Category: Role of psychologists

Reflections on the value of psychology services

When psychologists provide direct care services to long-term care residents, a note is required for every session, documenting symptoms, therapeutic interventions and other information proving that each and every session is medically necessary. The goals and progress of treatment are reviewed every three months. Audits and case reviews by insurers are not uncommon. Other disciplines in the organization read the notes and can incorporate the work into their efforts or, occasionally, question why the resident is being seen.

Sometimes, particularly when I haven’t had a vacation for a while, I wonder if I’m being truly helpful. I don’t want to discontinue treatment too soon because often mine is the only consistent, deep contact a resident has in life, but the steady drumbeat of needing to prove it’s worth it can lead to doubts at times.

Luckily, my residents have a way of letting me know that my services make a difference to them.

I was considering discontinuing treatment with a somewhat confused woman. When I woke her from a nap the other day, she smiled broadly, pointed to my business card which she keeps by her nightstand and almost leaped out of bed to talk to me. She spent the session following up on topics we’d been addressing in previous sessions and proudly showing me her progress on activities in which I’d encouraged her to engage.

I’ll keep going with her a while longer.

Another resident approached me in the hall recently, saying he’d been waiting for me and telling me, “You give me a reason to live.”

I’d consider that medically necessary, wouldn’t you?

Help for hoarders, and those who care for them

Here’s my latest article on McKnight’s Long-Term Care News:

Help for hoarders, and those who care for them

It can be challenging for long-term care providers when residents amass large quantities of possessions. Facilities generally worry about hoarding when the amount of belongings prohibits the resident or staff members from safely moving about their room or apartment.

Other concerns include fire safety and the possibility of attracting vermin in spaces that are unable to be properly cleaned, as well as apprehension that a cluttered room will attract negative attention from state surveyors.

On the other hand, cleaning out a room against the will of a resident could be perceived as a violation of their right to “security of possessions.”

Facilities often feel stuck between the proverbial rock and a hard place.

Firsthand observations

Over the years, I’ve observed many different scenarios that arise when facility try to manage residents’ hoarding. Here’s a small sample:

• “The State is going to be here any minute,” the Director of Social Work told me, her voice rising a couple of octaves with panic, “We need you to tell Mrs. White that she’s got to get rid of all that junk.”

• Hoarder Number One, complaining bitterly about Hoarder Number Two: “Why are they telling me I need to throw away my things when she has even more stuff than I do? Her room is a mess! At least mine is organized. They just don’t bother her because she’s friends with the administrator.” (All accurate perceptions.)

• Comment from the maintenance guys to the hoarding resident after showing up at the door with cardboard boxes and a dolly: “We’re going to pack up your room for a few weeks until after the State visits, then we’ll bring it back.”

• Sitting with Ms. Rosario following an unannounced purge of her room while she was at dialysis: “How could they do this to me? I trusted them! That stuff was really important to me,” she said, referring to, among other things, an assortment of straws and every food tray slip she’d gotten since her arrival at the facility over a year ago.

What is hoarding?

For the entire article, visit:

Help for hoarders, and those who care for them

Seeing Virginia (an anecdote): Part Two

Seeing Virginia: Part One

Like many of my residents over the years, Virginia had been a nursing assistant prior to her retirement. In our early sessions, I encouraged her to discuss how it felt to be “on the other side of the stethoscope,” as I put it, but she was too focused on the plot to steal her home.

I spoke to her social worker about it. “I’m not sure if Virginia is going to benefit from therapy because she’s pretty confused, but is there any reality to her worry about her house?”

Her social worker sighed. “I was hoping when she first got here that she could go home, but her daughter is selling her house so that’s not going to happen.”

I could see how that could be interpreted as theft.

I kept meeting with Virginia, making mental notes on how much time in each session was spent on agitated theories versus reasonable discussion of confirmable events. I met her comments about plots with empathy and redirection; I greeted her reports on attending activities with enthusiasm. Our early meetings were about 90% agitation and 10% reality, then 80/20, then 70/30. We were making progress.

A minor health crisis proved mentally beneficial. We discussed her doctor’s recommendations, things she could do to take care of herself and what to expect when she went to the hospital for her medical procedure. The conversation was now 80% reality.

The week after her return from the hospital, she expressed concern about her roommate. “Tell them to check her for a rash. I thought I noticed something last night.”

They checked. There was nothing. But Virginia the nursing assistant was back.

Seeing Virginia (an anecdote): Part One

The first time I met 87-year old Virginia, it was immediately apparent why the nurses had made the referral. She spoke too quickly, words pouring out one after the other without pause. She had vague theories that a staff member was trying to steal the house she’d vacated a few months ago and attempting to steal her boyfriend as well. She couldn’t identify which staff member it was, nor could she recall what day it was or the name of the United States president. “He’s got a wife and two kids, I remember that much,” she told me.

Her gray hair was orange at the ends, giving her an unfortunate clown-like air; the flowers on her hat emphasized this effect. Her fingernails had been painted red weeks ago with only small bits of color remaining. She lifted up her floral shirt despite my protests to show me that she had no bra in her clothing collection.

“Do you think I’m crazy?” she asked with concern at the end of the interview.

“I think you’ve got a lot going on,” I demurred, “and I’d be happy to try to help you sort it out.”

“I wish you would,” she replied, satisfied.

Seeing Virginia: Part Two

Kind words from residents

Here’s my latest article on McKnight’s Long-Term Care News:

Kind words from residents

At a conference last week, I remarked to my audience of recreation therapists, “None of us went into this field for the money — we did it for the juice.” And by “the juice,” I mean the good feeling we get from helping seniors and the nice things they say to us in return.

This is why your employees stay, despite everything else.

To get us in the spirit of gratitude for Thanksgiving, I’ve included a sample of comments made by residents to their psychologists. (I solicited material from my colleagues in my favorite shrinky organization, Psychologists in Long-Term Care. I actually heard some of them at work myself, but I’m not gonna tell you which ones.)

• “Without you, I’m like a ship without a rudder.”

• “Girl, I am so happy to see you. I love your smiling face. You help me so much when you come. I don’t feel so crazy.”

• “Thank you for listening to me & not giving up on me.” (Written on a “Wow!” card.)

• “I know you understand. I’m not crazy, but sometimes I feel like I am. My family doesn’t get it and the girls here don’t have time to talk to me.” (LTC Alzheimer’s resident with pain issues.)

• “You help me to look at my life here in a way that my family, friends, and nursing staff can’t.”

• “You don’t know how much it helps to have someone come in and listen and talk to me! I’ve just felt lost. I know I forget things, but since you’ve been coming, it seems like I’m less befuddled!” (LTC resident with early onset Alzheimer’s disease.)

For the entire article, visit:

Kind words from residents

‘The Adventures of The Geropsychologist’!

Here’s my latest article on McKnight’s Long-Term Care News:

‘The Adventures of The Geropsychologist’!

“The Adventures of
The Geropsychologist!”

Starring Dr. El as
The Geropsychologist!

There have been thousands of movies and TV shows about the exciting work of cops, lawyers, and hospitals, but long-term care? Fuhgeddaboutit!

Here, Dr. El aims to correct that oversight with a show that reveals the versatility and pragmatism of a nursing home psychologist willing to do what it takes to meet the needs of her residents.

Act 1, Scene 1

In today’s episode, Dr. El walks into 85-year old resident Frank Corolla’s nursing home room. His bed is neatly made and the curtain is drawn between his bed and his neighbor’s in their semi-private room. Mr. Corolla is sitting in his chair in his pajamas and bathrobe, listening to the radio.

Dr. El (in a loud voice): Hey, Mr. Corolla! It’s Dr. El. How are you doing today?
Mr. Corolla (looking sad): Not good.
Dr. El (sitting on the edge of the bed): What’s the matter?
Mr. Corolla: My eyes are hurting me so bad I was crying today.
Dr. El: Did that help?
Mr. Corolla: No.
Dr. El: I’m sorry to hear that. I’ll talk to the nurse. I’ll be right back.

Act 1, Scene 2

Dr. El appears at the nursing station and waits while the nurse finishes her phone call. The nurse hangs up.

Nurse: How are you, Dr. El? How can I help you?
Dr. El: Well, I’m good, thanks, but Mr. Corolla eyes are hurting him so badly he was crying today. I wrote a note for the doctor last week but I don’t see any follow up. Do you know what’s happening with that?
Nurse (looking in the computer): I don’t see anything from the doctor. I’ll call the nurse practitioner.
Dr. El: Thanks!

Act 1, Scene 3

Dr. El runs into the nurse in the stairwell.

Dr. El: Were you able to reach the nurse practitioner?
Nurse: Yes. She put in an order to see the ophthalmologist.
Dr. El: Awesome!

[Canned applause]

Act 2, Scene 1

Dr. El walks into Ms. Johnson’s room and finds her frantically rummaging through her closet with one hand. With the other, she holds on to the wall. She looks like she’s about to fall.

Dr. El: Ms. Johnson! Are you OK? What are you doing?
Ms. Johnson (looking up with tears in her eyes): I was looking for a shirt I wanted to wear and look how they do my things! All crammed in here like they was nothing! They’s something to me. They’s all I got.

For the entire article, visit:

‘The Adventures of The Geropsychologist’!

Behavioral health care — not drugs — for dementia

Here’s my latest article on McKnight’s Long-Term Care News:

Behavioral health care — not drugs — for dementia

Antipsychotic medications have proved ineffective at reducing the symptoms associated with dementia. They also have serious side effects in older adults, including restlessness, dizziness, higher likelihood of falls and other problems that can contribute to an increased risk of death.

Behavioral health interventions, on the other hand, have no such side effects and have been found effective in reducing behaviors such as aggression, care refusal and wandering.

Employing behavioral health techniques with people with dementia becomes increasingly valuable as facilities in this country endeavor to follow the Centers for Medicare & Medicaid Services guidelines and reduce the use of antipsychotic medications.

Global efforts

Dementia care is a pressing issue around the world, and other countries have made headway in shifting from medication to behavioral interventions. Psychologist Paula E. Hartman-Stein, Ph.D., of The Center for Healthy Aging, writes about international programs that implement behavioral health methods in the September/October edition of The National Psychologist.

Dr. Hartman-Stein spoke with Cameron Camp, Ph.D., an expert who consults with long-term care facilities in the United States and abroad.

France

Dr. Camp reports that the French government pays nursing homes to train their staff in non-pharmacological approaches to dementia. The training includes various strategies, including Montessori techniques such as those described by Dr. Camp in his excellent book, “Hiding the Stranger in the Mirror,” and other publications.

Australia

Camp notes that Alzheimer’s Australia provides funding to train staff in behavioral health approaches. Its website, Alzheimer’s Australia Information for Health Professionals, offers helpful information and brief videos that explain the techniques used.

Canada

In Canada, the Canadian Foundation for Healthcare Improvement reports on the success “beyond the team’s expectations” of an effort to reduce antipsychotic medications and implement non-pharmacological approaches. The project saved $400,000 in six months across the Winnipeg region.

STAR-VA in the USA

Here in the United States, the Veterans Health Administration, less constrained by the fee-for-service psychotherapy model that plagues the rest of the country, utilizes staff psychologists and other behavioral health professionals in their Staff Training in Assisted Living Residences (STAR-VA) model.

For the entire article, visit:

Behavioral health care — not drugs — for dementia

Spirituality in Long-Term Care

Here’s my latest article on McKnight’s Long-Term Care News:

Spirituality in Long-Term Care

Last week, a New York Times article referred to the lack of training to prepare doctors to recognize the spiritual needs of their patients. Hospital physician Robert Klitzman, M.D., emphasized in the Well section article the value of meeting these needs.

Psychology graduate school also avoided focusing on clients’ spiritual needs, which were considered to be the province of those with formal religious training. Despite this, I’ve found that many of the conversations I have with residents can be considered spiritual work.

In the beginning of my LTC career, I quickly recognized that in order to be of service in this environment, I needed to come to a spiritual understanding of how such nice people could be dealing with such difficult illnesses. This led me to the book by Harold S. Kushner, “When Bad Things Happen to Good People.” The gist of the book, as I recall it, was that the question is not so much, “Why me, God?” but, “Why not me?”

That stance allows me to help people come to terms with their experiences and also to recognize very clearly that this could be me, or me down the road a few paces. I am merely assisting others as I hope someone will assist me when it’s my turn.

For the entire article, visit:

Spirituality in Long-Term Care

I’m honored to win the 2015 PLTC Professional Service Award!

I’m thrilled to share with you that I’m the recipient of the Psychologists in Long-Term Care Professional Service Award for 2015!

Psychologists in Long-Term Care is “a network of psychologists and other professionals dedicated to the enhancement of mental health and quality of life for those involved in long-term care through practice, research and advocacy.”

They are an amazing group of committed professionals who work diligently on behalf of elders. I’m proud to have my efforts recognized by them.

Dr. El’s Shrinky LTC Fantasy

Here’s my latest article on McKnight’s Long-Term Care News:

Dr. El’s Shrinky LTC Fantasy

I hung up the phone with the managed care case reviewer. The patient in question was in her late 50s, with multiple sclerosis and other physical problems that had unexpectedly interfered with her ability to return home or even to sit comfortably in a wheelchair. Bed-bound, she was irritable with the staff and distressed about the changes in her life, and in financial circumstances that had resulted in this new insurance coverage.

“You can see her for another 30 days,” the case reviewer told me. “After that, I’ll have to send it to a second level review.”

I sat at the desk in the administration office, hyperventilating. What else would need to happen to this resident in order to get more than a month of treatment? An amputation? The death of her only child?

I took my mind to a better place:

I was in my office at the rehabilitation and care center reviewing the psychology calendar for the month:

• This week I’d shadow the east wing staff and focus on team building.

• My weekly open office hours with the staff had several appointments already filled to discuss conflicts with coworkers, finding better ways to interact with a difficult resident, and how an otherwise excellent worker could get to work on time.

• The topic for the August family group meeting was set: How to partner with the staff.

• The monthly staff training topic was planned to coordinate: How to work with families. Other trainings I had in mind were on facing challenges such as aggressive residents, understanding mental illness, dementia without medication and team management of end-of-life care, in addition to handling work/life balance, reducing stress, time management, and coping with loss.

• The data collection for my research project was progressing nicely. Copies of my book, “The Savvy Resident’s Guide,” had been distributed to the recreation therapists, who were using them to run discussion groups with the residents based on chapter topics such as “Working with the staff” and “Making the most of rehabilitation.” Residents were being measured on acquired knowledge, level of anxiety, conflicts with staff and participation in rehab.

For the entire article, visit:

Dr. El’s Shrinky LTC Fantasy