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This Issue:The Aging Veteran | Table of Contents: Summer 2018 | Download this issue

Spotlight on Career Development Awardees

Relaxation training can help older Veterans who suffer from anxiety

 Dr. Christine Gould, a psychologist and VA researcher, is investigating the effectiveness of a new intervention to help older Veterans who experience anxiety. (Photo by Adan Pulido)
Dr. Christine Gould, a psychologist and VA researcher, is investigating the effectiveness of a new intervention to help older Veterans who experience anxiety. (Photo by Adan Pulido)

Dr. Christine Gould, a psychologist and VA researcher, is investigating the effectiveness of a new intervention to help older Veterans who experience anxiety. (Photo by Adan Pulido)

Dr. Christine Gould is a clinical geropsychologist—a psychologist who works with older adults—and a researcher with the Geriatric Research Education and Clinical Center at the VA Palo Alto Health Care System. She is also an affiliated instructor with Stanford University in the department of psychiatry and behavioral sciences.

Her research is focused on understanding and developing new treatments for anxiety disorders that occur in older adults—those who are 60 years or older. She is currently investigating the effectiveness of a new delivery method for an intervention to help older Veterans who are experiencing anxiety in later life.

VARQU spoke with Gould about her Career Development Award to help develop a video-based relaxation therapy for older Veterans.

How common is anxiety in later life for Veterans and older people in general?

Anxiety is actually almost twice as common as depression in older adults. We don't have great data on the number of older Veterans with anxiety, but we did find that 1 in 10 older Veterans has elevated anxiety symptoms using the Health and Retirement Study data.

I believe that one specific anxiety disorder—one of the more problematic ones called generalized anxiety disorder—affects about 12 percent of Veterans. When older Veterans have other conditions like medical problems and PTSD in particular, anxiety disorders other than PTSD often co-occur with both medical conditions and PTSD.

What do you aim to accomplish through your Career Development Award?

My award is focused on improving functioning in older Veterans with anxiety disorders. There are two parts to it. One part is to develop and test the relaxation intervention. The other part is to look at ways that older Veterans are interested in receiving psychological treatment over a distance.

We know many older Veterans live in more rural areas or might live at further distances from VA clinics, in addition to having mobility difficulties or transportation difficulties which make it hard to get into clinics. So what I wanted to do was to find and identify some ways of receiving treatment that older Veterans are interested in, for further dissemination.

How are you providing the relaxation therapy?

The relaxation videos—we are calling it the BREATHE program—are delivered through DVD videos. Eventually we might consider using internet delivery or mobile app delivery as well. But right now, people get a set of DVDs—it’s a four-week program—and each week they are asked to watch a video lesson, which explains what anxiety is, teaches diaphragmatic or deep breathing, and teaches a specific type of relaxation called progressive muscle relaxation.

People will watch the lesson once and then they have a practice video which they can use to guide their relaxation practice every day. It's a four-week treatment, and each week they have a different lesson that builds on the previous week.

There is a coach as well, so the patients will receive a telephone call from a provider who will coach them through the treatment, help them adhere to it, and troubleshoot any issues that come up.

Could you explain more in-depth what the BREATHE technique involves?

The BREATHE program is pulling together some different techniques that research has shown work well for anxiety. Diaphragmatic breathing or deep breathing is a skill that is often taught to individuals with anxiety. So we teach that along with the modifications for older Veterans who might have different medical conditions such as lung programs, like COPD.

Then the relaxation technique is progressive muscle relaxation. It's been around for many, many years. It has been well-studied since the 70s. What this technique does is you go through your body and you are guided in tensing and then releasing each muscle group. The thought is first that is helps people really understand and identify where they are holding tension in their body, which often comes up when people are worried or feeling anxious. And also it helps promote relaxation by tensing and releasing different muscle groups—we say it gives patients a running start to relaxation, rather than trying to relax that muscle group from the beginning.

It also gives people who worry a lot a strategy to release that tension and focus on something else, and really focus on taking care of themselves.

How well was the BREATHE program received by Veterans?

We obtained feedback on the videos from 20 older Veterans. It was well-received—they gave us a lot of great feedback about how we could clarify the videos. Right now we are testing those revised videos with 10 older Veterans. Some of the comments—which are still being collected—were that individuals had learned this technique previously in a group therapy or another setting, but by being in a structured program where they have the videos, a schedule when they are supposed to practice, and a coach following up with them by phone, it really has helped them integrate this technique into their daily lives. And really stick with it, as opposed to just learning it once in a group therapy-type setting. 

Does the practice of mindfulness have any similarity to guided relaxation therapy?

Yes, that's a great question. Some of the principles are the same, in that you are really paying attention to your body and noticing the differences between tension and relaxation. One of the main differences is that with progressive muscle relaxation you are manipulating your body by tensing the muscles—where in mindfulness, you would be noticing the sensations in the present moment.

I conceptualize the progressive muscle relaxation as a nice step prior to mindfulness—especially for individuals who are anxious. Mindfulness is a great tool, but it is hard to do if you are not ready to sit there with your thoughts. It is hard to accept anxious thoughts in the moment, to engage in that kind of nonjudgmental observation of them.

Mindfulness requires you to be very still and screen out everything around you—is that correct?

Yes, and just noticing the thoughts that are there. Let's say you have a worry about a medical condition that you have, and you are worried about maybe your blood pressure. With mindfulness you would just be noticing your worries, trying not to judge yourself for being worried, and also, trying not to control or get rid of those thoughts.

Progressive muscle relaxation, on the other hand, is a little bit more active, and could be a good tool for people who are more anxious and need something to help them feel like they get a little bit of control over their thoughts by using this more active intervention. But eventually, mindfulness could be a great next, more advanced, step.

You mentioned that this type of relaxation therapy would be appropriate for Veterans with PTSD. Are there other conditions where this therapy would be helpful?

Definitely, for people who might have pain, you can actually make modifications to the relaxation therapy. If you are having acute pain, you can just imagine the tensing, and that was found in research to actually work just as well as doing the tensing itself. And in the findings that I presented at the Association for Behavioral and Cognitive Therapy conference, in my pilot study, we found that BREATHE intervention reduced anxiety symptoms, depressive symptoms, and also somatic symptoms.

I should say one thing. I spend a lot of time speaking about the relaxation, but the one thing that makes the BREATHE program a bit different is emphasizing taking the relaxation techniques that you have learned and then applying them in your daily life. One of the things that the coaches are aiming to do is to help the Veterans make it a habit—and by making it a habit, I mean really using those relaxation techniques to get back in their daily lives. With chronic pain, movement is actually important, but people avoid the movement because it is very uncomfortable and anxiety provoking. So a tool like relaxation can help people bridge that gap and continue to maintain their functioning as they age.

Once you complete the study, where would you like to take further research?

I think next steps would be thinking about disseminating this intervention. We've created a provider manual to help to disseminate the program more broadly within VA, when we are ready. I can see it being used as a tool for providers in home-based primary care. Psychologists there might have Veterans who live a long distance from their home VA facility use the BREATHE program as a guided self-management technique.

Another avenue of future research is technology. Technology research with older adults is an exciting field because there are many different factors to take into account. One of the factors is advancing technologies. It is harder to find computers with DVD drives/players these days—not as many people have DVDs players.

One of the things that I've found in my study on older Veterans' preferences for technology is that many older Veterans own a smartphone and are interested in using mobile apps. In my study with older Veterans, ages 60 to over 90 years old, 74 percent of those owned a DVD player and 70 percent owned a smart phone. So that is a potential future way of disseminating the treatment.

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