Psychotherapy creates meaningful identity for the LTC resident
Dr. Brenda Smith-Booth, Clinical Psychologist, TeamHealth
“Oh, no…no…I am so not ready for bingo...EVER!” said Ms. Jones*, my 60-year-old long-term psychotherapy patient.
Chronic, progressive multiple sclerosis had led to her admission to the nursing home where I work as a clinical psychologist. She went on to flick her hands and say, “I was an English and Philosophy major. And I drew. Now I can't do my art. My last drawing – Nurse Runs After Med Cart – I can't even sign my name to it.”
Some long-term care residents are simply beyond bingo. That's not to imply that bingo is a bad thing, not at all. I've seen bingo uprisings when bingo time was cancelled. Yet many long-term care residents know, deep down, there is “something more” out there; and that “something more” is often something unfinished – a hope or aspiration that never came to full fruition in their lives. This is the hidden existential issue of the long-term care arena.
For the long-term care psychologist evaluating the appropriate plan of care, the treatment issue is this: Do we just listen and validate the reality of the loss, helping the resident grieve and then let go of the “hoped for” self? Or do we embrace and support the resident's struggle to continue to achieve important life goals? It depends. If the resident still has the will to “rage against the dying of the light” and the facility is willing to endorse some culture change, there are great opportunities for residents to continue to evolve creatively and personally.
In Ms. Jones' case, there were massive losses to grieve. Shortly after her father's death from pancreatic cancer, her mother and primary caregiver fell down a flight of steps and suffered a traumatic brain injury that landed her in another long-term care facility. In rapid succession, Ms. Jones had lost her father, her mother's care and her home of many years where she was surrounded by the artwork, music and books she loved.
Not surprisingly, the initial stages of our individual psychotherapy focused on the immediate challenges most long-term care residents face following admission. Early on, Ms. Jones had to process and adjust to loss of control and privacy, the facility's specific care routines and discussions about how she wanted to live the final chapter of her life. As we started our exploratory therapy, a theme quickly became evident: she was disappointed and saddened by a lifelong failure to bring her artistic life to fruition. The challenges she'd encountered were not unique – divorce, the need for money, family issues and illness. But at this point in her life, she considered it a tragedy that she had turned out “so very average.” At least in her world.
For some long-term care residents, there is the painful irony that they finally have the time – but not the capacity – to reinvent part of their lost dream. There are shriveled hands, jerking movements, loss of eyesight, etc. It is a natural recipe for grieving the “lost self.”
However, contrary to the concept of “custodial care,” nursing homes can be wonderful environments for the kind of exploratory therapy in which Ms. Jones was ready to engage. For residents like her, the long-term care setting is an ideal forum to engage in the pursuit of the “hoped-for self.” The combination of time, motivation, facility participation and technology provides opportunity for self-exploration and reinvention.
In psychotherapy, we are envisioning a “second chance.” On the practical level, a solution can be as easy as a software package designed to allow the disabled to draw. Access to this kind of technology allows Ms. Jones' vivid imagination to begin to appreciate the wide variety of artistic expression available online and starts to channel her inner Picasso, even using her poetic skills to name the abstract drawings. She does not expect perfection. Significant depression is behind her now. Shame is still on the horizon, but she is able to see the pattern that shame takes. Shame will not interfere with her optimism in the long run. Even talking about the plan helps. First steps have been taken. I am using her natural artistic tendencies and technology to eke out an existential solution for what I see as an existential problem.
Another resident, Mr. Chung was referred to me after he said the nursing home was like a “prison camp” with “torture.” When I assessed him for suicidal ideation there was no plan, but he had not lost the theme. Fortunately, a family member set up a computer program on which he began to write short stories in his native Chinese. Eventually he wrote a poem about a tree that he translated into English. The poem reflected the seasons of the year and the falling of the last leaf. At first it might sound sad, but he was quite pleased with this poem and it allowed him to connect with others.
Mr. Chung is a retired airline mechanic who never had much time for poetry while raising a family. Since he started writing, his depressive symptoms are virtually gone now, and he is almost completely weaned off of Zoloft.
For many residents, the most difficult part of living in a long-term care facility is the loss of interpersonal connections with friends in the community. Mrs. Green is a 72-year-old elder who sustained a traumatic brain injury in a severe car accident, leaving her aphasic. She had enjoyed a very successful career as a math teacher with a master's degree in education. Shortly after her accident, her expressive aphasia and placement in long-term care seemed like a permanent disconnection from others. Her family and grandchildren did not live close by, only adding to her depressive symptoms.
Mrs. Green is now emailing her family and is delighted to be able to communicate and receive responses. With these renewed personal connections, her depressive symptoms are significantly lessened, as are her feelings of “not fitting in.”
As these examples illustrate, psychotherapy, in conjunction with a motivated facility and the creative utilization of technology, can result in meaningful last chapters for our patients.
Brenda Smith-Booth, Ph.D., is a clinical psychologist at TeamHealth.
*Names within this article have been changed to protect patient privacy.