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i
evidence-based treatment with older adults

ii
E VID E N C E - B ASE D P R ACTICES
series editors:
David E. Biegel, Ph.D.

Elizabeth M. Tracy, Ph.D.
Jack, Joseph and Morton Mandel
School of Applied Social Sciences,
Case Western Reserve University
Family Psychoeducation for Serious Mental Illness

Harriet P. Lefley
School Social Work

An Evidence-Informed Framework for Practice
Michael S. Kelly, James C. Raines, Susan Stone, and Andy Frey
Mental Health Treatment for Children and Adolescents

Jacqueline Corcoran
Individual Placement and Support

An Evidence-Based Approach to Supported Employment
Robert E. Drake, Gary R. Bond, and Deborah R. Becker
Preventing Child and Adolescent Problem Behavior

Evidence-Based Strategies in Schools, Families, and Communities
Jeffrey M. Jenson and Kimberly A. Bender
School Social Work

An Evidence-Informed Framework for Practice
Michael Kelly, James Raines, Susan Stone, and Andy Frey
Supporting Families of Children with Developmental Disabilities

Evidence-Based and Emerging Practices
Mian Wang and George H. S. Singer
Evidence-Based Treatment with Older Adults

Theory, Practice, and Research
Nancy P. Kropf and Sherry M. Cummings
The Evidence Based Practices Series is published in collaboration with the Jack, Joseph and
Morton Mandel School of Applied Social Sciences at Case Western Reserve University.
iii
E VI D E NC E- B A S ED T REATMEN T
W I T H O L D ER A DU LTS
THEORY, PRACTICE, AND RESEARCH
Nancy P. Kropf
Sherry M. Cummings
1
iv
1
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Printed by WebCom, Inc., Canada
v
C O NT ENT S
Part I Overview of Later Life Issues
1 Introduction to the Aging Population 3
2 Settings and Contexts for Geriatric Practice 22
Part II Evidence-Based Interventions With the Older Population
3 Cognitive Behavioral Therapy: Theory and Practice 47
4 Cognitive Behavioral Therapy: Evidence-Based Practice 69
5 Problem-Solving Therapy: Theory and Practice 87
6 Problem-Solving Therapy: Evidence-Based Practice 103
7 Motivational Interviewing: Theory and Practice 127
8 Motivational Interviewing: Evidence-Based Practice 151
9 Psychoeducational and Social Support Interventions:

Theory and Practice 173
10 Psychoeducational and Social Support Interventions:

Evidence-Based Practice 191
11 Reminiscence and Life Review: Theory and Practice 207
12 Reminiscence and Life Review: Evidence-Based Practice 228
v
vi
vi C o n t e n t s
Part III Challenges in Implementating Evidence-Based Treatment
13 Implementation Issues 245
14 Future Directions in Interventions with Older Adults 257
Ind e x 275
vii
Evidence-Based Treatment with Older Adults

vii
1
I
OVE R VI EW O F L AT ER LIFE IS S U ES
2
3
1
I N TR O D U C T I O N T O TH E AG IN G
P O P U L AT I O N
I have discovered that there is a crucial difference between society’s image of old
people and “us” as we know and feel ourselves to be… . To break through that
image, we must first understand why, how, and by whom it is perpetrated. We must
also glimpse some new possibilities and new directions, both as individuals and as a
society, that belie that image … there are choices we can make along the journey we
all, sooner or later, must take that truly open surprising new possibilities.
—B. Friedan, The Fountain of Age, p. 31
As the baby boom generation enters their later years, significant changes are taking place
within the older population and US society. The increase in the aging population is not
limited to the United States, however; it is a global issue that is reshaping family life and
social policy throughout the world. Why are these changes expected?
There are several reasons that the older population is increasing and changing. First,
the sheer number of older adults is altering social and economic trends, including family
life and responsibilities. Second, the older population is becoming more diverse in sig-
nificant ways that impact health and social welfare. Additionally, the variation within the
older population is increasing as greater life expectancy results in multiple cohorts within
later life. Taken together, these are significant issues for professionals who practice with
older adults in health, mental health, and social welfare contexts.
In recent decades, numerous biomedical advances have extended the life span and
have increased life expectancy rates. Previously, later adulthood was viewed as a period
of disengagement and decline (Cummings & Henry, 1961). Currently, there are many
3
4
4 Evidence-Based Treatment with Older Adults
examples of adults of advanced age who are expanding the boundaries of functioning
during later life. In fact, a snapshot of contemporary society reveals individuals in fami-
lies, workplaces, and cultural venues who are thriving well into later adulthood.
Although the population of older adults is experiencing higher levels of health
and well-being than in previous generations, the probability still exists that health
and social changes will accompany advancing years. These challenges may test the
functioning and resilience of older adults. In addition, many in later life are manag-
ing chronic illnesses and require additional supports in the activities of daily living
(ADLs) or the instrumental activities of daily living (IADLs). As a result, families
and other informal supports often assume caregiving roles and provide assistance to
older adults. The demands and stress of caregiving can take a toll on their own levels
of health and well-being.
The aging of society has important implications for health and human service pro-
fessions. Sadly, many professions are woefully behind in preparing practitioners to work
with older adults. Decades ago, Elaine Brody, a pioneer in geriatric social work, admon-
ished social work for being unprepared for the coming advent of older adults (Brody,
1970). Since then, numerous efforts have been involved to increase the level of geron-
tological and geriatric care, including interprofessional education, upgrading labor force
capacity, and developing pipelines into geriatric care (Heise, Johnsen, Himes, & Wing,
2012; Hooyman, 2009; Kropf, Idler, Flacker, Clevenger, & Rothschild, 2015; Sisco,
Volland, & Gorin, 2005). Clearly, the aging of the population has created an awareness
that clinicians, service providers, and health-care workers need to understand the issues
of later life if they are to be effective in their practice.
While “experts in aging” are needed, such as geriatric social workers, nurses, and geri-
atricians, aging issues will be part of health, mental health, and social welfare practice
regardless of settings. As a result, all professionals need to have a basic understanding of
aging, as there will certainly be issues that are included in their scope of practice. Several
examples can help illustrate this point:
• Professionals within school systems (school social workers, teachers, school nurses,
and psychologists) are working with custodial grandparents who are raising their
grandchildren. Census data indicate that about 10% of all US grandchildren live with a
grandparent (Ellis & Simmons, 2014).
• The population of prisoners is aging. By the year 2019, prisoners over age 50 are pro-
jected to comprise about 28% of the total incarcerated population. This estimated
percentage is a 10% increase since 2011 (Kim & Peterson, 2014). Those who work
in criminal justice will work with these individuals who are “aging in place” within cor-
rectional facilities.
• As the baby boomers grow older, addiction patterns are increasing and changing.
Alcoholism and marijuana use are two areas where there are increases in addictions
within older adults (Cooper, 2012).
5
I n t r o d u c t i o n to t h e A g i n g P op u l a t i o n 5
• Although the percentage of older adults who are homeless is lower than other age
groups, these numbers are rising. One estimate indicates that the number of older
adults who are homeless will double between 2010 and 2050, resulting in over 95,000
in this population (Sermons & Henry, 2010).
These examples are but a few illustrations of non-geriatric service areas that will require
knowledge and skills in aging. Chapter 2 will discuss more traditional service settings in
aging, such as community-based and long-term care settings.
O LD E R ADUL T H O O D : A B I O P S Y CH O S O CIAL O V E RVI E W

Before proceeding to an analysis of evidence-based practice approaches, we present
information about the older population. To understand practice with older adults, it is
important to have a good foundation to understand the breadth and diversity of issues
during later life. In addition, health and functioning information is critical, as often these
are issues that precipitate involvement with health-care providers.
INCREASES IN THE AGING POPULATION

Currently, more individuals are living past infancy, childhood, and young adulthood into
later life. Illnesses that claimed the lives of young people, such as polio, smallpox, and flu
epidemics, have been eradicated or controlled by public health practices, vaccines, and
medical advances. In addition, changes in our economy have brought about new (and
safer) occupations that have decreased accidental deaths in the labor force.
As a result, there are fewer deaths earlier in the life course. Early detection, advances in
pharmaceuticals, surgical procedures, and preventive approaches allow individuals to live
with conditions that previously would have claimed their lives; notable examples include
cancer, hypertension, pneumonia, cardiac conditions, and diabetes, among others.
However, these advances also result in more chronic conditions in the older population.
Although older adults account for about 14% of the US population, this group consumes
34% of all prescription and 30% of over-the-counter drugs (Albert et al., 2014).
Life expectancy rates have increased; people are staying alive longer, with increased
rates at both age 65 and 85 years. Currently, people who reach age 65 can expect to live
an additional 19.2 years (Federal Interagency Forum, 2012). This period is 5 years lon-
ger than life expectancy rates at the same age in 1960. Yet within the older population,
there is variation in these rates. In all racial and ethnic groups, women’s life expectancy
is greater than that of men (Arias, 2014). There are also differences in life expectancy by
racial/ethnic background. Asian Americans have the longest life expectancy at 86.5 years.
Latinos (82.8) have the second longest life space, outliving Whites (78.9) by nearly
4 years. African Americans (74.6) have the shortest life span, and Native Americans are
expected to live to be 76.9 years old (The Social Science Research Council, 2014).
6
An additional reason that there are greater numbers of older adults today is the large
number of baby boomers who are aging. As already stated, the baby boom generation
consists of those individuals who were born between 1946 and 1964. This cohort was
born after World War II during a time of prosperity in the United States, when families
could afford children. This period also preceded the advent of widely available and con-
venient contraception, and thus family sizes were larger. These baby boomers are now in
their fifties, sixties, and seventies and are reaching their later years.
Aging trends are significant when growth is viewed as a proportion of the population.
In 1900, 5% of the population was over 65 years of age. As stated earlier, this group cur-
rently accounts for about 14% of the overall population. By 2050, when all the baby boom
generation is in later life, 20.2% of the population is expected to be 65 years or older (US
Census Bureau, 2015). That is, in 1900 one in 20 people was over 65 years. By 2050, the
proportion of older adults will increase to one in four individuals.
As stated previously, the population of the oldest old is growing most rapidly. The
greatest growth is in the over-85-year-old group, with the population of centenarians
(those 100 years or older) having the overall greatest increase (US Department of Health
and Human Services, 2013). While living a century or more was once a major feat, cente-
narians are now found in societies across the world (United Nations, 2013). In addition,
supercentenarians are those individuals who live past 110 years of age. The Gerontology
Research Group compiles an updated list of validated supercentenarians worldwide
(http://supercentenarian-research-foundation.org/TableE.aspx). Currently, these 47
individuals are found across the globe, with almost half living in Japan (n = 23).
DIVERSIT Y IN LATER ADULTHOOD

During later life, there is greater heterogeneity than there is during any other period of life.
This situation is attributed to both individual factors, such as one’s personality and unique
history, as well as the social era in which one lived (e.g., Vietnam War and Watergate).
These lived experiences, both as an individual and a member of a cohort group, have
shaped worldview and behavior in unique ways. As a result, there is substantial behavioral
and attitudinal variation among older adults.
Race and Ethnicity

The older population is diverse by race and ethnicity. While White older adults still com-
prise the majority of the population, this trend is changing. By 2050, the older popula-
tion is expected to be made up of 12% African American, 20% Hispanic, and 9% Asian.
Native Americans and Alaskan Natives can expect to see large growth relative to their
small populations (US Census Bureau, 2010b).
Immigration trends are important in understanding the later life experiences of those
who are aging. Within the United States, the number of older adults who were born in
other countries has been increasing (see Figure 1.1). In 2010, more than one in eight US
adults ages 65 and older were foreign-born, a share that is expected to continue to grow.
7
U.S Foreign-Born Population Ages 65+ (in millions)

4.6
3.2 3.3
3.1 3.0
2.7 2.7
1950 1960 1970 1980 1990 2000 2010
F i g u r e . Foreign-born older adults in the United States. Source: US Census Bureau, historical
census data, 1950–2000; and Current Population Survey, 2010.
As an example, the US elderly immigrant population rose from 2.7 million in 1990 to
4.6 million in 2010, a 70% increase in 20 years (US Census Bureau, Historical Census
Data, 1950–2000; and Current Population Survey, 2010a).
The changing racial/ethnic composition is significant for health and social service pro-
viders. The concept of double jeopardy defines the later life experiences of older persons of
color who bring a lifetime of cumulative social disadvantage to their later years. Racism,
combined with ageism, results in marginalized social experiences for many within these
groups. Within the Hispanic and Asian groups, this condition is further complicated by
language barriers, as many immigrate later in life to help support their families. As a result,
they have low levels of language skills, and lack social connections and assimilation into
society, which results in isolation and depression (Kim, Park, & Heo, 2010).
Gender Differences
There are also significant gender issues within the older population. Women’s life expec-
tancy is greater than that of men in all racial and ethnic groups (Arias, 2014). As a result,
widowhood is a normative social role for women. Because of the pool of available women,
men who lose a spouse in later life are more likely to re-partner (US Department of
Health and Human Services, 2013). However, the lack of available men results in women
living alone or with their adult children.
Poverty is another late-life gender issue. While programs such as Social Security and
Medicare have reduced the overall poverty rate in the older population, segments within the
population continue to struggle with adequate resources. For example, there are substantial
differences in poverty rates by race and gender. White males had the lowest poverty rate,
while older Black and Hispanic women had the highest (Federal Interagency Forum, 2012):
• The poverty rate for White men over 65 years was 5%, as compared to 14% for older
Black, Hispanic, and Asian men.
8
• White women over age 65 years had an 8% poverty rate. This percentage compares to
15% for Asian women, and 21% for both Black and Hispanic women.
Cohort Variations
The older adult years span several decades, from age 60 to 100+ years, and includes dif-
ferent cohorts. As a result, there are variations and differences within the older adult
population, which is another aspect of diversity. Birth cohorts are defined as a “group
of people born during a particular period or year” (Segen’s Medical Dictionary, 2011).
Older adulthood includes multiple generations, including those who have experienced
the Great Depression (born between 1901 and 1924), World War II (born between 1925
and 1945), and the baby boom generation (born between 1946 and 1964).
The social era in which an individual develops will impact and shape behavior and
responses. For example, the baby boom generation experienced the Vietnam War,
Watergate, and the rise of the civil rights movement. As a result, this generation has been
more questioning of authority, with the expectation that baby boomers will be more
“consumer-oriented” in their approach to health and social welfare services. That is, they
will be less apt than the previous generation to take information from health and service
providers at face value, and they may investigate alternatives or seek multiple options
more often than their parents and grandparents (Olson & Wiley, 2006).
HEALTH AND FUNCTIONING

Although older adults are living longer than previously, advancing age often includes
health-related declines and decreases in functional ability. There are examples of excep-
tional individuals who maintain high levels of fitness into very late life. For example,
Olga Kotelko successfully competed in track and field events until her death at age 95
(Grierson, 2014). However, most individuals are not at this peak level of capacity at
this point in the life course. Approximately 91% of older adults have at least one chronic
health issue; 75% of older adults have at least two chronic conditions, such as diabetes,
arthritis, or hypertension (National Council on Aging, 2014), and often these conditions
have a negative impact on their functioning and well-being.
Within a health-care context, acute health problems were previously associated
with high death rates. For example, the Spanish flu of 1918 had a dramatic impact on
the population worldwide, especially on young adults. Estimates of death range between
50–100 million people (Taubenberger & Morens, 2006), which is about one of every
five individuals in the world. These global pandemics now are quite rare as vaccines, tech-
nology, and advanced public health practices have become more sophisticated and have
decreased the prevalence of outbreaks.
As a result, the more typical pattern is for an older individual to manage a chronic
health problem. All but one of the leading causes of death of older adults are chronic
9
conditions. Although heart disease has declined since the 1980s, this remains the leading
cause of death for people over age 65. The other leading causes of death in the older popu-
lation are (in order): cancer, chronic lower respiratory disease, stroke, and Alzheimer’s
disease, diabetes, and pneumonia/influenza (Federal Interagency Forum, 2012). While
these chronic conditions are serious, many can be managed by appropriate treatment.
However, there is also a probability that individuals with these health conditions will
require other types of support to manage these conditions, such as care provision, modi-
fication of their household, or a move to a more supportive residential situation, such as
a long-term care facility.
Differences exist in health conditions by sociodemographic variables. Women
have higher rates of asthma, hypertension, and arthritis than men. However, men have
more cancer, heart disease, and diabetes than women (Centers for Disease Control &
Prevention, 2014). Different health patterns are also reported by race and ethnicity.
Older African Americans and Hispanics had higher rates of diabetes than Whites of simi-
lar ages. In addition, older African Americans also had higher rates of hypertension than
Whites. However, older Hispanics had lower levels of arthritis as compared to similar age
Whites (Federal Interagency Forum, 2012).
One of the most challenging conditions of older life is Alzheimer’s disease, the most
common type of dementia, which is characterized by memory impairment, person-
ality changes such as agitation and hostility, and decreased judgment and orientation.
Alzheimer’s disease can last for years, and requires increasing support, which is mainly
provided by family (US Department of Health and Human Services, 2014). As a result,
those who are in care provider roles (mainly spouses, partners, adult children) ben-
efit from interventions and resources to help them cope with the multiple and complex
tasks of care associated with dementia. Dementia is a serious concern, both as a health
and public policy issue, because of the nature of the disease process. With the advanc-
ing growth of older adults who are 85 years and older, the rates of Alzheimer’s disease
and other dementias are expected to double for every 5-year interval beyond age 65 (US
Department of Health and Human Services, 2014).
MENTAL HEALTH ISSUES IN LATER LIFE

In addition to health conditions, later life may include mental health issues for older
adults. For example, the multiple changes that are experienced during this part of the life
course—such as role shifts (e.g., retirement, widowhood) and functional limitations (e.g.,
no longer driving)—can be precipitating factors in geriatric depression. However, other
conditions are lifelong experiences that older adults bring to their later years. For example,
people with severe mental illness (SMI) are living longer lives than previously (Cummings
& Kropf, 2011). In later life, people with SMI may exhibit different symptoms, and require
care and support to deal with the interaction of aging with their mental health condition.
10
Therefore, the mental health conditions of older adults may emerge during this period of
life, or might be a long-standing issue that is carried into their later years.
Geriatric Depression
The most prevalent mental health conditions of later life are geriatric depression and anx-
iety. The Geriatric Mental Health Foundation (2015) references the following statistics
about geriatric depression:
• Depression affects 15 out of every 100 adults over age 65.

• Rates of depression in the community range from 1% to 13%.
• The prevalence rate of major depressive disorders (MDD) is 1.8% in the over-65
population.
• 13.5% of depressive syndromes are considered clinically relevant in this population.
• During the first year, over half of the residents of long-term care facilities experience
depression (54.1%).
Depression can have grave consequences for older adults. Those older adults who
suffer from geriatric depression have poor physical and cognitive functioning, poorer
perceptions of their own health status, lower health utilization rates, and increased
health-care costs (Cole & Dendukuri, 2003).
A particularly devastating outcome of geriatric depression is elder suicide. In many coun-
tries in the world, including the United States, older adults have high suicide rates, espe-
cially older men (Conwell & Thompson, 2008). In the United States, suicide rates for males
are highest among those aged 75 and older, with a rate 36 per 100,000 individuals (CDC,
2010). Suicide is a significant public health concern during later life, and this trend is con-
tinuing as the baby boom generation ages. Between 1999 and 2010, the suicide rate among
men aged 45–64 years increased 43%. For adult women, the largest percentage increase in
suicide rate was in the 45–64-year age group, a (Curtin, Warner, & Hedegaard, 2016).
Substance Abuse and Addiction

Addiction is another serious concern in later life, and rates and patterns of addictions are
changing as baby boomers enter their later years. Currently, the annual number of older
adults with substance abuse disorders is about 2.8 million. This number is expected to
double by 2020, when it is expected to increase to 5.7 million (Han, Gfoerer, Colliver, &
Penne, 2009).
Nicotine is the most common addiction and impacts 18%–22% of the older adult
population. The next most prevalent addiction is alcohol, which impacts up to 18% of
older adults (Blazer & Wu, 2009a). Currently, illegal drug rates remain low (less than
1% of the over-65 population). However, marijuana use is increasing as the baby boom
generation ages. Marijuana dependency accounted for .12% of the over-65 age group, but
was about 4% in the 50–64-year group (Blazer & Wu, 2009b; Han, Gfoere, & Colliver,
2009). With changing patterns and types of addiction, additional research is needed on
effective treatment approaches, as well as interactions with other medication.
1
Older adults are an over-prescribed population, and medication can create several
problems with this population. First, the interaction of prescription drugs and alcohol
can be dangerous or lethal. An estimate is that 19% of older Americans may be impacted
by using both medications and alcohol (Blow, 2013). Additionally, age-related changes
create more health-related problems when older adults use alcohol. Decreases in the
percentage of water in the body means that alcohol impacts older adults more quickly
(especially older women) and absorbs more slowly. Therefore, alcohol is cleared less
efficiently and stays within the system, risking drug reactions and health problems
(e.g., ulcers, risk of falls). Additionally, those who are long-term drinkers are at risk
for psychiatric illness. Older adults are three times more likely to develop depression,
cognitive losses, or anxiety disorders if they have a lifetime diagnosis of alcohol abuse
(Blow, 2013).
Severe Mental Illness

As the general aging population is increasing, so is the population that is aging with a
severe mental illness (SMI). The typical diagnoses that are classified as SMI are schizo-
phrenia and schizophrenia-related disorders, bipolar disorder, major recurrent depressive
disorder, and personality disorders (Cummings & Kropf, 2011). Current estimates sug-
gest that about 1.4% of the US population have a severe mental illness and are over age 65
(Hudson, 2012). As the baby boom generation ages, challenges in meeting the increased
mental health needs of the older population are also expected to increase. Unfortunately,
the mental health needs of older adults continue to be overlooked in treatment and policy
arenas (Friedman, Williams, Kidder, & Furst, 2013).
The intersection of aging and SMI creates particular challenges in treatment and care
provision. Compared to their counterparts without psychiatric disorders, older adults
with SMI have more health-related challenges. In addition, older adults with SMI or
addictions are more likely to have multiple chronic illnesses (Lin, Zhang, Leung, &
Clark, 2011). Due to the nature of certain psychiatric conditions, persons with SMI
may also have compromised social, financial, and emotional resources that are needed
in later life (Shepherd, Depp, Harris, Halpain, Palinkas, & Jeste, 2012). These combined
factors can create challenges for the care of older adults who age with a severe psychiat-
ric condition.
SOCIAL CONDITIONS
Several social conditions have also created changes that impact the experience of later
life for older individuals, families, and societies. Family structures have changed, with
greater diversity in the family forms of today. In addition to diversity in race and ethnicity,
as already discussed in this chapter, family structures are shifting by sexual orientation
and identity. These trends are changing the dynamics of later life and have an impact on
caregiving and support for older adults.
12
Shifting Family Structures

Since the baby boom years were a time of high birth rates and lower life expectancy rates,
the population had a greater number of younger individuals than older adults. Since then,
birth and pregnancy rates have changed, which has resulted in different generational con-
figurations within families. During the baby boom years, families had a pyramidal shape;
that is, there were many children, two parents, and perhaps a grandparent or two. Families
of today have a “beanpole” shape; that is, there are fewer children and multiple genera-
tions in later life. On a population level, the pyramids are shifting and becoming more of
a rectangle than an actual pyramid. In Figure 1.2, two population pyramids are displayed,
and the change in the shape over the 45-year time period is dramatic. Corresponding
changes in family structure result in greater numbers of older adults (e.g., older parents,
grandparents, and possibly great-grandparents) with fewer in younger generations to pro-
vide care and assistance.
Families are changing in other ways as well. For example, the United States has
recently experienced a transformation in marriages. In 2004, San Francisco became the
first location in the United States to legalize same-sex marriage (although the ruling was
later overturned). The first couple wed was Del Martin and Phyllis Lyon, who were in
their eighties when they married, after having been together for decades. Later that year,
Massachusetts legalized same-sex marriage, and subsequently, states had the ability to
allow same-sex marriage, although these unions were not recognized at the federal level.
In June 2015, the Supreme Court overturned the ban on same-sex marriage, thus allow-
ing gay and lesbian couples to legally marry in all states within the United States (http://
www.supremecourt.gov/opinions/14pdf/14-556_3204.pdf).
Since the 1960s, when advances in civil rights opened up new opportunities for gay
and lesbian populations, significant advancements in social and political responses to
LGBT issues have been dramatic. Although there continue to be discrimination and back-
lash, LGBT individuals have rights to bear and adopt children and openly serve in the
armed forces (with benefits to their spouses), as just two examples. In addition, special-
ized services to LGBT older adults also exist, which is imperative, as an estimated 2 mil-
lion Americans aged 50 or older identify as LGBT, with that number expected to double
by 2030 (Fredriksen-Goldsen et al., 2011). For example, research on Area Agencies on
Aging (AAA) indicate that four-fifths of the agencies surveyed were willing to provide
training on sexual identity and aging to agency staff to be a more inclusive and welcoming
organization for older LGBT individuals (Knochel, Croghan, Moone, & Quam, 2012).
Caregiving Issues
As the older population increases, families are dealing with issues related to support
for older adults. The majority of care for older adults is provided by informal support
such as family, friends, or other close relationships. As a result, interventions, support,
and resources for the care provider are part of aging services. The “average” US care pro-
vider is “a 49-year-old woman who works outside the home and spends nearly 20 hours
per week providing unpaid care to her mother for nearly five years. Almost two-thirds
13
Male United States: 1980 Female

100+
95–99
90–94
85–89
80–84
75–79
70–74
65–69
60–64
55–59
50–54
45–49
40–44
35–39
30–34
25–29
20–24
15–19
10–14
5–9
0–4
15 12 9 6 3 0 0 3 6 9 12 15
Population (in millions) Age Group Population (in millions)
Male United States: 2025 Female

100+
95–99
90–94
85–89
80–84
75–79
70–74
65–69
60–64
55–59
50–54
45–49
40–44
35–39
30–34
25–29
20–24
15–19
10–14
5–9
0–4
15 12 9 6 3 0 0 3 6 9 12 15
Population (in millions) Age Group Population (in millions)
F i g u r e .2 Population pyramids: 1980 and 2025. Source: US Census International Data Base, http://
www.census.gov/population/international/data.
of family caregivers are female (65%). More than eight in ten are caring for a relative
or friend age 50 or older” (Feinberg, Reinhard, Houser, & Choula, 2011, p. 1). As this
description suggests, caregiving is another “job” for many in this role. Additionally, care
provision is frequently assumed in addition to other role responsibilities, such as being a
parent, employee, and spouse or partner.
14
Caregiving is associated with significant costs for families. One estimate is that
unpaid family caregiving equals about $450 billion per year (Family Caregiving
Alliance, 2012). However, there is great variability in the cost of care by different con-
ditions. The average out-of-pocket costs for someone with dementia was 81% higher
than caring for patients with other health conditions (Kelley, McGarry, Gorges, &
Skinner, 2015).
However, not all caregiving is provided to older adults, as substantial numbers pro-
vide care to younger generations. Parents who remain in care-provision roles for adult
children with cognitive, physical, or psychiatric conditions have unique support needs.
Typically, these caregivers provide physical, economic, and/or emotional support long
past the usual time period of parenting. Often, they are managing their own age-related
changes and challenges in conjunction with the care needs of their adult child (Greene
& Kropf, 2014). In addition, other family members may assume caregiving roles, such
as grandparents who are raising grandchildren. Currently, approximately 2.5 million
grandparents are responsible for raising one or more of their grandchildren, with 59 years
being the average age of the caregiver (Ellis & Simmons, 2014). Clearly, late-life caregiv-
ing needs to include attention and support for older adults who are in caregiving roles for
their children and grandchildren.
E L E M E N T S O F E F F E C T IV E P RAC T IC E WI T H O LD E R ADUL T S
Although the older population is diverse in terms of functioning and experience, effective
practice needs to take into account the age-related changes of later adulthood. While sub-
sequent chapters provide more specific principles, there are some basic and fundamental
tenets that are a foundation for practice with the older population. The Gerontological
Society of America (GSA) has compiled an evidence-based summary of communica-
tion practices with older adults (GSA, 2012). These include both content and method of
interactions when communicating with older adults.
Although older adults bring a vast experience from their decades of living, those com-
municating with them may use a demeaning or infantilizing tone. Younger generations
may address older individuals in elderspeak—that is, with short, simple sentences, exag-
gerated intonation such as a sing-song effect, or endearing or diminutive terms such as
“dear” or “sweetie” (Balsis & Carpenter, 2006; Williams, Kemper & Hummert, 2004).
In interactions with older adults, practitioners should begin by recognizing if they have
any preexisting ideas about working with aging individuals (stereotypes about cognitive
and physical limitations, for example). In addition, communication needs to be respect-
ful (e.g., “Hello, Mr. Anderson”) and convey a sense of dignity for their life circumstances
(e.g., a knock on a door before entering a nursing home room).
In order to overcome some of the changes that can make communication more dif-
ficult, there are some strategies that need to be in place to maximize interactions with
older adults. Hearing and sight changes can make reading, talking, and listening more
15
difficult. As a result, good practices include attending to the environment when interact-
ing with older adults (e.g., reduce background noises, reduce glare, face older person
when speaking). To be sure that important points are comprehended correctly, a good
practice is to distribute critical information in visual form (e.g., handouts, diagrams, bul-
let lists).
One strategy that older adults use to help with communication is to bring a family
member or close friend to appointments. In a study of physician visits, about 19% of
older adults brought someone along to appointments (Wolff, Boyd, Gitlin, Bruce, &
Roter, 2012). This strategy is helpful; however, practitioners need to be sensitive to com-
munication patterns when another person is involved. In these situations, older adults
need to be involved in discussions and addressed within the dialogue. Avoid marginal-
izing the older adult by using third-person language with the individual is present (e.g.,
“How is he feeling?”).
Much communication is based upon language used, and there are cultural and
cohort variations that can compromise understanding by older adults. Practitioners
may become entrenched in the jargon of their discipline, and terminology may be
unclear to older adults. Additionally, vague language can cause confusion, such
as “take two pills twice a day.” A clearer statement is to tell an older patient to take
two pills after breakfast and two pills after dinner. This provides a clear picture that
enhances understanding and adherence. As younger cohorts, we are accustomed to
dealing with abstract phrases and language. As adults age, plain and specific language
is most helpful in communicating.
O RGANI Z A T I O N O F CHA P T E RS IN T HIS V O LUM E

Practitioners across professions need to be knowledgeable about effective interventions
in practicing with older adults and their families. The purpose of this book is to examine
evidence-based practice with the older population—that is, to analyze which interven-
tions have credible, empirical evidence associated with their implementation with the
older population. With the significant changes in the older population—including size, life
expectancy, health and mental health challenges, and increased diversity—practitioners
in multiple practice contexts need to be well versed in intervention approaches that pro-
mote functioning and quality of life with older adults and their families.
This book is organized into three major parts to provide an analysis of evidence-based
practice. Part I (Chapters 1 and 2) provides an overview of the older population. Content
on the diversity of the population, including sociodemographics, health, mental health,
and functional abilities, is provided. In addition, the various contexts for treatment and
practice are introduced. Settings include community-based, long-term care, and acute-care
settings. Integrated health care issues and models will also be presented within this part.
Part II (Chapters 3–12) critically examines evidence-based intervention approaches
with older adults. The American Psychological Association (APA) defines evidence-based
16
practice as “the integration of the best available research with clinical expertise in the
context of patient characteristics, culture, and preferences” (American Psychological
Association, 2006, p. 280). Based upon the standards promulgated by the Division 12
(Clinical Psychology) Task Force of the APA (1995), the following criteria are used to
evaluate evidence-based treatment (Chambless & Hollon, 1998):
1. At least two good between-group design experiments must demonstrate efficacy in

one or more of the following ways:
a. Superiority to pill, psychotherapy placebo, or other treatment
b. Equivalence to already established treatment with adequate sample sizes.
2. Experiments must be conducted with treatment manuals or equivalent clear descrip-
tion of treatment.
3. Characteristics of samples must be specified.
4. Effects must be demonstrated by at least two investigators or teams.
In addition, this book focuses on those interventions that have been implemented with
samples that either are specifically older adults, or with a substantial number of adults
who are beyond 60 years of age.
Five intervention approaches are included within the chapters. The first type of treat-
ment presented is cognitive behavior therapy (CBT), which is the most commonly used
evidence-based practice to treat mental disorders, especially depression (Field, Beeson, &
Jones, 2015). An individual’s cognitive appraisal (e.g., thoughts, images) shapes the inter-
nal landscape, such as the way the person feels about a situation. As a treatment approach,
CBT works to modify automatic thoughts (Beck, Rush, Shaw, & Emery, 1979) that trig-
ger maladaptive perceptions such as “I’m a burden,” or “I can’t do anything.” The practi-
tioner works with clients to bring understanding about these thoughts and feelings in an
effort to change to more adaptive and functional ones. Since geriatric depression is one
of the most common mental health conditions of later life, CBT is a treatment approach
that has utility with the older population.
The second treatment approach is problem-solving therapy (PST). This approach
assists individuals by enhancing coping abilities to decrease the stresses of negative physi-
cal and mental health conditions. The goal of PST is to help clients engage in resolving
problems that they are currently experiencing (c.f., Hegel & Areán, 2012). The process
involves identifying the particular problems experienced, generating solutions to the
problem, implementing selected options, and evaluating the outcome. Since later life
often involves stresses resulting from managing health and mental conditions, decreased
functional abilities, and residential and social transition, PST is an appropriate treatment
choice to assist older clients with these and related issues.
A third approach is motivational interviewing (MI). This is a counseling approach
that assists clients in resolving ambivalence in an effort to create behavioral changes. In
MI, the process of change involves engaging the client, focusing on a direction for change,
17
evoking the process that the client will undergo to achieve change, and planning strate-
gies to change behavior. This method has been used widely with problems in younger
generations, such as addictions and weight loss (c.f., Armstrong et al., 2011; Heckman
& Egleston, 2010). Although a relatively new approach with older adults, a growing lit-
erature indicates that MI is effective with older adults who have addictions, as well as in
promoting behaviors to support health and wellness in this population.
Two of the more typical treatment types with older adults are psychoeducational
and social support interventions. These are used with a range of conditions, including
situations in which older adults or caregivers need to learn new behaviors (e.g., diet
management in diabetes or hypertension), ways of coping (e.g., caregiving for a person
with dementia), or providing connection with others (e.g., bereavement group). These
approaches are often structured around the unique issues of the individuals, such as a
support group where caregivers have a space to discuss whatever they are dealing with
in the care situation. As such, few of these interventions employ a manualized approach.
However, a robust literature exists around the effectiveness of these two approaches and
the breadth of conditions and contexts where these approaches can be implemented. For
those reasons, psychoeducational and social support interventions are included in the
chapters.
The final intervention approach is unique to aging, as life review and reminiscence are
typically used with older adults over other age cohorts. Although these approaches have
a different focus, both life review and reminiscence use the process of recall and remem-
bering past situations and experiences to enhance present functioning. These interven-
tions are easily employed in various community-based and residential contexts, and can
be used to maintain and preserve functioning and to deal with challenges and functional
decline. Unlike some of the other approaches in this book, reminiscence in particular has
been used widely in dementia care.
For each of these five approaches, theoretical foundations are presented and dis-
cussed. To illustrate implementation, a case example of a practice issue with an older
adult client is presented. Additionally, the empirical research on this intervention with
older adults will be summarized.
Part III of the book (Chapters 13 and 14) examines implementation and chal-
lenges of evidence-based practice in more detail. Factors and conditions that facilitate
successful implementation and produce effective results will be highlighted, as well as
challenges and barriers to successful implementation. As a brief introduction, treat-
ment fidelity refers to the degree that essential elements of an intervention approach
are delivered as intended within the standards and protocols of the approach (Cohen
et al., 2008; Gearing et al., 2011; Naleppa & Cagle, 2010; Tucker & Blythe, 2008).
Different factors can comprise fidelity, such as lack of training for interventionists,
or organizational or structural issues in the setting (e.g., lack of privacy in a nursing
home or staff turnover). Within intervention research, studies typically summarize
the degree and magnitude of change in the dependent variable, such as a decrease in
18
depression scores after participating in CBT. However, there has been less descrip-
tion of the treatment, or independent variable, including description of the treatment
approach and duration, and modifications in using the approach with older clients.
Due to the importance of this issue, treatment fidelity will be discussed in greater
detail in Chapter 13.
Chapter 14, the final chapter, looks toward the future and includes a summary of
“promising interventions” with older adults. In particular, behavioral activation and
mindfulness-based stress reduction will be discussed, as a substantive body of literature
in practice with younger cohorts exists for these two approaches. Finally, the book will
conclude with some thoughts about next steps in geriatric research and practice.
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Another random document with
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III
KING COAL (1810-1910)
THE “Industrial Revolution” that changed the face of a large part of
England is generally stated to have commenced about 1770, when
machinery began to displace hand-labour and so drove the workers
out of their homes into factories. About the same time came the
construction of canals connecting the chief waterways and centres of
population, and the slow improvement of the roads. But none of
these important changes greatly affected the outward appearance of
our villages until about forty years later, when, as the title of this
chapter indicates, the steam-engine replaced the water-wheel in the
factories, and when coal began to make its influence felt all over the
country. Simultaneously there grew up a system of macadamised
roads and stage-coaches, which gave place in thirty or forty years to
railways. For a century coal was the dominant factor in English life,
but since 1910 petrol has played the main part in altering the aspect
of the countryside.
Meanwhile, of course, minor causes have always been in operation.
The progressive enclosure of common land and the gradual
grouping of the old one-acre holdings into large hedged fields
continued all through the early part of the nineteenth century, in spite
of violent agitation by Cobbett. Whatever may have been the
arguments in favour of enclosure, the inevitable effect on village life
was to squeeze the small man out of existence and to perpetuate the
big farm employing workers at starvation wages. Poverty stalked
through the little cottages, many of which were unfit for human
habitation. The cruel game-laws did not prevent the rapid increase of
poaching, and the woods were sprinkled with man-traps and spring-
guns, which sometimes claimed a gamekeeper for victim instead of a
poacher.
And, while economic conditions were rapidly abolishing the old self-
supporting village community, changes in the means of transport
brought machine-made goods to its doors, thus destroying at one
blow the independence of the village craftsman and the rustic
character of village architecture. Too scattered, too cowed, and too
poor to organise a successful revolt, many of the villagers found their
consolation in the little barn-like chapels erected by the Primitive
Methodists and other Nonconformist bodies in the early part of the
century. Usually severe and uncompromising, often ugly, these
buildings represented a revolt against the partnership of squire and
parson with its iron grip on village life. The dignified brick meeting-
houses of the seventeenth and eighteenth centuries were of another
type, the flamboyant Gothic chapel of Victorian days had not been
conceived, but the village Bethel of 1810 or so is a standing witness
to the cottager’s grievance against the ruling class of his day. Very
little cottage-building was done, for though the population was
increasing very fast, it was migrating from country to town in order to
be near the new factories.
The network of canals that spread over England between 1760 and
1830 or so did not greatly influence the appearance of the
countryside, though their numerous lockhouses and bridges have
the merit of severe simplicity. But the system of new roads
introduced by Telford and Macadam early in the nineteenth century
had an immediate and far-reaching effect. With them we enter on the
brief but glorious coaching-period, which holds such a grip on the
English imagination that it still dictates the design of our Christmas
cards. The “old-fashioned Christmas” that has been such a godsend
to artists implies unlimited snow, holly, mistletoe, and plum-pudding,
with the steaming horses standing in the inn yard and the red-nosed
driver ogling the barmaid. Dickens made the most of it in literature,
Hugh Thomson and Cecil Aldin in art. For the stage-coach
immediately enlivened every village and town lying on the great
highways. The roadside inn came into its own, but after some forty
crowded years of glorious life declined again until the motor-car
provided it with a new lease of prosperity, or at any rate until the cult
of the bicycle gave it a fillip.
The influence of railways on the appearance of the countryside has
been mainly indirect, in the sense of having destroyed the isolation
of villages and hamlets and with it the local characteristics that they
possessed. For example, the use of purple Welsh slates was almost
unknown outside Wales up to the beginning of the nineteenth
century, when they came into common use, for though their colour
and texture is unpleasing, they are relatively cheap and can be fixed
on lightly constructed roofs. So first canals and then railways
combined with factories to spread machine-made goods all over the
country. Otherwise the railway has not greatly defaced the landscape
as a whole, for there are still large tracts of country where one can
be out of sight and sound of it, and it is not so ubiquitous as the
modern motor-car. Many village railway-stations and cottages are
inoffensively designed, and in the “stone” districts of England are
usually built of local materials, but their appearance suffers as a rule
from the dead hand of central and standardised control. The habit of
erecting enormous hoardings in the fields bordering a railway must
go far back into the nineteenth century. Presumably these eyesores
have some object in view beyond merely annoying the traveller and
defacing the landscape, but certainly they must come up for
consideration in the last chapter of this essay.
Two hundred years ago, even more recently than that, the populous
and prosperous parts of England were East Anglia, Kent, Sussex,
Surrey, Somerset, Gloucestershire, and some neighbouring
counties. Agriculture, sheep-farming, and the wool trade formed the
main source of wealth: and the only notable exception was the iron
industry of the Weald, where a sufficiency of wood fuel was available
for smelting. Between 1750 and 1850 the great northward trek took
place, and King Coal became supreme. He ruined an appreciable
part of Yorkshire and Lancashire, smeared his ugly fingers over
mountain valleys in South Wales and elsewhere, created the “Black
Country” in his own image, and last of all produced the terrible blot
that we call the “Potteries,” where the whole landscape looks like a
bad dream.
The most hideous nightmare-panorama that comes to my mind is a
scene of utter desolation not far from Etruria (a singularly
inappropriate name), in Staffordshire, where slagheaps, collieries,
blast-furnaces, potbanks and smoke dispute the foreground. Yet an
old print that I saw in Messrs. Wedgwood’s adjoining works proves
that less than two hundred years ago this was unspoiled country.
From that time onwards, the northern half of England became the
national workshop, and a large part of southern England became a
private garden. At the present moment half the total population of
England is concentrated in five comparatively small districts:
“Greater” London, South Lancashire, West Yorkshire, the “Black
Country” and Tyneside.
Examples of the early factories built towards the end of the
eighteenth century are to be found in the beautiful valley above
Stroud, and in many wild and lonely dales among the Pennine hills.
They stand beside fast-running streams which at first provided the
necessary power, but before long the steam-engine replaced the
earlier method, and a tall chimney was one immediate result.
Smoke, of course, was another. Yet so many of these old “mills” still
survive that we can study their architecture. There are mills in the
Stroud Valley admirably designed in the Georgian manner, with well-
proportioned windows divided into small panes, stone-slated roofs,
and stone walls, innocent of soot and now golden with time. Built of
local materials, they harmonise well with their surroundings. The
same may be said of a few Yorkshire mills, though for the most part
they have been blackened with smoke and are more austere.
Standing by some deserted building of this type, its great wheel
disused and its windows broken, in a lonely valley with only the noise
of the stream audible, one always thinks of the machine-breakers in
Charlotte Bronte’s Shirley, a grim incident of the countryman’s fight
against progress.
But even if an occasional example of these old factories has some
vestige of architectural merit, nearly all of them were unsuited to their
purpose. It does not seem to have occurred to their builders that a
“mill” existed for any object beyond the grinding of the last penny out
of the sweated men and women and children whom it housed. Light,
warmth, decent sanitary conditions—all were utterly ignored. It is
hardly to be expected that the slave-drivers of early Victorian days
would produce buildings of any interest, and in fact the great gaunt
prison-like boxes that desecrate so many Yorkshire and Lancashire
hillsides are a very fair expression of that greedy scramble for money
that has caused such a backwash in our own day. For it must not be
forgotten that some of the most beautiful places in England were
violated in this way. Many people have never visited our northern
counties, which they regard as a foreign land, yet which contain
scenery at least comparable with anything south of the Trent.
But if one takes, for purposes of comparison, the two valleys in
which the ruined abbeys of Fountains and Kirkstall now stand, one
obtains a very fair illustration of the effects of industrialism. They are
only some twenty miles apart, they were founded by monks of the
same Order at about the same time, and in their original state they
must both have been attractively situated. The modern visitor to
Fountains, as he rounds the bend that has hitherto concealed the
Abbey, invariably gasps at the beauty that bursts upon him, for here
a nobleman’s park protects the site and no coal or iron lies near. But
Kirkstall is blackened and overcast by the huge ironworks that sprawl
over the adjoining hillside, a sooty mass of tumbledown sheet-iron
sheds, bristling with tall chimneys belching out smoke; and the river
that formerly fed the monks with trout is now covered with an evil-
smelling and iridescent film of factory waste.
Yet, many and various as were the insults heaped upon rural
England by “captains of industry” in the good old days when England
was making money hand-over-fist, they sink into insignificance
compared with the early Victorian achievement in housing. The
golden age of self-help, philanthropy, missionary enterprise,
evangelical zeal, individualism, and all the rest of it, produced the
“back-to-back” house. The meanest streets of the East End, the
worst slums of our Northern and Midland cities, were built while the
Romantic Revival was in full swing and while Ruskin was lecturing
on the Seven Lamps that he had discovered hanging in Venice. The
wind sown in those prosperous days is quite clearly producing a
whirlwind for us to reap in more difficult times, and one recalls
another text about the sins of the fathers. This is not a faddist or an
extreme view. Mr. G. M. Trevelyan, in his new History of England (p.
683), writes of “the ever-advancing bounds of the realm of ugliness
and uniformity, in its constant destruction of the beauty and variety of
the old pre-industrial world. Indeed the more prosperous and
progressive the country was, the more rapidly did that increasing
work go forward.” And he quotes the grave words of another critic:
“The Nineteenth Century did not attack beauty. It simply trampled it
under foot.”
Proceeding with our examination of the various symptoms for which
we shall eventually have to prescribe, let us now consider what are
the shortcomings of the houses built for the people in the early and
mid-nineteenth century, and more particularly how they have
affected the appearance of our countryside. In themselves they
were, as a rule, either entirely sordid, or both sordid and pretentious.
The former were erected by manufacturers and colliery-owners in
long rows to provide shelter for their “hands” at the minimum price,
the latter were more often the work of that public benefactor known
as the “jerry-builder,” and were erected as a speculation. In the
former case the tenants had no option but to accept what was
offered, so paid the rent required and occupied the house without
demur. The jerry-builder’s houses, on the other hand, had to attract
tenants, hence the pretentious element was introduced in order to
ensnare the tenant’s wife. In those days, nearly all small property
was held on weekly rentals and architects were hardly ever
employed to design cottages or small houses.
But the houses had to be designed somehow, so the builder had
recourse to sundry manuals or copybooks of designs for “Villas and
Terrace Houses” in the worst style of the day. The idea of using such
books originated in the second half of the eighteenth century, when
numerous little calf-bound volumes appeared, but they contained
little more than details of the Roman “Orders,” and such features as
chimneypieces, doorways, etc. The result was that the speculative
builder, who made his first appearance about that time, continued to
build in the traditional manner, but added a classical porch and
interior panelling and similar trimmings, which, even if they were
often rather pedantic and un-English, were always in excellent taste.
The nineteenth century copybooks sprang from a very different
source. “Gothick” architecture, for two centuries a byword and a
reproach among all cultivated people, had been rediscovered. From
Queen Victoria’s coronation to her jubilee, architects romped over
Europe and brought home sketches of Gothic detail from France and
Flanders and Venice. Ruskin, who was not greatly enamoured of
English Gothic, but loved it in its French and Venetian forms, spread
the glad tidings among the middle-class; and the famous architect,
Street, ransacked Italy and Spain in his quest. All this mass of
drawings was broadcast over the country at its period of greatest
industrial prosperity. Once I worked in a provincial office facing a
replica of a Venetian palace, and witnessed the erection of a factory-
chimney copied from Giotto’s campanile at Florence.
Naturally the smaller fry in the building world aped their betters.
Second-rate architects and hack draughtsmen set to work to adapt
and caricature these fashionable forms for use by the builder on
shops and villas. Terra-cotta manufacturers gladly joined in the
game, so that soon scraps of Venetian carving and ornament came
to be turned out by the mile and capitals copied from French
churches were moulded in artificial stone in tens of thousands. To
this movement may be ascribed a very large share in the
deterioration of English towns and even villages, for the “Gothic”
craze naturally spread from the centres of fashion to the smaller
places. A travelled and studious architect, set down in a street of
suburban villas to-day, should be capable of tracing the ultimate
source of the pretentious porches, the tile cresting on the roofs, all
the mechanical ornament reproduced down the row; and in nearly
every case he could derive it from a Gothic church in France or Italy.
The sad thing is that these revived ornamental forms were only a
travesty of the old. Gothic architecture was, perhaps, the highest
form of natural and legitimate building that the world has ever seen:
as adapted by the speculative builder, it had no structural meaning
whatsoever, and consisted in mere chunks of crudely caricatured
ornament, generally misapplied. Ruskin preached truth and honesty
in architecture; but his pigmy disciples missed the whole spirit of
Gothic. The barns and cottages of old England represent that spirit
as well as the French cathedrals and Venetian palaces on which he
concentrated with such disastrous effect, yet the English village has
suffered terribly from the Gothic revival.
For the movement spread to village shops and banks, and, of
course, all new churches erected after 1830, or even earlier, followed
the new fashion. Because every old village already possessed a
parish church, now becoming too large for its needs, there was little
for the Church of England to do outside the towns, though there are
many cases such as that at M—— in Middlesex, where an amateur
effort in church-design by the saintly William Wilberforce, just a
century ago, has ruined a beautiful old village highway. But the
Nonconformist bodies, now flourishing and sometimes even wealthy,
were not to be outdone in the race: so they abandoned the stark
galleried chapels, that had hitherto followed the Protestant type
invented by Wren for his City churches, for an ambitious and often
flamboyant variety of “Gothic” that has created a discord in many a
village street. There seems to have been a prevalent idea that every
place of worship must be decorated with a spire, with tracery, and
with a quantity of ornamental features, quite regardless as to
whether funds permitted of a single one of those features being
worthily executed, whether any of them symbolised the entirely
English and healthy movement that produced Nonconformity, or
whether they harmonised with surrounding buildings. Our final
conclusion must be that the Gothic Revival, which, in the hands of a
man like William Morris, who loved England passionately, might have
done so much to save her countryside, was in fact largely
responsible for its defacement.
Another characteristic of this singular movement was its utter
disregard of what we now call “town-planning.” When Ruskin advised
his audience to treat railway-stations as “the miserable things that
they are,”[2] because he disliked railways, he seems to have been
voicing the spirit of his day, which was quite content to speculate on
the symbolism of a piece of carving in a remote foreign city while
men continued to build the most appalling slums. No town was
“planned” in those days: it “just growed.” Occasionally a
manufacturer like Sir Titus Salt coquetted with the idea of a rational
lay-out for a town, but no scheme got very far until the idealist
founders of Bournville and Port Sunlight inaugurated a new school of
thought, proving effectually that good housing was not necessarily
bad business.
At the present time, when authorities on town-planning have long
made it clear that orderly development is both desirable and
practicable, the haphazard growth of suburbs into the country is a
deplorable and even a painful sight to every intelligent person.
English individualism, sometimes an asset, becomes almost a curse
when it interferes, as it still does, with nearly everything that can be
done to save the English countryside from complete uglification.
Consideration of the possibilities of town-planning in this direction
must be deferred to our last chapter; for the moment let us consider
one or two characteristics of nineteenth-century town growth.
Almost without exception, any man could buy a plot of land
anywhere, and build on it anything he wanted. Tripe-dressing,
sausage-skin making, and one or two other “noxious” trades might
be prohibited in a few favoured localities; the obscure and often
absurd law of “Ancient Lights” occasionally restrained his ardour.
Otherwise, so long as his building was strong enough to remain
standing, and provided with adequate means of drainage, he was as
free as air. Building was essentially a commercial business; the
rights or needs of the community did not enter into the question.
Each man built for his day and generation: the future was left to take
care of itself. Yet even from a financial point of view this was a short-
sighted policy. When Wren’s plan for rebuilding London was upset by
vested interests, a chance was lost of making wide streets that are
now urgently necessary but cannot be formed except by payments of
incredible sums for compensation. A more modern instance is to be
seen in the Euston Road, which was a residential thoroughfare
looking over fields when my grandfather knew it a century ago. Then
shops came to be built over the front gardens as the old residents
fled from the invading streets: and now these shops have to be
swept away with heavy payments for compensation to allow the road
to be converted into the great artery that any intelligent person could
have foreseen when it was first built. This phenomenon is not
peculiar to towns: it applies with equal force to the country districts
that are continually being absorbed by towns. Half the squalor of
modern suburbs is due to indiscriminate development. Trees are cut
down and houses are run up along a main road. Traffic increases,
and the tenants move away. The houses are clumsily converted into
inefficient shops, extending over the front garden, or into seedy
inefficient tenements. Empty plots are covered with hideous
hoardings. Without undue interference with the liberty of the subject,
much of this feckless muddling could be avoided by the exercise of a
little rational foresight.
For this is a question deeply affecting the whole community, not a
petty professional grievance. The mad race from towns to the fringe
of the country is destroying the country for miles round: and the
pathology of destruction is now clearly understood. A brilliantly
realistic description of the growth of “Bromstead,” a typical London
suburb, is to be found in Mr. H. G. Wells’ The New Machiavelli. All
who have witnessed the slow spread of this malignant disease will
agree that he does not overstate the case.
IV
THE AGE OF PETROL (1910
ONWARDS)
IT may well be objected that this is a mere journalese title, for the
influence of motoring on the appearance of the countryside is not
always apparent, and many other factors have been at work, among
them the Great War and its considerable legacy of troubles.
Moreover, some readers may point out that motor-cars were to be
seen in England long before 1910. That is true; but they did not
appreciably alter our countryside before that date, and the number of
them was relatively small.
The most obvious influence that motoring has exerted on England
has been in the direction of road “improvements,” especially since
the War. Few of us foresaw that the clumsy and not very speedy
vehicles which made their first appearance on our highways some
thirty years ago, preceded by a man bearing a red flag, would
eventually cause so radical a change in our ideas of the nature of a
road. For a long time nothing happened. As motors increased in
number and speed and bulk, they continued to become more and
more of a nuisance to the cyclists and pedestrians and horse-drawn
vehicles still forming the majority of road-users. Clouds of dust
whitened the hedges, and choked the inhabitants of all houses
anywhere near a main highway. Accidents became frequent. All this
was unavoidable, because even the best roads made by Telford and
Macadam were unequal to the new conditions, and the far larger
number of narrow winding country lanes were altogether inadequate
for the strain that was now put upon them. An excellent instance of
the resulting state of affairs may still be seen in the Isle of Wight,
where several of the “main” roads are tortuous narrow lanes sunk
between high banks topped with thick hedges. In the summer
months a stream of huge charabancs tears over the whole island
every day. At many places there is no possibility of these
Juggernauts passing each other. Even a hay-cart presents such a
complete obstacle that one or other vehicle has to back till the road
widens, and in places the blockage caused by the charabanc forces
a cyclist or a pedestrian to climb up on to the steep grassy bank
while the monster with its cargo of yelling hooligans pushes past
him. Either roads must be widened almost everywhere or motor
vehicles of all types must be abolished, and, as the latter alternative
is out of the question, we must accept the former as inevitable. How
it may be effected with the minimum of damage to the beauty of our
countryside will be discussed in the next chapter. England has not
yet sunk to the level of the Western States, where it is a simple
matter to shift a barbed-wire fence a few yards back on each side of
the furrows that do duty for a road, and where the iron or wooden
shacks that constitute a “home” may readily be wheeled to a new
site on the prairie. England is a crowded little country full of sacred
associations that go back to the beginnings of our race, and that is
why we hate to see crazy new bungalows lining the Pilgrim’s Way.
Their very appearance is an insult to our English sense of
orderliness and decency, such as we should feel if a negro
cheapjack started selling mouth-organs in Canterbury Cathedral.
In some parts of the country there are stretches of road that can be
widened without material defacement of the landscape, but they are
few. Ancient landmarks hamper progress in most places. Old
bridges, for example, are altogether unsuited to heavy and fast
motor-traffic. Often built askew with the line of a main road, they are
nearly always very steep, very narrow, and, though often sturdy in
appearance, are incapable of bearing the weight of a heavy lorry and
trailer moving with the speed of a railway train. Here again is a
problem requiring solution. Some people would attempt to adapt the
old bridge to modern needs, others prefer an entirely new structure
placed parallel with the old one, and, of course, the third alternative
is complete demolition. The first method is generally impossible, and
there is much to be said for a frankly modern design in reinforced
concrete, provided that it does not stand in too close proximity to the
ancient monument that it supersedes.
Another familiar rural feature that must perforce give way to the
insistent needs of the motorist is the ford or “watersplash.” Much as
we may regret its disappearance, it has to go.
But most difficult of all is the question of dealing with the narrow High
Street of a town or village through which a main artery passes.
Occasionally the jerry-builder has anticipated us here, and has
erected some terrible Victorian nightmare of a shop right up to the
old building-line of the historical cottages that he has demolished. In
such a case the children of the Petrol Age may be able to expiate the
sins of their fathers by pulling down that shop. But more often there
is a building of real merit standing at the very bottleneck through
which the procession of traffic has to squeeze its way, such as the
old church at Barnet or the Whitgift Hospital at Croydon; and then we
are in a quandary, impressed on the one hand by the legitimate
needs of our time, deterred on the other hand by an almost religious
sense of the sanctity of the past. Sometimes the obstacle is a mere
cottage, a barn, a pump, a stone cross, or a quaint structure such as
blocks Hampstead Lane near the Spaniard’s Tavern, yet even these
must be treated with respect. The “by-pass” road, as suggested in
the next chapter, is sometimes the best solution, but is not
practicable everywhere. And lastly, there are the trees. As I write
these lines I can hear the crashes of falling elms and yews that I
have known since childhood. A snorting tractor is pulling them down
bodily with a steel hawser, so that the grass-lined lane that runs near
my home may be widened for the growing needs of what was once a
pretty village.
But a wide straight road does not exhaust the motorist’s
requirements. He becomes thirsty at times, and the village inn has
already risen to the occasion, usually, it must be admitted, without
detriment to the village street. The architecture of licensed premises
is looking up. His car also becomes thirsty, (hence the petrol-station),
and its occasional liability to gastric trouble involves the provision at
frequent intervals of telephone-cabins and repair-shops or garages.
We may profitably consider the design of these accessories and their
relation to country surroundings in the next chapter. The phenomenal
development in the use of motor charabancs has involved the
provision of extensive “parking-places” in all pleasure resorts, e.g., at
Brighton, where a large part of the sea-view from the Esplanade is
blocked. The provision of a “park” at Glastonbury has led to an
outcry recently, and everywhere the problem is pressing.
Finally comes the very vexed question of housing, municipal and
private, that has grown so acute since the War. In this movement the
motorist has played a prominent part, for he has helped to extend
the “Housing Problem,” from its obvious location on the fringes of our
towns, away to the remoter parts of the country. From Kent to
Hampshire the bungalows line our southern cliffs. Housing needs
may be divided into three groups: those of the townsman, the rustic,
and the week-ender. The first concerns us here only to the extent
that new housing in urban districts must of necessity be provided in
the adjoining rural areas: thus London is now so congested that its
County Council has had to acquire large estates in Essex, Kent, and
Middlesex to provide houses for city workers, who are quite properly
dissatisfied with the tenement-dwellings that are their only
alternative. Then, although in many country districts the population is
decreasing, new standards of decency impel the newly-wed to
demand something better than the leaking and verminous hovels
where their parents dwell. All these new houses, whether in country
or town, have been provided in increasing proportion by municipal
enterprise since the War, and hence their design is subject to a
measure of control. Whether that control is sufficient to ensure a
tolerable standard of architectural expression is a matter for further
consideration: at this point it is important to realise that practically all
the post-War “Housing Schemes” have been scientifically laid out on
rational lines, with due regard for the future. It is that central control,
whether exercised by a public body or by a properly constituted
private organisation, which makes all the difference between the
“lay-out” of Becontree or Port Sunlight on the one hand and an
average bungalow settlement on the other. One is a design, the
other an accident,—and the Italian word for “accident” is disgrazia!
Some sixteen years ago I endeavoured to interest the inhabitants of
the district where I live in the possibilities of the then newly-passed
Town-Planning Act. The more enlightened among them readily
responded, but there were some who said that this was a rural area
and that they had no wish to see it turned into a town. Since then it
has turned itself into something resembling a town, but its growth
has been spasmodic and irregular. A few years later came a
proposal to acquire two fields in the centre of the district for a public
park. Again the objectors appeared; what does a semi-village need
with a public park, at a high price too? Fortunately the fields were
acquired, and already they are nearly encircled by building plots.
Meanwhile a great Arterial Road has been driven right across the
new park, cutting it in half and reducing its attractions. Under a
proper town-planning scheme such things would be impossible.
Roads and parks would be laid out on paper years before they were
required; and, though modifications of the first plan would become
necessary from time to time, the ultimate gain would be enormous.
Groups of adjoining authorities are already preparing regional town-
planning schemes in concert, so that trunk roads may be provided in
such a way as to pass through each area to its benefit and not to its
detriment. If “Rusticus” stands too long while the river flows by, as
the quotation on my title-page suggests, he will find the countryside
engulfed.
In my last chapter something was said of the possibilities that the
new science of Town-planning has to offer us, as a result of many
years’ experience and experiment. We have seen the appearance of
innumerable municipal housing-schemes, of “Satellite Towns” like
Letchworth and the new Welwyn, of model industrial communities
like Bournville and Port Sunlight, of communal efforts like the
Hampstead Garden Suburb, of many admirable achievements in the
developments of private enterprise. Originating at the time (1876 et
seq.) when Bedford Park was laid out, the idea developed slowly
before the War and has made great strides since. It is one of the
brightest spots in the history of English progress, but it has not been
sufficient to stem the rush of ersatz building that followed the War.
For it is the bungalow craze, with all that it now implies, which has
most seriously damaged the appearance of rural England during the
last eight years. There is nothing inherently unpleasant in the
bungalow type of house. Properly designed and constructed, it may
be made a thing of beauty harmonising perfectly with its
surroundings. But, to my mind, its advantages have been grossly
exaggerated. On the count of cost, the primary consideration
nowadays, it shows no superiority over the two-floor house;
reasonable privacy for its bedrooms is secured with difficulty; and it
is apt to sprawl over the ground. One cannot quite realise why it has
been so much favoured in recent years; possibly it is merely a
transient fashion, like face-powder or crinolines. There was a great
and a genuine demand for houses after the War, which had to be
satisfied. Nine people out of ten took what they could get, and they
got bungalows. For the most part their ménage consisted of
husband, wife, and a two-seater. Neither servants nor children
entered into the picture. There was a prejudice against everything
connected with the pre-War period, especially with its social
distinctions, and perhaps the ex-service man sought for the
antithesis of the suburban villa. Accustomed for four years to scenes
of ruin and to leaky Army huts, his mind readily accepted the slap-
dash bungalow with its familiar barbed-wire fence and no-man’s-land
of a garden. The effect of flimsiness and impermanence that
characterises so many of these little buildings may be ascribed to
three causes: the difficulty of paying for a house and a car out of an
income that only provided a house before the War, the prevalent
restlessness which almost rejects the idea of settling down in one
place and letting oneself “take root,” and the insidious hold that the
architecture of dumps and sheds had gained on the average man’s
mind in 1914-18. His two-seater carried him out into what was (at
first) the peace of the country, where land was cheap. Run up at
express speed to satisfy an enormous demand, these bungalows
spread out for miles along the roads adjoining the towns, thus
avoiding the road-making charges that have to be met on an
ordinary estate. And next this “ribbon” development continued far out
into the country, so that people who had a slight surplus after
meeting their hire-purchase payments for car and furniture could
enjoy a sight of the sea on Saturday and Sunday from a bungalow
perched on the Sussex cliffs. Thus this singular movement has had
its main effect in rural districts, whose little Councils, with their often
rudimentary by-laws, find the problem almost beyond their power to
solve.
For these bungalows are for the most part designed without
knowledge or taste, without regard to the tradition of English
architecture or the claims of the English landscape. They are
generally built of flimsy machine-made materials, largely imported
from abroad. Yet they have satisfied a perfectly legitimate demand
for accommodation, they have been erected honestly by builders
and paid for by their owners, and they have so far complied with the
laws of the land that they have earned a Government “subsidy”
towards their cost. Hence the bungalow, which many of us regard as
the motorist’s least acceptable gift to the countryside, constitutes a
topic which must be criticised with extreme tact and caution.
There must be many beauty-spots in England that have been spoilt
by motorists and charabancs since the War, but as a fair case one
may cite X—— in Romney Marsh. A few years ago this was an
artists’ paradise and a haven of peace. It has now become a glorified
bus-park, where one is surrounded by petrol-pumps, garages,
blatant exorbitant cafés run by loud-voiced aliens, “souvenir” shops
full of Brummagem and German products, ice-carts, and
innumerable direction-posts to “ladies’ cloak rooms.” All the charm of
the place has gone in bribes to the tripper, and when he tires of it the
ugliness will remain. When one sees a beautiful village or landscape
prostituted to such ends, one wishes that the petrol-engine had
never been invented.
But is ugliness an inevitable concomitant of motoring? Last April it
was my good fortune to travel some 200 miles over the main roads
of Tuscany. In that considerable distance I saw not a single petrol-
station, and hardly a poster or a hoarding. The petrol-pumps must
have been there, but at any rate they were not obtrusive enough to
attract notice. Some people may say that the apparent absence of
these accessories of civilisation furnishes an additional proof of
Italian backwardness, others that the iron hand of Mussolini prevents
progress; but to me, as a lover of Italy, it is a satisfaction that she
has contrived to reconcile the legitimate needs of to-day with the
beauty of her countryside.
V
THE FUTURE
THE first part of this little book described rural England as it existed
in its unsullied perfection, the second part the regrettable changes
due mainly to the use of coal and petrol, and now we have to
consider what prospect there is of saving the best of the old and
making the best of the new. If “Rusticus” desires to preserve the
remainder of his heritage, he must adopt some bolder policy than
that of gazing at the flowing stream. Nor will the tactics of Canute
serve his purpose: the tide of “civilisation” will not stop for him. There
is every indication that it will flow with undiminished velocity in the
coming years.
Our efforts must therefore be directed to two objects: the
preservation of such relics of the past as are of recognised worth,
and the regulation of all tendencies that are harmful to the beauty of
the countryside. It is heartening to see, in the recent formation of the
Council for the Preservation of Rural England, some public
expression of interest in this vital matter. Without presuming to offer
suggestions to so august a body, it is my purpose to set down in
order the chief factors in the situation, present and future.
In a previous passage it has been remarked that ruin as such is a
matter for regret, not for admiration. One might go a step further and
say that old buildings are not necessarily good buildings. Strictly
speaking, that is true, but is also dangerous doctrine. Nearly all old
buildings are good buildings, and when we find one that we are
disposed to reckon as bad, we must not forget that the canons of
architectural taste have always been fickle. In the eighteenth century
Gothic buildings were ridiculed, and were treated accordingly. In the
nineteenth, taste was completely reversed. On the other hand,
certain architects of the Gothic Revival were so enamoured of a
special variety of Gothic that they endeavoured to remould all old
churches of any differing period nearer to their hearts’ desire. Hence
the formation in 1877 of that body which is familiarly and even
affectionately known as the “Anti-Scrape,” more precisely as the
Society for the Protection of Ancient Buildings. It was founded by
architects and others to protest against excessive zeal in
“restoration” by architects and others, and has done a noble work. It
is still maintained partly by architects, whose disinterested efforts in
preserving old buildings are worthy of note because architects
naturally depend for their living mainly on new buildings. As its
headquarters are in London, its work in other centres is most
effectively done through the medium of a local committee. The
essential qualifications for such a committee are taste and
disinterestedness. Suppose that an old cottage or barn on a village
street in Blankshire is threatened with demolition. If the matter is
brought to the notice of the Blankshire local committee by any self-
appointed (even anonymous) “informer,” that committee will offer an
opinion, backed by the expert advice of the S.P.A.B., who may be
able to suggest some alternative to demolition. Their knowledge of
the technical details of restoration is unrivalled, especially as regards
building materials suitable for use in an old structure. If the cottage is
older than a.d. 1714 and of sufficient merit, the aid of the Ancient
Monuments Commission may be invoked. Once such a building is
scheduled as an “ancient monument,” the owner is deprived of his
right to demolish or alter it, and its existence is safeguarded by the
Government. Another means of frustrating base designs on an old
building is to appeal to the National Trust for Places of Historic
Interest or Natural Beauty, who may be induced to launch an appeal
through the Press for funds to purchase it. At present they maintain
over twenty buildings, including some which are of literary interest
(e.g., Coleridge’s cottage) rather than of great antiquity. A third
alternative is to enlist the sympathies of a local authority or a local
philanthropist. In any case the delay in demolition caused by creating
an outcry will serve a useful purpose, for a thoughtless owner may
be led to reconsider his original intentions, and by so doing may find
that the building may be preserved after all. The restoration of old
buildings is much more practicable than any yet discovered use of
monkey-gland is to old people. But of course there are cases,—and
sentimentalists are apt to overlook this fact,—where an old building
has no architectural merit, and simply must give way before the
march of progress. It is difficult, too, to see how a man can be
compelled to maintain a disused windmill. It may be added that
bridges are among the “buildings” scheduled as “Ancient
Monuments.”
As regards natural features, it must be generally known that the
National Trust, already mentioned, has been very active during
recent years in acquiring and preserving all manner of beauty-spots
in England, including such various sites as the mountains of the
Lake District, strategical points on the North and South Downs, river
banks, hill-tops and cliff-tops all over the country. Unfortunately the
era of enclosing commons is not yet over, and another organisation
—the Commons and Footpaths Preservation Society—was founded
in 1865 to further the excellent objects indicated by its title. It saved
Epping Forest, Hampstead Heath, Wimbledon Common and many
other familiar places for us, and continues to watch over the interests
of all lovers of the country. But, like the other societies mentioned
here, its activities are limited by its funds. However, we must
remember that any district which has adopted a town-planning
scheme can now invoke the majesty of the law to save its open
spaces and natural features, for the first Schedule of the Town-
Planning Act of 1925 includes a reference to “the preservation of
objects of historical interest or natural beauty.”
There have been many recent agitations—notably in regard to Ken
Wood, the Seven Sisters, the Devil’s Dyke, and the Darenth Valley—
which have shown that, in the last extremity, the public will
sometimes rise to the occasion when a beauty-spot is threatened.
Considering the narrowness of the average village High Street, and
the concentration of its historical relics in its centre, there is much to
be said for the construction of a “by-pass” road to carry through
traffic round the village. Otherwise the village green, the pond, the
stocks, the inns, and nearly all the old landmarks would have to go.
Traders object in the case of the larger towns, but vested interests
always turn up somewhere, and it seems fairly certain that the “by-
pass” road meets the needs of the greater number besides

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Evidence-based treatment with older

adults : theory, practice, and research

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E VID E N C E - B ASE D P R ACTICES

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Family Psychoeducation for Serious Mental Illness

School Social Work

Mental Health Treatment for Children and Adolescents

Individual Placement and Support

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Evidence-Based Treatment with Older Adults

Published in the United States of America by Oxford University Press

© Oxford University Press 2017

All rights reserved. No part of this publication may be reproduced, stored in

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Part I Overview of Later Life Issues

1 Introduction to the Aging Population 3

2 Settings and Contexts for Geriatric Practice 22

Part II Evidence-​Based Interventions With the Older Population

3 Cognitive Behavioral Therapy: Theory and Practice 47

4 Cognitive Behavioral Therapy: Evidence-​Based Practice 69

5 Problem-​Solving Therapy: Theory and Practice 87

6 Problem-​Solving Therapy: Evidence-​Based Practice 103

7 Motivational Interviewing: Theory and Practice 127

8 Motivational Interviewing: Evidence-​Based Practice 151

9 Psychoeducational and Social Support Interventions:

10 Psychoeducational and Social Support Interventions:

11 Reminiscence and Life Review: Theory and Practice 207

12 Reminiscence and Life Review: Evidence-​Based Practice 228

Part III Challenges in Implementating Evidence-Based Treatment

13 Implementation Issues 245

14 Future Directions in Interventions with Older Adults 257

Evidence-Based Treatment with Older Adults

4 Evidence-Based Treatment with Older Adults

O LD E R ADUL T H O O D : A B I O P S Y CH O S O CIAL O V E RVI E W

INCREASES IN THE AGING POPULATION

6 Evidence-Based Treatment with Older Adults

DIVERSIT Y IN LATER ADULTHOOD

Race and Ethnicity

U.S Foreign-Born Population Ages 65+ (in millions)

1950 1960 1970 1980 1990 2000 2010

8 Evidence-Based Treatment with Older Adults

HEALTH AND FUNCTIONING

MENTAL HEALTH ISSUES IN LATER LIFE

10  Evidence-Based Treatment with Older Adults

• Depression affects 15 out of every 100 adults over age 65.

Substance Abuse and Addiction

Severe Mental Illness

12  Evidence-Based Treatment with Older Adults

Shifting Family Structures

Male United States: 1980 Female

Male United States: 2025 Female

Part II Evidence-Based Interventions With the Older Population

4 Cognitive Behavioral Therapy: Evidence-Based Practice 69

5 Problem-Solving Therapy: Theory and Practice 87

6 Problem-Solving Therapy: Evidence-Based Practice 103

8 Motivational Interviewing: Evidence-Based Practice 151

12 Reminiscence and Life Review: Evidence-Based Practice 228

4 Evidence-Based Treatment with Older Adults

6 Evidence-Based Treatment with Older Adults

8 Evidence-Based Treatment with Older Adults

10 Evidence-Based Treatment with Older Adults

12 Evidence-Based Treatment with Older Adults

14 Evidence-Based Treatment with Older Adults

16 Evidence-Based Treatment with Older Adults

1. At least two good between-group design experiments must demonstrate efficacy in

18 Evidence-Based Treatment with Older Adults

20 Evidence-Based Treatment with Older Adults