but to wait for the potential patient to call them. Seniors, however, can be particularly hesitant to initiate these services.

This dilemma of how much to pursue a potential patient is illustrated by one of the programs at the authors' clinic, the Center for Aging Resources. Through a contract with the police department, reports on all senior victims of crime in the city of Pasadena are referred to the crime victims program at this clinic. Each victim receives a debriefing telephone call, during which the victim will often talk extensively about the trauma. When further counseling is offered, however, the senior frequently gives ambivalent responses as to whether he or she wants further counseling. For example, one client talked for 45 minutes during the initial call about her fears after a man broke in through her window. She would not agree to formal counseling, however. The clinician's approach is usually to offer to call the victim back in a week or so to check on how he or she is doing. The victim usually agrees to this follow-up call, as did the client previously mentioned. When the clinician called back, the victim talked extensively about stress symptoms, such as nightmares, but again would not agree to formal counseling. A decision then had to be made about how many times to call the victim. The goal is that after several calls, the victim will develop trust in the counselor, and want to go on for more formal sessions in the clinic, in the victim's home, or sometimes over the telephone.

Terminology: Another adaptation of the therapeutic process concerns the language used to talk about the services. Elders in this cohort, as described earlier, carry many stereotypes about terms such as psychiatrist, psychologist, and mental health treatment. Rather than using sophisticated labels and professional jargon, simple, descriptive language is typically more effective. For example, the label clinician or counselor seems to be more acceptable than psychotherapist. A straightforward description of the process, such as, "I would like to come out to see you and talk with you about how you're feeling" or "I'd like to talk with you about problems you may have been feeling and see if I can help you solve some of them" is less threatening than the term psychotherapy.

Before talking with the senior, it is helpful to talk with the referring person or gatekeeper, find out what language this individual uses, and use those terms. If the person says he is lonely or bored, these words will be understood more easily than depression; if she says she has nerves, this will be more acceptable than anxiety disorder; if the senior complains of bodily pains that the professional suspects are caused or worsened by psychological issues, it may be helpful to talk about feelings or stress that exacerbate the pain. It is important not to challenge the person by insisting on a formal label like depression, which may connote failure and shame. Talk about what the senior already accepts as a problem, using familiar language.

Education: Many elders need basic education on the symptoms of psychological distress and the benefits of psychotherapy. They often do not know that the consequences of a major loss event (e.g., bereavement, relocation) can be boredom, fatigue, or loneliness; they do not know that stress can cause stomach aches and headaches or can aggravate arthritis. They often have not learned about how "just talking about it" will help. It can be beneficial for the clinician to tell the patient, based on experiences with others that, "Talking about your feelings of being bored can help"; "You can learn ways to have more energy"; "Let's consider things you might be interested in"; or "Talking about your feelings can help so you won't feel so alone with them."

Analogies can help when educating these older adults. For example:

Psychological symptoms can be compared with a weight or burden: "Talking about your concerns can help you feel less weighed down by so many burdens."

A person's experience of distress can be com­pared with a pressure cooker: "Talking about your thoughts or feelings can help you let off steam like an old-fashioned pressure cooker, so you won't feel so pressured inside that you reach the point of exploding."

The process of psychotherapy can be com­pared with purging: "When you have losses or stresses in your life, they can leave you with a lot of uncomfortable or distressing things inside you. Counseling can be like cleaning purging those out."

Psychotherapy can be compared with wearing glasses: "When your eyesight gets worse, you don't think it is bad or shameful to use glasses to help you see better; counseling is a well­established tool to help you think or feel better; it is not any more of a `crutch' than glasses."

In providing education, it is important to give information about the length and nature of treatment, including where and when it will occur, how long it will take, and how it will be paid for.

Rapport-building techniques: Once an individual agrees to begin therapy, it is helpful to use approaches that bring quick, concrete help and lay the groundwork for a trusting relationship, that will facilitate work on the long-term, psychological goals. Rapport-building techniques can include the following:

Referring the senior to a case manager and arranging for a concrete need (such as getting a housekeeper) to be met.

Helping the client to reactivate a dormant interpersonal relationship.

Teaching the client progressive muscle or other relaxation techniques, and making an audiotape for him or her.

Informed consent: One of the complicated is­sues that emerges in undertaking some of the above described adaptations to traditional psychotherapy is the place and form of informed consent. Traditionally, a client comes to a mental health professional with an already established idea of what psychotherapy is and a willingness to sign a form that states he or she understands the nature of the process and the limits of confidentiality. These older adults are often reluctant to sign any­thing, however, particularly something that formally states they are engaging in psychotherapy. Although current standard practice among psychologists is to obtain written informed consent, many seniors, if pressured to sign forms with a stranger, will terminate the relationship.

One approach to this is to develop funding streams in addition to traditional medical insurance, so that more services that are considered outreach rather than psychotherapy can be provided, therefore eliminating the need for a signed consent form. Even within the area of outreach, however, mental health service providers are ethically bound to assure that they do not force ser­vices on someone who does not understand and voluntarily consent to receiving such services. It is critical to assess regularly with the clients whether the services currently being provided are acceptable to him or her. Informed consent may be progressive, in that the elder is initially verbally asked if it is "okay" for the clinician simply to talk generally with him or her, and then later asked formally to agree to counseling. During the outreach phase, we try to teach the seniors what it means to talk about their thoughts and feelings. We assess their interest in it and try to assess and meet whatever needs we can on a time-limited basis.

For certain purposes, a traditional informed consent rewritten into informal language can be useful. For our Center's psycho-educational discussion groups, described below, a form entitled "Support Group Agreement Form," rather than "Informed Consent," is used. It clarifies in simple language the guidelines of the group, the group's aim to discuss members' concerns, the clinician's limits in keeping confidentiality under certain circumstances (i.e., elder and dependent adult abuse, child abuse, homicidality, suicidality), and the expectations for members to maintain privacy regarding other members' issues.

Alternative Modes of Treatment

Telephone sessions: At times, telephone sessions are conducted. If a client lives in an environment that is unsafe for the clinician to enter­with an abusive family member or in a home with loaded guns, for example-therapy is better conducted by telephone, if the patient cannot or will not come to the clinic.

Telephone sessions are also conducted when the patient has particular dynamics, resisting a face to face session in the home or in the clinic. For example, one man was the victim of a scam in his home. (Two men came to his door, suggesting he needed his roof fixed. They convinced him to walk around the house, pointing out parts in need of repair. While one man talked with him, the other slipped back, entered his home, and looked for money and jewelry.) After this scam, we contacted him through our crime victims' program. He was receptive to talking over the telephone. After two or three telephone contacts, when our clinician asked to come to his home or meet him at the clinic, he refused. He was hesitant to be seen by the clinician. Dynamics of shame as well as fear of dependency seemed to inhibit him. He was willing, however, to receive weekly 45-minute telephone calls, which we conducted for the program's set of 10 sessions.

Psycho educational groups: Another alternative mode of offering psychotherapeutic help is through discussion groups at senior residence buildings and senior centers. Catchy, somewhat upbeat titles are given to the groups, for example, "Healthy Living," "Transitions," or "Living Well Discussion Group." Fliers are posted announcing a time and place for a discussion group. Topics are prepared for discussion on issues of interest to seniors, topics that include psychological content through which adaptive strategies can be taught, but that are not emotionally threatening. For ex­ample: Memory Improvement Reminiscence, Making Friends, Enjoying Your Grandchildren, Enhancing Wellness, Coping with Illness, Stress Reduction, Relaxation, Coping with Change, Learning to Live Alone, How to Sleep Better. Initially, the participants prefer a teaching format, but after the group gains cohesiveness, they be­come more open to processing their feelings and aging issues.

In-Home Psychotherapy
Opportunities and Pitfalls

Using in-home psychotherapy as a treatment modality presents significant opportunities to overcome the barriers to treatment, but also creates several potential pitfalls. A review of the literature reveals little discussion of the efficacy of providing in-home psychotherapy (Lipsman, 1996; Stoke, Kessler, & LeClair, 1996). More has been written about other types of in-home social services (Aneshensel, Pearlin, Schuler, & Roberleigh, 1993; Biegal, Bass, Schulz, & Morycz, 1993; Burnette & Mui, 1995; Lawton, Pow­ell, Moss, & Dujamel, 1995; Malone-Beach, Zarit, & Spore, 1992; Noro & Am, 1997; Rabiner, 1992; Rabiner, Mutran, & Stearns, 1995; Stephens, Kinney, & Ogrocki, 1991; Wallace, Campbell, & Lew Ting, 1994) and about providing mental health services in other nontraditional settings, like nursing homes (Spayd & Smyer, 1996).

The primary advantage to in-home treatment is accessibility. When a psychologist sees a client at home, he or she is able to engage an elder who cannot or will not come to the office. Sessions are not likely to be missed due to difficulties with transportation, and so on. The home may feel like a safe environment for the client, which may foster rapport-building. In fact, this may decrease the stigmatization for the client in regarding mental health services. Many older adults are, as discussed earlier, reluctant recipients of psychological care and are unlikely to go to a mental health clinic. The psychologist can readily assess the home environment and obtain information about people with whom the older adult has significant relationships. In fact, family treatment may be more likely to occur.

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