This edition has a special focus on cognitive and behavioural work with older people. Many of the papers have been written by national and international experts in their respective fields and demonstrate the variety and breadth of work undertaken within the specialty. Older people bring heterogeneity to the therapeutic context, with unrivalled opportunity for challenge, versatility and creativity. For example, during a single working day one could find oneself treating a centenarian with depression, a 60-year-old patient with early onset dementia, a person with pseudo-dementia whose anxiety mimics a Parkinson's presentation, a depressed person with chronic heart failure, and a depressed family carer. Alternatively, one could find oneself working with nursing home staff who are struggling to deal with a resident with challenging behaviour. Practitioners require knowledge and skills in neuropsychology, chronic disease management, standard 1:1 therapy, family and systems work. They must also be able to apply a wide ranging set of conceptual frameworks and associated interventions to people with varying degrees of cognitive impairment as well as undertake activities such as supervision, consultation and training of carers, staff and colleagues. Thus therapists working with older people are often acutely aware of the importance of extending treatment to the individual's supporting social context and the system within which treatment is offered.

Cognitive behaviour therapy (CBT) has proven efficacy as a treatment for depression in older people. An important debate amongst therapists working with older people is whether CBT needs to be adapted to ensure optimal treatment outcome and, if so, what adaptations are necessary. It is accepted that psychotherapy with older people can differ from psychotherapy with younger people in a number of important respects because of the higher likelihood of chronic conditions, changes in cognitive capacity, potential loss experiences and different cohort belief systems. As psychotherapists are often much less comfortable dealing with physical problems, they may become negatively biased in terms of outcome when patients present with co-morbid health issues. The impact of loss experiences in older people can also be overemphasized in their importance by inexperienced therapists and can result in lowered expectations for therapy outcome. Consequently, there is a need to develop a model that addresses age related issues within a coherent cognitive therapy framework suitable for older people. This paper describes a CBT model that is augmented with applied gerontological knowledge, taking account of cohort beliefs, intergenerational linkages, sociocultural context, health status/beliefs and role investments/transitions. Clinical examples are used throughout to illustrate clinical implications of the model.

This paper forms the second in a series of three articles on conceptualizations of older people's distress. The focus is on simple and concrete “mini-formulations” that keep the amount of information in them to a minimum, yet retain explanatory and predictive power. Such formulations can be used as the basis for action plans for intervention, while avoiding overburdening the cognitive capacity of the client or therapist. Simple linear and cyclical models are described, as are cognitive triad and dyad models. The uses of “mini-formulations” for group and individual settings are illustrated in a case example of a lady caring for her husband who has dementia.

This is the third in a series of three papers on cognitive therapy formulation with older people. The aims of this paper are to identify barriers to collaborative conceptualization, and to summarize useful strategies for overcoming these barriers. Obstacles to collaborative conceptualization with older clients have previously been thought of as a consequence of age-related skills deficits. In this paper we focus instead on the barriers created by therapistand client-held prejudicial beliefs. A social cognitive perspective is used to conceptualize stereotypical prejudices. Strategies are described for challenging or reframing prejudicial beliefs, and addressing the mechanisms that perpetuate these beliefs.

Mindfulness training (MT) is a meditation-based approach that, on its own or in alliance with cognitive therapy, can effectively impact on several therapeutic targets such as recurrent depression, some anxiety problems, and chronic physical pain. This article outlines how mindfulness training complements cognitive-behavioural therapy (CBT), and why it may be particularly useful to older people. The range of potential applications of MT is examined, followed by considerations of the evidence to date and both the advantages and dangers of current developments within the various MT programmes. The author's ongoing research on Mindfulness-based Cognitive Therapy (MBCT) for older people with recurring depression is described, as is the use of Mindfulness-based Stress Reduction (MBSR) in routine clinical practice. Suggestions are provided regarding future research into the range of applications of MT with older people.

Eliciting, evaluating and changing core beliefs are established features of cognitive behaviour therapy (CBT). However, care must be taken when working at this level of cognition. This is because therapists are dealing with core constructs that, whether dysfunctional or otherwise, influence the patient's self-concept, her world and future. This paper examines when it is appropriate to work at this level and some of the specific problems regarding assessment and the consequences of belief change. It is evident that achieving lasting cognitive change is a difficult task, and this may be in part due to the poor quality of the literature and training in the area. In an attempt to address this, the final section of the paper offers a set of practical guidelines concerning the continuum technique, a well-known CBT method for targeting, evaluating and changing core beliefs. It highlights process features (e.g. planning, management, and interpersonal skills) as being crucial in creating contexts in which change can take place. The work has been written for trainee cognitive therapists and those with a working knowledge of CBT who are seeking to improve their abilities in the use of change methodologies.

This paper summarizes a recently developed model for understanding the genesis of visual hallucinations, shows how this can be incorporated into a cognitive behavioural framework, and then illustrates possible ways in which this may be used to successfully treat the emotional distress that some older people experience as a consequence of their hallucinations. These ideas have been developed as a model-based clinical response to patients distressed by their hallucinations. The purpose of this paper is to outline this approach in order to stimulate discussion and empirical evaluation.

The aim of the study was to examine whether the personality dimensions of sociotropy and autonomy (Beck, Epstein, Harrison, & Emery, 1983) remained stable in older people with dementia. Sociotropy is characterized by the need for social reassurance, approval and contact. Autonomy reflects the need for control, self-determination and task-orientated achievement. A non-clinical normative sample (aged 17–87) confirmed Beck's theoretical dimensions of sociotropy and autonomy. This sample was used to determine cut-points for the two dimensions on the Sociotropy Autonomy Scale (SAS). The SAS was then used with 63 people with dementia to determine whether their personality profiles, in terms of sociotropy and autonomy, were similar to the earlier sample. Data obtained in the personality profiling were examined against mood and behavioural measures for people with dementia. Profiles for both samples were found to be similar, i.e. there were distinct minority sub-sets of high scoring sociotropic and autonomous individuals. Consistent with Beck's theoretical position, high scoring autonomy and sociotropy individuals with dementia were more likely to display mood and behaviour difficulties. It was therefore concluded that aspects of personality (i.e. temperament) remain stable in dementia. The SAS can identify older people with dementia who are vulnerable to mood and behaviour problems. This has direct clinical relevance to the targeting of effective care practices in residential settings.

Aggression, including physical assault, is a significant problem in providing services for older people with mental health problems. A range of bio-psycho-social correlates of aggressive behaviour have been explored in this client group, but little attention has been given to the role of anger as an activator of aggression, despite its demonstrated predictive association with aggression in other clinical populations. In this pilot study, a staff-rated anger measure was administered to 27 inpatients in a specialist service for older people with mental health problems. The Anger Index was found to have high internal consistency and inter-rater reliability, and it showed robust concurrent and discriminant validity with comparison measures completed by independent raters. Higher anger scores were associated with organic diagnoses, history of aggression, and hospital assault data. The potential role of anger in the activation of aggression, the utility of anger assessment in the evaluation of risk, and the value of therapeutic approaches for aggression problems in older adult patients are discussed.

This article provides a cognitive-behavioral model for psychotherapeutic interventions with suicidal elders. The approach is based on a general model of cognitive behavioral therapy (CBT) with older adults described in Laidlaw, Thompson, Dick-Siskin and Gallagher-Thompson (2003), with specific application to suicidal older adults (Coon & Gallagher-Thompson, 2001). The appeal of CBT in working with older clients is its practical nature and psychoeducational orientation aimed at empowering elderly clients to utilize the techniques outside the psychotherapeutic relationship, with the goal of helping elders develop skills that lead toward better daily self-management and increased life satisfaction. In addition, CBT can be effective in either an individual or group format (DeVries & Coon, 2002). This article begins with a brief review of the characteristics associated with suicide in this population, then describes a CBT model appropriate for use with elders struggling with affective disorders, suicidal ideation, or suicidal behaviors, and ends with a case example illustrating the model's use with suicidal older adults.

The treatment of depression in an older person with Alzheimer's dementia using cognitive behavioural therapy (CBT) is described. Treatment focused on identifying beliefs associated with dementia, behavioural experimenting to test the validity of these beliefs, and increasing pleasurable activities. Results were promising, suggesting that it may be possible to treat depression in people with cognitive impairment.

Carers' beliefs about the controllability of challenging behaviour have been shown to be related to their emotional and behavioural responses to such behaviour. This paper describes the psychometric properties of a new 15-item scale that assesses such beliefs. The scale has good internal reliability and a two-factor structure representing positive and negative beliefs about controllability. The negative beliefs about controllability sub-scale correlate highly with a wishful-thinking coping style but not with a practical problem-solving coping style. The clinical use of this scale is discussed.

Supervision of therapy has received a lot of attention, but it has only recently begun to be examined in a systematic and empirical manner. This exploratory project employed a new type of methodology for examining the process of change occurring over four sessions of supervision. Video recordings of four clinical psychology supervision sessions were made, and after each session the supervisor and trainee independently provided commentaries of their experiences of supervision. Based on these commentaries, and further post-hoc reflections, the trainee was asked to choose an aspect of supervision to explore further. She chose to investigate her emotional reactions within the sessions. Hence, she was asked to provide further details about her emotions in each of the four sessions. The focus of supervision was a patient with neuropsychological problems following a stroke. The process analysis revealed that the trainee experienced a wide range of emotions in all of the supervision sessions, with anxiety being the most frequent. These emotions appeared to be responsive to the supervisor's conscious attempts to ensure appropriate affective arousal. Subsequent reflections on the processes highlighted via this methodology suggested that the dynamics observed were consistent with Vygotsky's theory of the Zone of Proximal Development.