Category: Role of psychologists
Posted by Dr. El - June 28, 2011 - Anecdotes, End of life, Resident care, Role of psychologists
Nan was in the hallway, looking as thin and pale as I’d ever seen her.
“Are you okay? Do you feel well enough to meet today?” I’d heard in morning report that she’d been diagnosed with pneumonia.
“No,” she croaked, and then hesitated. “I mean, yes.” She looked at me intently. “It might be our last time.”
Alarmed, I wheeled her into her room, stopping along the way to pick up the newspaper, as she requested.
“You said ‘it might be our last time.’ Do you think you’re going to die before next week?”
“Yes.”
I could feel the tears coming. I’d known Nan for years and was very fond of her. “Is it okay if I cry for a moment?” I asked her, but even if it wasn’t, I couldn’t help myself, and it took a minute for me to get myself under control. Nan busied herself with her newspaper.
“Do you feel ready?” I asked her. We’d discussed her thoughts and expectations about dying in the past.
“Yes.”
“Is there anyone you want me to call?”
“No.”
—————————-
I came back later in the day to check on her and found her in bed. She asked me for water. “Would you like to go on hospice? They’d have someone here four hours a day to help you with stuff like this.”
She took a sip of the cup I held at her mouth, and shook her head no. I felt bad leaving her alone in her room.
—————————
On the way to work the next morning, I debated about whether or not to bring Nan some flowers. Would it violate my personal rule not to do things for one resident I wouldn’t do for another? I went back and forth for a while, and then decided that I’d probably do this for a resident I’d been seeing for a while who was dying and had no visitors to help them through to the end. I bought a flowering plant in a pot, not wanting to get something that might die before she did.
—————————-
“I brought you some flowers, Nan,” I told her when I came into the room the next day. “I’m going to put them here on the windowsill, and they’ll be like me watching over you.”
Her voice was weak. “You’re too good to me.”
“You know I’m very fond of you.”
—————————–
I came back to water the flowers after the weekend. “Someone else has done it already, Nan.” I remarked. Nan looked at me and nodded.
—————————–
By Thursday, Nan had passed.
I put the flowers on the desk at the nursing station.
Posted by Dr. El - May 23, 2011 - Anecdotes, Role of psychologists
“I’m sorry, Rita, I can’t breathe,” I said when she paused for a moment in recounting her story. “I have to go blow my nose.”
“Yes, I can hear that. It’s okay,” she said, reassuringly. In the many months I’d been seeing her, this type of interruption had never before occurred. Her movements painfully crippled by osteoarthritis, Rita couldn’t clear her own nose.
I went into her bathroom and pulled off wads of toilet tissue, blowing until the air flow returned. I could see her patient reflection in the mirror as I did this, but I was grateful she wasn’t watching me.
Sitting down, I apologized for the disruption to our session.
“That’s okay. It’s natural. We’re all human.” She paused. “When I first got here, I was so embarrassed by people having to take care of me. It was terrible.” She closed her eyes and shook her head slightly. “One time, the doctor had to look at my behind. I was turned on my side and completely exposed. When the doctor saw me closing my eyes, he said, ‘Rita, it’s okay, I’m the doctor. You can open your eyes.'”
“You were trying to hide, to protect yourself.”
“I wanted to disappear. But the doctor, he was very kind.”
“They see these things all the time. It’s hard to get used to the lack of privacy, though.”
“Yes. But what choice do you have?”
Posted by Dr. El - May 9, 2011 - Role of psychologists
The American Health Care Association (AHCA) chose the theme of “Fulfilling the Promise” for National Nursing Home Week May 8-14, 2011. According to the AHCA planning guide, part of this Promise is a focus on the whole person. Psychologists help fulfill this Promise every day, by addressing the emotional aspects of illness in addition to maintaining an awareness of medical concerns.
The AHCA planning guide suggests:
- Emphasize how you tend to the spirit: Psychologists often address spiritual concerns as part of the psychotherapy.
- Help spread the message that “It’s not your grandmother’s nursing home anymore”: Contrary to the popular belief that older adults find talking to a psychologist stigmatizing, I’ve had very few refusals of treatment based on this, and the new cohort of residents is actively seeking out mental health services.
- Explain that long term care is increasingly about “going home” rather than “staying longer”: A frequent focus of psychological treatment is reducing depression and anxiety, and making the most of the opportunity for rehabilitation in the early days after admission. This increases the likelihood residents will be able to return to their homes.
Nursing homes Fulfill the Promise of treating the whole person when they offer psychological services to their residents, treating the mind as well as the body.
Posted by Dr. El - May 3, 2011 - Personal Reflections, Resident care, Role of psychologists
When I worked in the psychiatric hospital, the focus of treatment was on the mental health of the patients. Physical complaints were usually thought of as an expression of mental illness and not reflective of an actual medical problem. We once sent a patient down to the tiny sub-basement medical clinic after she injured her left hand. The report came back with a thorough examination of her right hand, which was missing fingers after a self-inflicted gunshot wound ten years prior. Her left hand was still throbbing.
In nursing homes, I find the opposite situation. The focus is on medical care, and mental health concerns are “in the sub-basement,” so to speak. This is despite the intensely stressful experience of nursing home admission, as I’ve written about before: The Stress of Nursing Home Admission.
In her April 30, 2011 New York Times article, Jane Gross, founder of the NYT blog New Old Age, discusses the lack of mental health care in nursing homes. In Doctor Focuses on the Minds of Elderly, she reports on the work of psychiatrist Dr. Mark E. Agronin, my guest blogger last month. My favorite quote of the article, which is well worth the read:
Why, Mrs. Sachs asked, “do they send buses of psychologists to a high school every time there’s a tragedy,” but here, where death is constant, “there’s only a brief memorial service and cookies?”
Posted by Dr. El - January 31, 2011 - Anecdotes, Communication, Role of psychologists, Younger residents
“My aide treats me like I’m an idiot,” Katrina typed to me on her talking computer.
“What do you mean?”
“She thinks I don’t know what’s going on!” Her eyes radiated her emotional pain. “She’s a bitch!”
A series of strokes had stolen Katrina’s ability to speak, leaving her a silent observer of her surroundings and interactions. A former schoolteacher, she carefully typed her perspective on the world to me, hunt and peck with one good finger on each hand, then pushed a button that released them in a mechanical female voice. The computer saved her, but it was a slow process and the only way to prepare a sentence in advance was to store it in a memory key. We’d set it up so that Control-H was “Hello.”
“Does she know you can type on the computer?”
“That bitch won’t give me time to type!” Her brows were furrowed and she appeared ready to explode with anger. Her enforced silence was a frequent topic in our sessions.
“Let’s use psychology with her. We’ve got to show her how smart you are. And we need to make a personal connection to shift the dynamics. Is there anything you know about her we can use?”
Katrina thought a moment. “She used to work nights.”
“Perfect! What if we set up a macro that said, ‘How do you like the day shift?’ That way she’d know you knew her well enough to be aware of her schedule, and it would set up a friendly tone.”
Her eyes lit up and she nodded.
“What memory key do you want me to program? Hey, what about B for bitch?”
Katrina laughed.
I set up the macro and she pressed Control-B for practice. “How do you like the day shift,” the mechanical lady said. We discussed her plan: Control-H, Control-B the minute the aide came to her bedside.
———————-
The next week Katrina was beaming when I entered the room.
“Did it work?”
“Everything is different,” she typed. “She talked to me like I knew what was going on!”
“You pressed the key?”
“I didn’t have to! She just knew!” Katrina was smiling from ear to ear.
“Well, isn’t that interesting?” I said. “All we had to do was put it out into the world, and God took care of the rest!”
Posted by Dr. El - November 3, 2010 - Common Nursing Home Problems and How Psychologists Can Solve Them, Role of psychologists
Part Three of a Three Part Series
I recently interviewed Jeff A. Beaty, D.H.Ed., LMSW, QDCP, SSBB, Chief Development Officer for Signature HealthCARE, about the role of psychology at Signature.
I was pleased to hear that in addition to providing direct care to residents (which is generally paid through the resident’s insurance), Signature contracts with psychologists at least 20 hours per month for additional consultation. Their work includes:
- Staff training
- Assistance with research projects
- Intervening with staff as needed with particular residents
The services have resulted in medical cost offset through:
- Reduced use of psychopharmacology
- Reduced inpatient hospitalizations
According to Beaty, Serenity provides training programs to educate staff on the behavioral and psychological symptoms of dementia, particularly agitation. These psychosocial interventions have been shown to reduce caregiver emotional distress, he reports.
Serenity HealthCARE, in conjunction with the International Center for Long-Term Care Innovation and its partners, also has several ongoing research projects geared toward helping those with dementia lead more satisfying lives. One study focuses on matching residents and staff by personality type and attitude, anticipating an improvement in quality of life for residents and staff, reduced resident/staff conflicts, and improved employee retention. It reminds me of what my old supervisor used to say (and I have found to be true): “There’s a lid for every pot.”
I’m always interested to hear how mental health interventions reduce other costs, so if you have an example at your facility, please feel free to email me via the Contact button in the right sidebar, or add your comment below.
Posted by Dr. El - October 11, 2010 - Common Nursing Home Problems and How Psychologists Can Solve Them, Role of psychologists
Dear Researchers,
I’ve been a nursing home psychologist for the last 14 years, and, while there are many fascinating areas to be studied in the field of geropsychology, I’m writing to you with the hope that we’ll see more research on the medical cost offset of psychological services.
One type of study could look at archival data from Medicare/Medicaid or private insurance companies comparing the medical costs of beneficiaries receiving psychological services with those who do not. I’d expect to see decreased use of medications, and possibly reduced use of aggressive end of life treatments. Studies showing reduced medical expenditures could result in changing regulations to require psychological consults upon nursing home admission, much like therapeutic recreation and dental service evaluations are required, and would increase the likelihood that insurers would promote mental health services in physical health environments.
Another type of study would take place within individual nursing homes, comparing floors or units receiving psychological interventions with those that don’t. Such studies could examine the effectiveness of psychotherapy provided to residents on measures of resident, staff, and family satisfaction, absenteeism, incidents, turnover, etc. Other studies could measure the effects on those variables of a broader application of psychological services, such as team-building on a unit, communication skills training, conflict resolution, establishment of a therapeutic milieu, etc. If research indicated that providing psychological interventions to residents and staff decreased overall costs within individual nursing homes, perhaps we’d begin to see psychologists funded as part of the nursing home budget and able to provide a greater range of services.
If you’re a researcher who’s been working on medical cost offset studies, please contact me if you’d like a blog post about your research. Let’s get the word out.
Sincerely,
Dr. El
Posted by Dr. El - October 5, 2010 - Common Nursing Home Problems and How Psychologists Can Solve Them, Resident care, Role of psychologists
A recent article in McKnight’s Long-Term Care News (September 2010) caught my eye: Attitude appears to affect healing process for wounds. The article cites a research study in the August issue of Dermatologia that found patients who were less depressed had wounds that healed faster. It also found slower healing in those who had “confrontational” coping styles and therefore had difficulty with the loss of control around waiting for a wound to heal.
It turns out this isn’t an isolated conclusion. A
2008 study in the Journal of the American Podiatric Medical Association found similar results regarding depression and healing. Stress and depression were found to affect healing in a
2001 study in Psychosomatic Medicine. In 2008,
researchers at Cairo University found the use of relaxation techniques helped reduce depression and improve wound healing and recovery in post-Coronary Artery Bypass Grafting (CABG) patients.
- Residents recovering from wounds or surgery
Posted by Dr. El - August 30, 2010 - Depression/Mental illness/Substance Abuse, Resident care, Role of psychologists, Stress/Crisis management
In 1967, psychiatrists Holmes and Rahe created a scale that measures the stress levels of various life events, and found that people with stress levels over 300 are at high risk of illness. I’ve always considered a nursing home stay to be a very stressful experience, but applying the scale was illuminating.
I took the
Holmes and Rahe Stress Scale and modified it based on working with nursing home residents. For example, the Social Readjustment Rating Scale (SRRS) allots 65 points for a marital separation, but since moving away from one’s spouse to enter a facility isn’t a typical marital separation, I gave it 50 points. Nursing home residents aren’t technically imprisoned (63 points), but it is extremely confining, so I reduced that item to 50 points.
In my view, residents are not retired, but have started their jobs of working with the staff 24/7 in order to attend to the business of taking care of themselves, so I included many work-related items not usually considered the province of residents. This left me with the following items on the 43-item scale:
Marital Separation (50)
Imprisonment (50)
Personal Injury or Illness (53)
Business Readjustment (39)
Change in Financial State (38)
Change to a Different Line of Work (36)
Change in Responsibilities at Work (29)
Change in Living Conditions (25)
Revision of Personal Habits (24)
Change in Working Hours or Conditions (20)
Change in Residence (20)
Change in Recreation (19)
Change in Church Activities (19)
Change in Social Activities (18)
Change in Sleeping Habits (16)
Change in Eating Habits (15)
Grand Total: 471 points
471 points, on a scale that finds a high risk of illness at stress levels over 300 points. On the
updated SRRS, the total comes out much higher, with the person considered in a life crisis.
Upon admission to the nursing home, residents are required to see the dietician, dentist, social worker, and recreation therapist. A life crisis, and we have yet to require a psychological evaluation of the residents. Referrals are currently haphazard, and based on the psychological-mindedness of the nursing home staff.
Readers who feel they, their residents, or their loved ones might benefit from the assistance of a psychologist in coping with the magnitude of these life changes can suggest a referral for evaluation for a particular individual (until regulations catch up with the need).
Posted by Dr. El - June 4, 2010 - Business Strategies, Depression/Mental illness/Substance Abuse, McKnight's Long-Term Care News, Role of psychologists
I wrote a guest post for McKnight’s Long Term Care News addressing how psychologists can help nursing home residents and when a referral for treatment might be appropriate.
“The recent Illinois legal decision to move mentally ill nursing home residents into smaller mental health settings is likely to prompt an industry-wide examination of the practice of accepting mentally ill residents into long-term care. If nursing home residents are lucky, it will also trigger an evaluation of how we treat mental health issues in nursing homes in general.”
