‘Balancing complexity, resources and demand’ : a grounded theory of clinical decision making in psychological therapy for older people with posttraumatic stress symptoms.
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Background: Preliminary evidence suggests there are differences in how older people and younger people with posttraumatic stress disorder (PTSD) present. However, currently little robust evidence exists relating to the presentation, assessment and intervention of PTSD in a rapidly ageing population. Faced with limited and conflicting evidence, clinical psychologists are reliant on their clinical expertise to make decisions in this context. Method: Eight studies reporting current prevalence of PTSD in older people were systematically reviewed. Semi-structured interviews with eight clinical psychologists with experience of assessment and intervention of post-traumatic stress symptomology in older people were analysed according to grounded theory methods. The analysis abstracted categories of data to construct a substantive theory of clinical decision making in this context. Results: Current and 12 month prevalence of PTSD ranged from 0.7% to 4.0% and 0.2% to 0.4% respectively. Partial PTSD was estimated at 1% to 10%. The quality of evidence limits the generalisability of the results. ‘Balancing complexity, resources and demand’ emerged from participants’ accounts as the core theoretical category, underpinning decision making in this context. Seven sub-categories comprise the model, ‘culture’; ‘NHS’; ‘clinician competencies’; “what the client brings”; ‘reconciling understanding’; ‘tailoring’ and ‘therapeutic relationship’. Conclusions: PTSD appears to be relatively rare among older people but more research is required to better understand the presentation and prevalence of full and partial PTSD. The theoretical model is broadly consistent with extant literature pertaining to the adaptation of psychological therapy for older people, offering further detail on implementation and the influence of treatment non-specific factors.