6 common problems a shrink on staff can solve (and your consultant can’t): McKnight’s LTC News

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

6 common problems a shrink on staff can solve (and your consultant can’t)

As a psychologist consulting in long-term care facilities, I was paid through Medicare, Medicaid, and/or private insurance for only one task: direct contact with residents. That’s it. I provided a lot more because it was needed, but that’s all I was paid for.

There was much more help that I didn’t offer, not only because I wasn’t paid for it, but also because the organization wasn’t structured to accept this type of assistance. The facilities’ needs were the kinds of things that made me sigh and shake my shrinky head in frustration. Oh, what we psychologists could do for you if we were on staff!

Here are some examples:

Problem #1: Admissions decisions

As your admissions department scrambles to fill beds and wonders whether the facility can manage a new resident with a psych history and a recent diagnosis of cancer, imagine if they could ask the opinion of the psychologist likely to be treating the resident. Now imagine if they could do this for every questionable admission. Psychologists could set up mental health services upon the new resident’s arrival and you would have the support necessary to meet the mental health needs of the residents under your care.

As the number of residents with behavioral issues increases, this psychological screening becomes an increasingly important element of providing good care and preventing time-consuming problems on your units after admission.

Problem #2: Team Communication

Watching two aides argue about giving care to a resident over said resident’s head or observing an essential piece of information get lost between shifts, I’ve fantasized about offering in-service training to eliminate these destructive behaviors. Not half-hour meetings sandwiched in between resident care, but real training that allows time for examples and practice as well as observation and feedback on the floors.

Real training provides the opportunity for staff to turn to the psychologist for guidance in handling the sticky interpersonal dynamics that are inevitable as people work in groups.  It also offers assistance in designing and implementing procedures that facilitate written and oral communication.

Problem #3:  Interacting with residents

Improperly trained staff members frequently escalate tense situations, cause unintended distress in residents, or miss cognitive changes that signal physical illness. They aren’t doing this on purpose — they just haven’t been taught how to handle such situations.

For the entire article, visit:

6 common problems a shrink on staff can solve (and your consultant can’t)

Reducing Learned Helplessness in LTC (McKnight’s LTC News)

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

Reducing learned helplessness in LTC

Despite this, O’Connor points out, psychological services in LTC are often underutilized.  As I noted in my 2010 article, Improving the treatment of mental health issues in nursing homes, we can do more to identify residents who may benefit from psychological services and systematically refer them for treatment before problems become entrenched.

Learned helplessness

The University of Pittsburgh study reported that one of the helpful aspects of psychotherapy is the reduction of the learned helplessness often seen in depression. Learned helplessness comes about when a person believes that they have no control in a situation, even when they do….

Learned helplessness in LTC residents

There are many situations in long-term care that can lead to learned helplessness among our residents. Every time a call bell goes unanswered for too long, it leads residents to conclude that there’s no point in asking for help. When a staff member tells a resident she’ll follow through on a task and then doesn’t, that experience is reinforced.

For the entire article, visit:

Reducing learned helplessness in LTC

My book, The Savvy Resident’s Guide, is a great tool for reducing learned helplessness.  Please consider giving it to your residents or loved ones.

Dr. El speaks with The Practice Institute, Tuesday 4/9 @1pm ET

I was on the plane home from the American Psychological Association conference last August when I noticed that the man across from me had the same APA conference tote I was carrying.  My friendly inquiry led to a very pleasant 3-hour conversation on the flight with psychologist Dr. Jeffrey Zimmerman of The Practice Institute.  The Practice Institute features educational resources for mental health practitioners, including interviews with authors of books on various aspects of building and maintaining a private practice. It’s a treasure trove for psychologists, with timely and essential information from well-established therapists.

On Tuesday, April 9, 2013 at 1pm ET, I’ll be talking with Dr. Zimmerman about

• Working as a psychologist in long-term care
• How The Savvy Resident’s Guide can be used with elders and their families
• The Savvy Guide’s place in the classroom to acquaint students with the concerns of residents and a reasonable approach to addressing these concerns
• The use of social media to expand a private practice

If you’re not able to listen to the call on Tuesday, the recorded interview will be available for members of The Practice Institute on their website.

You can register for this FREE event at The Practice Institute’s Event Registration page.  I hope you’ll join us!

The World According to Dr. El debuts on McKnight’s LTC News

I’m very pleased to announce the debut of my new column at McKnight’s Long-Term Care News.  The World According to Dr. El is a twice monthly column that will address mental health issues in LTC.

Please visit and “Like” the page on McKnight’s to show your support for addressing the mental health concerns of all those involved with LTC.

Inside the mind of an LTC shrink

I sat in morning report as the nursing supervisor announced the arrival of a new resident.  An 80-year old woman was taken to the hospital after a fall at home, where she received a below-knee amputation and contracted C. diff before being transferred to our facility.

I looked around the room and speculated about what each of my team members were thinking, imagining thought bubbles over their heads:

• The wound care nurse was wondering how the leg was healing.
•  The rehab director was considering the chances an 80-year old woman might be able to manage on a prosthetic leg.
• The infection control specialist was mentally reviewing a checklist of infection control procedures that needed to be put in place.
• The social worker was hoping the woman lived in a ground-floor apartment.

What was I thinking about this new admission? I was worried she might be suffering from symptoms of Post-Traumatic Stress Disorder if she had been alone on the floor for any length of time after her fall.

I pondered how she might be handling the assault on her femininity of losing a leg. I wondered about the quality of her family supports and whether she’d consider attending the choir performance where one of the soloists was a glamorous amputee from the third floor.

For more: Inside the Mind of an LTC Shrink

New Old Age column: More Older People Treated for Depression

The New York Times New Old Age blog has an interesting, hopeful article by Paula Span regarding treatment for depression in older adults.  Regarding the stigma of psychotherapy the article mentions, I’ve found nursing home residents to be very receptive to my visits, especially when I phrase my help as “extra support during a stressful time.” Everyone agrees that entering a nursing home is stressful.  (See my earlier post, The Stress of Nursing Home Admission, for more on this.) Occasionally, when someone is resistant but I can tell they need me, we postpone the decision to officially start psychological services and I tell them I’ll “just stop by next week to see how things are going.”  Nine times out of ten, they’re glad to see me and appreciative that I showed up when I said I would.

Here’s the start to the New Old Age post; click on the title below to read the whole article:

 Anna Hill’s mother-in-law had suffered from depression for years, it was clear in hindsight, and had denied it for years, too. Only 73, she’d lost interest in doing much of anything. In chronic pain after an earlier accident, she was taking high doses of methadone. Last November, she stunned her family by declining, at the eleventh hour, to come to Thanksgiving dinner.

Falls in Older People? Anxiety Could Be A Cause

It was previously thought that seniors who are anxious about falling tend to avoid activities that could lead to falls, thus becoming de-conditioned and increasing fall risk.  New research, however, suggests that anxiety about falling itself can increase fall risk.  Hadjistavropoulos, T. et al. asked older adults to walk either in a low anxiety situation (on the floor) or a high anxiety situation (on an elevated platform).  Those who were more anxious (measured through heart rate, self-report, etc) had a less stable gait.  In addition, those who were multi-tasking by carrying a tray had a less stable gait.  The self-report of anxiety about walking was predictive of balance performance — in other words, if they said they were nervous about falling, they didn’t walk as well.

What does this mean for those of us working in LTC?

• We might consider formally or informally assessing the anxiety level of residents regarding their ability to walk.
• If residents appear anxious or report anxiety about falling, rehab therapists could discuss this with them or refer them for psychological services to address the issue.  I frequently talk with residents about the circumstances around their falls and ways to avoid a repeat of the mishap, helping them to feel more in control and reducing anxiety.
• We can advise residents to focus on moving safely about their rooms (or homes upon discharge), rather than on carrying objects from one point to another.

Team Communication: A Shout-Out for CNAs

“How in the world am I going to chart this?” I wondered as I sat across from Nell, who filled her large wheelchair to overflowing.  This was our second attempt at psychotherapy, which I’d discontinued a few months ago because I felt all my efforts had gone nowhere.  Nell sat in her room all day, doing nothing and talking to no one, yet she was clear in her thinking and clearly depressed.  She resisted all of my suggestions, recommendations, cajoling, begging, humor, and coordination with the team to adjust her medications.  Efforts to connect her with her estranged family had produced a tepid response.   “She’s been this way all her life,” her son told me when I’d finally called to tell him I’d stopped seeing his mom.  “I’ve given up,” he added.

Now here I was, three sessions after the team had referred her for psychological services again, trying to determine a treatment strategy in the face of her extreme hopelessness.

“There’s nothing I can do,” she said, “because I can’t see.”

Her talking clock, talking watch, talking books, radio, and TV sat unused after her initial training in how to operate them.

__________________

I consulted with colleagues the next week and they encouraged me to keep going.  “You’re the only person she talks to,” they said.  “That has value.”

__________________

A couple of weeks later I ran into Nell’s aide in the elevator after I’d finished a staff training.

“You know she asks for you all the time, don’t you?” she said.

“She does?” I was shocked.

“You’re Eleanor, right?”

“Yes.”

“She calls ‘Eleanor, Eleanor, Eleanor’ all day long.  And when she doesn’t want to take a shower, we tell her ‘Eleanor wants you to do it’ and then she goes along with it.”

“I had no idea!  Thank you for telling me that.”  I was flabbergasted — and relieved that my documentation could reflect some actual purpose and progress.

___________________

The next week I sat across from Nell with a lighter spirit.

“There’s nothing I can do,” she said, “now that I’ve lost my eyesight.”

“That must be a huge loss for you,” I replied.

Nursing Home Mental Health: The Case of the Call Bell

“I had a couple of relapses this week,” Betty told me, looking ashamed.

We’d been working in psychotherapy on her efforts not to snap at the aides and nurses who came to care for her.

“I try not use to my call bell,” she went on.  “Sometimes I sit here for two hours thinking about it before I press it.”

“Maybe that’s part of the problem,” I suggested.  “If you’re waiting for two hours before you let them know you need help and then it takes them a little while to get here, by the time they arrive you’re ready to explode.”

She nodded.  “That’s true.”

Betty was more psychologically-minded than many residents, so I took things a step further.  “It’s also not taking very good care of yourself to wait two hours to ask for help.  If you had a child who needed help, would you make them wait two hours?”

“No!”  Betty’s bulletin board was filled with the Mother’s Day, birthday, and Christmas cards her only child sent instead of visiting.

“Now you have a chance to give yourself the care you didn’t get as a child.”

“What do you mean?” she asked sharply, “My parents took care of me!”

“From the things you told me about what went on in that house, you children were not getting enough supervision.”

Betty, an incest survivor, stared at me.  “I never thought of it that way.”

“This may sound corny, but now Grown-up Betty has the chance to take care of Little Betty, and ask for what she needs when she needs it.'”

Betty burst into tears.  “Wow…wow…I never thought of it like that.”  She pulled a tissue out from the box on her tray table and blew her nose.  “I could do that. I could take care of myself.”  She gave me a piercing look.  “Wow…thank you!”

4 Ways Psychology Can Improve Your Bottom Line (Long-Term Living Mag online)

Check out my article, 4 Ways Psychology Can Improve Your Bottom Line, featured on Long-Term Living Magazine’s online site:

It’s common knowledge that mental health and physical health are connected, but are you aware that applying mental health concepts to your organization could save you money? Observe the four theories below and my hypothetical long-term care scenarios. Who knows, this could be you.

1. Take a tip on workplace behavior from industrial-organizational psychology.

The nurse searched through the file drawer for a Consultation Form, flipping through one torn, faded manila folder after another. “I don’t have time for this now!” she said to no one in particular, eyeing a stack of paperwork at the nursing station. “I’ll get it on the way back from lunch.”

But the afternoon brought a new admission, and the referral never occurred. This didn’t escape the notice of the state surveyors, who cited it as a deficiency. The missed referral also resulted in a downturn in the health of the resident, who required a readmission to the hospital. Her family later filed a lawsuit for negligence.

The nurse, visiting Starbucks while searching for a new job, watched the barista prepare her coffee drink. All his equipment was in reach and clearly labeled. With a few movements, her drink was set on the counter for pick up—the same way it’s done in every Starbucks everywhere. She sighed. If only that Consultation Form had been within reach….

Borrow franchise-like organization systems to streamline functioning, with standardized tools in standardized locations, facilitating movement of staff between facilities and from unit to unit, which cuts time spent on repetitive tasks. Five minutes per staff member spent searching for a pantry key, a syringe or some clean linens quickly adds up, even if they don’t contribute to a citation, hospital readmission or lawsuit. Get organized and save yourself a bundle.

For more, read 4 Ways Psychology Psychology Can Improve Your Bottom Line…

Dr. El Interviewed by Jobshadow

Dr. El offers the inside story on what it’s like to be a psychologist: Jobshadow interviews Dr. El