Category: Role of psychologists

It’s The Simple Things

When I arrived at Mr. Johnson’s room, he was sitting in the doorway in his wheelchair, frowning at the passersby. He was immaculately dressed, as usual, in a button-down shirt and shorts on this hot summer day, looking much younger than his 90 years.

Lately he’d been frustrated that his memory was interfering with his ability to get things done. Last week I’d tacked onto his bulletin board a calendar we’d created to outline the days and times of his favorite activities.

“How are you?” I asked, settling into the chair across from him.

“Not good.” He shook his head. “My daughter Letty is in the hospital and I can’t reach her. She just had surgery and I’m worried about her.” He spoke in slow, measured words, so that sessions with him, while always fruitful, took on his Caribbean pace.

I could tell his anxiety was high, and not good for any of his medical conditions. “Can we call her?”

“I lost my cell phone. And I dropped the answering machine with her message giving me the phone number and all my messages disappeared.” He sounded close to tears.

“Is there someone else we could call who might have her number at the hospital? Or does she have a cell phone? Let me see your phone book.”

He dug around in the bag on the back of his wheelchair, pulled out a book, and slowly started flipping through the pages. I held out my hand. “May I?” He handed it to me and I saw it was filled with neatly written phone numbers in no particular order.

“Look for her brother, Clifford Johnson. He might know how to reach her.”

I found and dialed the number, and handed him the phone. A brief, pleasant conversation ensued with his daughter-in-law, who then put his son on the phone. After a few minutes Mr. Johnson handed me the phone. “I’m out here in Oregon,” Clifford Johnson told me, “and our sister Annette might have her number, but she’s visiting her daughter in Florida. I’ll give you that number. I appreciate what you’re doing for my father.”

A few minutes later I had Annette on the phone. Mr. Johnson gestured for me to talk to her.

Great iPhone Interventions for Nursing Home Residents

Now that I know I’m not going against State regulations (see Dr. El Goes Undercover with the NYS Department of Health), I’ll confess I love to use my iPhone with the residents. In nursing homes that don’t yet have computer access, the iPhone and other web-enabled mobile devices bring the world right to the residents. (For more on the subject, see Therapeutic Use of the Internet in Nursing Homes.)

What Nursing Home Residents Talk About in Psychotherapy

Have you ever wondered what nursing home residents discuss with their shrinks behind closed doors? Here I solve the mystery, revealing the types of conversations I’ve had with residents over the years.

From Yahoo: Study finds end-of-life counseling improves mood

The two most important moments in a person’s life are coming into this world and leaving it. I might not be able to help someone have a good life, but I can help them make the most of their last months or years and to have a good death. That’s well worth my time and energy. More on that in a future post. Here’s a link to an article on the topic that was posted on Yahoo today.

Link to Yahoo story

Study finds end-of-life counseling improves mood

By CARLA K. JOHNSON, AP Medical Writer – Tue Aug 18, 4:00 pm ET

CHICAGO – As a political uproar rages over end-of-life counseling, a new study finds offering such care to dying cancer patients improves their mood and quality of life.
The study of 322 patients in rural New Hampshire and Vermont also suggests the counseling didn’t discourage people from going to the hospital. The research didn’t look at costs.
The study’s publication in Wednesday’s Journal of the American Medical Association coincides with the fight over health care overhaul proposals in Congress.
Some conservatives have called end-of-life counseling included in one version of the bill “death panels” and a step toward euthanasia. A House proposal allows Medicare to pay doctors to chat with patients, if they desire it, about living wills, hospice and appointing a trusted person to make decisions when the patient is incapacitated.
President Barack Obama called the euthanasia charge “simply dishonest.” Health and Human Services Secretary Kathleen Sebelius has said the end-of-life proposal is likely to be dropped from the final bill.
In the new study, trained nurses did the end-of-life counseling, mostly by phone, with patients and family caregivers using a model based on national guidelines.
All the patients in the study had been diagnosed with terminal cancer. Half were assigned to receive usual care. The other half received usual care plus counseling about managing symptoms, communicating with health care providers and finding hospice care.
Patients and their caregivers also could attend monthly 90-minute group meetings with a doctor and a nurse to ask questions and discuss problems in what’s called a “shared medical appointment.”
Patients who got the counseling scored higher on quality of life and mood measures than patients who did not.
On the quality of life scale, patients could score up to 184 points. The groups were about 10 points apart in the last assessment before they died. On the mood scale, patients could score up to 60 points and the groups were about 5 points apart.
The patients who got the counseling also lived longer, by more than five months on average, but that finding didn’t reach a statistical level of significance.
Patients getting such counseling often thank the nurses helping them, said lead author Marie Bakitas, a researcher and nurse practitioner at Dartmouth Hitchcock Medical Center in Lebanon, N.H.
“They seem to feel a whole lot better knowing there’s someone who’s looking at the rest of them and not just the tumor,” Bakitas said.
In both groups, hospital stays were rare: six to seven days on average during the patients’ last year of life. Betty Ferrell of City of Hope Medical Center in Duarte, Calif., who has done similar research but wasn’t involved in the new study, said that’s not surprising.
“It’s patients and families in their own living rooms who are dealing with end-of-life care,” Ferrell said. “They’re not in the hospital. They’re at home.”
Ferrell, who leads a guidelines panel on end-of-life care, praised the study, which was funded by the National Cancer Institute, and said she hoped it would clear up misconceptions.
“This is about helping people live with the diagnosis the doctor has given,” Ferrell said. “This study reflects on what kind of support do people deserve when they’re dying.”

Helping Mentally Ill Nursing Home Residents

The July 2009 report, Trends in Mental Health Admissions to Nursing Homes, 1999 – 2005 notes that “the proportion of nursing home residents with mental illness, in particular depression, has overtaken the proportion of those with dementia”. According to a July 1, 2009 article by Liza Berger in McKnights.com, “younger mentally ill people now account for nearly 10% of the nation’s nearly 1.4 million nursing home residents”. While there is discussion of more preferable housing options for these residents, here are some suggestions to help those currently in long term care. As always, if there’s something I’ve missed, please add it to the Comments section.

1. Collect as much information as possible prior to admission about the psychiatric history and the medications which stabilize the individual.

2. Upon admission, refer the resident to the psychiatrist to assess mental status, review medications, and to establish a relationship. Mentally ill residents need to feel there are people in the nursing home looking after their mental health care as well as their physical care.

3. Upon admission, refer the resident to the psychologist, who can offer additional mental health support and monitoring. It’s better to refer someone before problems arise than to wait until negative behaviors and conflicts have been established. For more on this, see my earlier post, The Critical Period in Nursing Home Placement.

4. The social worker, as the most consistently available member of the mental health part of the treatment team, can act as the liaison between the psychiatrist, psychologist, resident, family, and the rest of the nursing home team, helping to share information.

5. Train the staff, especially the CNAs and nurses, to be familiar with the signs and symptoms of mental health problems.

6. Add the element of “behavioral rounds” to the change of shift report, noting any changes in behavior. In the psychiatric hospital, we did it very quickly, running down the names of the patients on the unit, speaking up if any unusual behavior occurred. For example, when the CNA-equivalent on the psychiatric team reported she’d seen a man with Bipolar Disorder laughing by himself in the hallway, the psychiatrist immediately increased his meds, recognizing the early signs of a manic episode. Early detection is particularly important because the lag time between referral for and completion of a psychiatric consult can be substantial.

7. Refer unstable or aggressive residents out to the psychiatric hospital as soon as possible. Doing so sends the message to other residents, staff, and visitors that their emotional and physical health are important, and relieves them of the anxiety of living or working with a resident who might be dangerous to themselves or someone else. It also provides the limit-setting such a resident requires for their own well-being.

8. Establish a relationship with a psychiatric hospital that’s familiar with the needs of older adults and provides adequate stabilization. For example, one nursing home changed the psych hospital they used after a paranoid schizophrenic resident in her 80s returned from a hospitalization still actively psychotic, with a baby doll, reflecting the hospital’s view of the elderly.

9. If possible, use the resident and family as resources. Knowledgeable residents and family members will be able to tell the team what medications have been successful in the past, and what proved troublesome.

10. When the right combination of medications is found, post this prominently in the chart and educate the resident and family so they have the information for future use.

11. If there are a group of residents with a psychiatric history who are functioning relatively well physically, it can be beneficial to provide them with a well-monitored space for group activities such as dominoes and card games which they can initiate without staff intervention. Training the staff monitors to work with groups of mentally ill residents will make such programs more successful.

12. Consider providing access to support groups such as Alcoholics Anonymous, either on-campus or in the community. Many mentally ill residents have a comorbid substance abuse history due to attempts at self-medicating. Such groups will provide emotional support and skills for living.

13. The social worker and psychologist can prepare appropriate residents for living in the community in a less restrictive, but still supportive, environment such as an adult home.

The Critical Period in Nursing Home Placement

I couldn’t wait to go to college.  I was ready to shake off the old me, and begin a brand new self.  No one would know who I’d been, and I could therefore be whomever I wanted to be.  

In my Psych 101 textbook, there was a picture of animal behaviorist Conrad Lorenz, followed by a row of baby geese. The goslings had found Dr. Lorenz during their critical period of imprinting, when they bonded to the first suitable stimulus they saw. Conrad Lorenz became the goslings’ mama.

When residents enter nursing homes, they have the opportunity to create new identities.  They are surrounded by strangers and novel social situations, with as limited a pull from family and friends to be their old selves as they are likely to have experienced in decades.  While most residents aren’t necessarily looking to become new people, their early nursing home contacts can affect how they settle into their environment.

Mrs. Leibowitz arrived at the nursing home depressed, but wasn’t referred for psychological services until months after her arrival.  She’d already established the pattern of spending days alone in her room, watching television for hours at a time.  She was irritable with staff members, often refusing care, or chasing them out of her room with her foul language.  “There’s nobody to talk to here,” she told me.  I had my work cut out for me.  The critical period had been lost.

Mr. O’Conner, on the other, was lucky enough to be placed in a room with Mr. Chu, the President of the Resident Council.  Mr. Chu took Mr. O’Conner under his wing (so to speak), and together they played cards with some of the other gentlemen, and attended activities which appealed to them both.  Our new resident integrated nicely into the community and never needed psychological treatment.

I’d like to see every nursing home form a welcoming committee, by residents, for residents, to help aid the transition to the nursing home.  And I’d like to get my referrals early, during the critical period, instead of after the conflicts, isolation, and other problems have become entrenched.  That way I can more easily help people take advantage of the best that nursing homes have to offer.

The Equalizer

Louise was a petite 79-year old woman who spent her days watching TV and working her needlepoint, anchoring the tapestry frame against her chest with one arm while she slowly pushed the needle through with her good hand. I first met her casually because she was the roommate of another resident I was seeing. I’d say hello and excuse myself as I pulled the curtain for “privacy” while I spoke to her roommate, Cynthia, who was dying of cancer. I wasn’t too sure how much Louise could understand, since her speech was garbled and unintelligible, but we always acknowledged each other when I arrived for my weekly sessions with her roommate. When Cynthia died, I made a point of stopping by to offer my condolences. To my surprise, Louise burst into tears and held up her good hand for me to wait, while she labored over a note she wrote on the back of the recreation calendar. She pushed the paper toward me. I read it out loud. I was in the room when she died. I was in the room when my father died. She began to wail, and I murmured reassurances and stayed with her until she became calm.