An Interview with Psychologist Julie Erickson
Julie Erickson, Ph.D., C.Psych is a Clinical Psychologist at the Forest Hill Centre for CBT in Toronto, Canada and adjunct faculty member for the Department of Applied Psychology and Human Development at the University of Toronto. She specializes in the treatment of anxiety disorders in older adults.
Tori Steffen: Hi, everyone. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Tori Steffen, a research intern at the Seattle Anxiety Specialists. We are a Seattle based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today Clinical Psychologist, Julie Erickson. Dr. Erickson is an adjunct faculty member for the Department of Applied Psychology and Human Development at the University of Toronto.
She practices at the Forest Hill Centre for CBT in Toronto, Canada. She's an expert in the field of anxiety disorders and has written several articles on the topic, including “Anxiety Disorders Late in Life: Considerations for Assessment and Cognitive Behavioral Treatment”. As well as “Associations Between Anxiety Disorders, Suicide Ideation, and Age in Nationally Representative Samples of Both Canadian and American Adults.” Dr. Erickson is also planning to publish a CBT workbook for older adults with New Harbinger in the fall of 2023.
Before we get started today, could you please let us know a bit about yourself and what made you interested in studying anxiety disorders in older adults?
Julie Erickson: Yeah, absolutely. Thanks for having me. I live and practice in Toronto, and maintain a pretty steady clinical practice and I do some teaching as well. In terms of what got me interested in this area, so it actually started way back in one of my first jobs when I was a teenager. I worked in the recreation department of a nursing home. As part of that job, I was helping facilitate different recreation programs for residents, and noticed that it was the same group of people coming to recreation programs all the time.
It tended to be a group of people that were maybe more optimistic. They tended to be more social. They also tended to be the same group of residents that had more people visiting them. Relative to other residents, who were maybe a little bit more withdrawn or isolated, maybe a little bit more pessimistic or had fewer visitors. Just seeing the contrast made me curious. Why did some people tend to thrive and do quite well, as they got older and were in nursing home care, versus some people really have a more difficult time?
Ultimately, wanted to understand some of the psychological and social factors behind aging well. How to help people live better lives as they grow older and to be more fulfilled. As part of that, how to manage the anxiety and the stressors that can come up for people in late life. Ultimately, this led me to the field of clinical psychology and the intersection between that and gerontology.
Tori Steffen: Okay, great. Thank you. Would you say that older individuals experience anxiety similarly to younger people?
Julie Erickson: Yeah. I would say generally speaking, there's probably more similarities than differences. The similarities being maybe focusing on worst case scenarios, feeling agitated or restless, having difficulties relaxing, struggling with indecision or doubt, difficulties concentrating, so a whole host of similarities. Where some of the differences might be though, might be the types of symptoms that end up getting endorsed. Older adults can tend to report more physical symptoms of anxiety or at least report those predominantly.
One of the first things they might report to their family doctor, could be the physical symptoms like upset stomach, or having a racing heart or shortness of breath. As opposed to going to their family doctor and saying, "I'm worried about what people are thinking about me in social situations." That's one difference. The other difference might involve more of the content of the worries that older adults have. That's going to be a little bit different than younger adults. It's less focused on things like academic success, or career building or parenting.
It tends to be a little bit more focused on things like changes in your physical health or mobility, caregiving concerns, or even identity shifts that might be happening because of things like retirement. The surface nature of the worries will be a little different, as well as sometimes the types of symptoms that older adults report.
Tori Steffen: Okay. Yeah, that definitely makes sense. Would you say there are any limitations that you've found that might prevent the treatment of anxiety disorders in older adults?
Julie Erickson: Yeah. There's several unfortunately, and several big ones that can get in the way of older adults getting treatment for anxiety disorders. The first one relates to something called mental health literacy. This relates to someone's ability to recognize the symptoms of a mental disorder. Knowing where to get information about mental health concerns, and knowing where and how to get help. Some research suggests that older adults tend to have lower rates of mental health literacy relative to younger adults.
That might be one of the things that prevents them from detecting that part of what I'm experiencing could be a psychological issue. It also might prevent them from knowing there're effective treatments out there and knowing where and how to get help. That's one of the first limitations. The second more has to do with a systems issue, so lack of access to qualified, geriatric mental health professionals. There's an undeniable shortage of us who specialize in treating older adults. That can certainly make it quite difficult to get qualified help.
Thirdly, also probably a societal or systemic issue, stigma. Some older adults may come from a generation or social or cultural background, where going to see a psychologist or a psychiatrist is only when someone is really sick. It still might be shrouded in a lot of their shame. That can be something that really gets in the way. Then finally, I would flag ageism as a potential issue that gets in the way of getting treatment. Sometimes symptoms of mental health conditions in late life can be missed by healthcare professionals.
They might be very well-intended, but maybe more inclined to look at some of the symptoms that older adults might be presenting with, as more attributed to a physical problem as opposed to a mental condition. It's not just maybe healthcare professionals, but also older adults themselves can hold some ageist types of beliefs. They might be inclined to see older adults as less capable of changing. If they hold that belief, which is an ageist stereotype, that can really defer them from seeking treatment as well. A whole host of different things that can get in the way of older people getting help.
Tori Steffen: Right. Yeah. Those are some great points, as far as limitations go. Your research discusses the ways that CBT can defer among the younger and the older patients with anxiety disorders. Could you explain the differences for our audience?
Julie Erickson: Absolutely. There's a few that I'll highlight. The first has to do with the pacing of treatment. It's important to know that with CBT, in particular with older adults, things might take a little bit longer for a number of reasons. It's longer to gather maybe a personal history from an older adult client. There's lots of background information to get. Depending on the client's experience with therapy, you may need to devote some extra time to socializing them to therapy. So they have more of a working understanding of what this is, what to expect as you engage in treatment.
There's also an issue of pacing if you're working with someone with cognitive impairment. Or even an individual with normal age-related changes in cognition, you might want to slow down the speed at which you're talking about interventions or introducing new things in session, or even consider having shorter sessions. I'm thinking for people who might have medical conditions that make sitting or sustaining their attention for full hour sessions more difficult. Pacing is one first thing to consider that would make treatment a little bit different with older adults.
The second issue relates to being more attuned to medical issues and how these might be likely to impact your conceptualization of a client and also treatment. Given that a sizable proportion of older adults are experiencing either chronic, physical health issues or more acute issues, there's likely going to be an interplay between some of those symptoms and the anxiety that they're reporting. For example, I had an older adult client diagnosed with tachycardia, and subsequently developed panic attacks every time she had an irregular heartbeat.
Doing a careful assessment and asking about physical health issues is particularly important, so you understand how this might be impacting an older adult in your treatment with them. Another potential difference and an issue to keep in mind, stems from cognitively how an older adult is doing. Cognitive issues require some assessment, even if it's just a brief screener at the outset of treatment. Just to take into consideration how that might impact treatment, and to consider how to best pace and deliver content.
Age-related, cognitive decline is pretty normal and primarily affects things like your short-term memory, your word finding, maybe speed of processing. This may or may not require any alteration in your treatment. But if you're seeing someone who's maybe got a cognitive impairment that's related to dementia, maybe they've got mild to moderate types of dementia. This is going to require some tailoring, in terms of your pacing, but also lots of use of memory aids, right?
Handouts, writing things down, even audio recording sessions, so clients can help retain what you're talking about in session.
Tori Steffen: Okay.
Julie Erickson: Then finally, what I'd flag in terms of how things look a little bit different with older adults, has to do with just the types of themes that might come up in treatments. There might be more themes to pay attention to around loss, right? Grief in a bunch of different forms, whether it's of people or of roles in your life.
Or grieving mobility, or functionality or independence. But also themes of isolation, identity changes, or even dealing with regrets. Being attuned to just some of the developmental concerns that can emerge in late life, I think is particularly important with older adults.
Tori Steffen: Great. Thank you. Thank you for that. Then I know we spoke about it earlier, the somatic symptoms that older adults may experience. Can you explain what types of somatic symptoms that they typically experience and why that might be?
Julie Erickson: Yeah. A lot of the somatic symptoms older adults experience, would be some of the typical ones we would see in early life as well, around whether it's upset stomach, or just feeling on edge, or restless or even elevated heart rate. Even things like feeling sweaty or short of breath, in cases like panic. Some of those somatic symptoms will look very similarly. As far as to why they might present more with some of those somatic symptoms. Well, we don't know for sure. There's a couple possible explanations.
One of which might be that there could be either biological or psychological, or social factors that influence how anxiety disorders are experienced or present, or seem more prominent in late life. It seems reasonable to expect that the types of symptoms that people might present with can change as one grows older. Due to things like different medical conditions or just age-related changes in things like sleep or emotion and how people experience it. It could just be that there are developmental changes in how anxiety disorders present.
But the other possible explanation relates back to something that I was talking about earlier around lower rates of mental health literacy in older adults. If older adults are less aware of what some of the different symptoms of anxiety disorders are, they may underrecognize some of the symptoms, for example, some of the cognitive symptoms. May be less likely report some of those symptoms, if they don't know that's in keeping with an anxiety disorder. If that's actually the case that this is more of a reflection of let's say a cohort effect, right?
That it's this generation of older adults who lack mental health literacy, we might expect to see that as younger generations of adults now as they get older, that they would be more aware of and more likely to endorse a greater array of anxiety symptoms. So we'll see, and probably research will have more to tell us in the coming decades about some of these age-related differences.
Tori Steffen: Yeah. That'll be interesting to see the changes as time goes on and people grow older. Are there any other approaches than CBT, that older adults can utilize to combat the symptoms of anxiety disorder, maybe fear of aging?
Julie Erickson: Yeah, it's a good question. The challenge is that there's probably relatively less therapy outcome research for older adults, compared to other age groups and most of it tends to focus on CBT. But if we look outside of this modality, there's some support for approaches like motivational interviewing or problem-solving therapy to have some success with older adults. One other approach that might be more useful and maybe more unique to late life.
Maybe more helpful too in dealing with issues like fear of growing older, or fear of aging or coming to terms with one's mortality, is the practice of reminiscence and life review, so reminiscing therapy. And while we all might reminisce about the past and recall the good, the bad, and the ugly of our lives, this is particularly important for older people as a developmental task. Older people use the process of reminiscing to help create meaning and integrate life's events.
Maybe even have a heightened awareness of things like the finiteness of life. And to work to create meaningful roles for themselves in their later years, which can be challenging given that society largely pushes older adults to the sidelines. This practice of reminiscence and life review has particular relevance to older adults, who might struggle with fears of growing older or come to terms with what that means for them.
Tori Steffen: Okay. Yeah, that definitely makes sense. Your article also mentions that the presence of cognitive impairments. We were talking earlier, dementia as an example, can make it more difficult for older adults to engage in CBT as a treatment for anxiety.
Would you mind just explaining this a bit more? Do you think CBT could ever be a suitable treatment option for an older adult with a cognitive impairment?
Julie Erickson: Yeah. Yeah. Cognitive impairment can vary in late life. There's a certain degree of cognitive change that's normal as people get older, like declines in short-term memory, forgetting names of people or forgetting where you left an object, or walking into a room and not remembering why you walked in there for. That's all pretty normal, versus dementia is not considered a normal part of growing older.
Dementia's an umbrella term for a wide variety of different conditions that can include things like Alzheimer's disease or vascular dementia, or Lewy body dementia. They can come with more severe difficulties with memory, attention, speed of processing, language. It can be much harder for these folks to learn and retain new information, especially as the disease progresses. Now, it's not to say though that older adults with dementia can't benefit from CBT, but it really depends what stage of the disease that they're in.
There is research to suggest that if you're in the more mild to moderate severity range of dementia, that you can still benefit from this type of approach. But you want to ensure that your CBT protocol maybe is streamlined and simplified, in terms of the level of complexity. And to make sure there's ample use of memory aids. Things like handouts, keeping written notes of what's happening each session, and having the client keep their own notes as well, audio recording each session.
Things of that nature, as much as you can do to help the client remember and encode the information you're talking about in session, the better. You might be able consider involving significant others in the client's life to help assist with remembering information. I'm thinking of one client in particular, who after our sessions, she would often talk to her daughter. And would talk to her daughter about part of what she learned in her CBT session that day.
Then part of that was just to help her remember and consolidate what she's learning. But also, to bring her daughter into the loop so her daughter's more aware of what's going on in her treatment. Those are some of the things to keep in mind that might still help an older adults with dementia, let's say, benefit from CBT.
Tori Steffen: Great. Yeah. It's good to know that it can still be helpful for older adults with those cognitive impairments. The case study outlined in your article, showed that older adults who experience regular panic attacks can improve such occurrences with the help of CBT tactics. Could you speak a little bit about this and what may help with that?
Julie Erickson: Yeah. Yeah. Let's start with in its simplest form how we conceptualize something like panic disorder. Most simply, panic disorder is a fear of fear. Where individuals who might be experiencing normal or benign physical symptoms of anxiety, become quite fearful of these sensations because they start to assume that they mean more catastrophic things, like having a heart attack or being on the verge of fainting, going crazy or losing control.
When anxiety symptoms are viewed in that way, of course, it's very distressing and can typically result in avoidance of activities or situations, or things where people think that those physical symptoms might be activated. They might start to avoid things like cardiovascular exercise, caffeine, or even things like taking the stairs. With some of those avoidance behaviors, this can really reinforce and even magnify some of the fears that people have around those physical sensations of anxiety.
It can sometimes be the case that for older adults with panic disorder, the onset of those difficulties can go alongside other medical issues, like the tachycardia example I discussed earlier, or even GI conditions. The onset of these medical issues can make people more hypervigilant to changes in physical sensations, to be a bit more anxious or on edge about them. Now, when you're doing CBT for panic with older adults, the overarching goal is to help people learn that the physical sensations that occurred during panic are uncomfortable but not dangerous.
They don't actually need to try to actively control these sensations, that they'll dissipate on their own. Part of how we do this is by cognitive restructuring, so helping older adults to change their minds about what these sensations mean. With some older adults, they've had pretty longstanding beliefs about what these sensations mean, that they're crazy or they're unable to control themselves. Good psychoeducation is going to help people start to shift the perception of these symptoms.
Now, the other thing though that's really going to go a long way, is doing interoceptive exposures, which is basically making active, intentional efforts to try to mimic the sensations of panic. In doing so, is going to allow people to learn that these sensations aren't going to result in some catastrophic outcomes, like going crazy or having a heart attack. We'll often encourage people to do things like breathe through a straw for one minute and plug your nose. Run on the spot as quickly as you can or purposely hyperventilate for 30 seconds.
Doing that repeatedly is going to help people start to learn that these are at most, uncomfortable but not actually dangerous feelings for me. Now, the thing that's maybe more important if you're doing those interoceptive exposures with older adults, is to make sure that you inquire about any medical conditions that might contraindicate some of these exposures or require you to adapt them. For example, there's some cardiopulmonary conditions that you might want to avoid.
Certain forms of interoceptive exposures where you activate either cardiovascular symptoms or respiratory symptoms. Likewise, if you've got individuals with asthma or COPD, or renal disease or seizure disorders, some of those folks are advised not to do certain forms of exposures that involve breathing through a straw or inhaling more CO2. For this, don't work in isolation. Check with your older adult's primary care physician to get clearance to do some of these exercises.
Well, collectively, some of the cognitive work and the exposures in CBT for panic, can really go a long way into helping older adults reduce the frequency of those panic attacks, and ultimately, to feel more confident about their abilities to deal with anxiety.
Tori Steffen: Great. That's great to hear that those tactics can help with panic disorder and definitely good. I know that CBT is best and ideally done under the treatment and guidance of a licensed mental health professional.
Are there anything things that older adults can do on their own to potentially reduce or lessen those symptoms of anxiety?
Julie Erickson: Yeah, absolutely. There's a number of important things that they can be doing. One of the first things I'd encourage older adults to do, is to try to be a detective with their anxiety. By that, I mean trying to make note of a few things when they feel anxious. To make note of where and when they tend to feel more anxious. Is it before trips to the doctor, while driving, before traveling? To also identify what thoughts that they may be experiencing at the time that they feel anxious.
What if I get into an accident? What if my doctor gives me terrible news and the like? Also to make note of what behaviors that they engage in when they feel anxious, whether it's avoiding driving or researching physical symptoms online. Making note of those different things can help understand the full picture of your anxiety and how it shows up in your life. That can ultimately help you be better situated to interrupt some of those usual things that go on when we feel anxious.
The second thing I think older adults can do is to talk to themselves like they would talk to a loved one or a close friend who was feeling anxious. If we had a loved one who was worrying about an upcoming medical appointment, we'd probably try to understand, to empathize and even to comfort them. Oftentimes, if we can do that for ourselves, that just tends to feel better and helps us feel a little bit better situated to cope with feelings of anxiety that might be coming up.
The third thing and final thing I'll mention that might help older adults in dealing with anxiety, has to do with experimenting with doing the opposite to what your anxiety pushes you to do. If you notice that your anxiety tends to make you want to avoid things like socializing, exercising, or trying new things, try to attempt to gradually face and overcome some of these fears by doing the opposite. If you notice perhaps that your anxiety makes you overdo things.
So over-come it, over-prepare for things, over-research, experiment with scaling back on some of those things. And people can find that if they change their behavior when they feel anxious, many of their feelings of anxiety can reduce over time. Those are some of main things I would encourage older adults to do, who feel anxious.
Tori Steffen: Great. Thank you for sharing that. I'm sure it's helpful information and definitely relates to mindfulness and exposure therapy as well.
Well, Dr. Erickson, do you have any final words of advice or anything else that you'd like to share with our listeners today?
Julie Erickson: Yeah, sure. I always like to plug some optimism for growing older. As much as there can be some negative stereotypes of aging and fear surrounding the process of growing older, there's also a lot to look forward to. The later years of life can bring a lot of freedom from responsibilities that were present earlier in life, so like child rearing or building a career.
Older adults acquire a lot of wisdom and emotional maturity that tends to peak in later life. Alongside that, they tend to have more clarity about the people and the things that are most important to them and tend to spend their time accordingly. As much as there are considerable challenges to growing older, there are a lot of upsides and things to look forward to.
Tori Steffen: That's great. I love the optimistic perspective on that. Well, thank you so much for joining us, Dr. Erickson. It's been really great speaking with you today. Thank you so much for contributing to our interview series.
Julie Erickson: You're welcome. Thanks for having me.
Tori Steffen: Thank you. Have a great one.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.