John O’Connor’s recent post on the pain/depression cycle raised some interesting points about depression in long-term care. He referenced a 2009 study that found that over 47% of nursing home residents suffer from some level of depression, and he reported on a University of Pittsburgh Medical Center study showing the effectiveness of talk therapy with elders.
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.
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.
In Martin Seligman’s early research on the subject, dogs were given small shocks with no means of escape. When the barrier to escape was removed, the dogs didn’t leave even though they could now get away from the shocks. Instead, they sat on the floor and whimpered.
In further research on humans, participants were told that solving puzzles would turn off an unpleasant noise. The first group of subjects was given puzzles that were unsolvable while the second group could solve the puzzles and stop the noise. When presented with a new scenario where they actually could make a change in their environment, participants in the insolvable puzzle group did significantly worse than those in the second group who were able effect a change in both situations.
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.
Much of what nursing home psychologists do is teaching residents how they can intervene on their own behalf — who is the right staff member to go to for a particular problem, how to ask for things in a way that can be heard, and when to request that others advocate for them.
When residents feel they have some control over their lives within the facility, their depression is reduced. While psychologists can intervene on a one-to-one basis (if we get the referral), there are system-wide techniques that can reduce learned helplessness.
Facility-wide techniques to reduce learned helplessness
1. Train staff to answer the call bell immediately, even it it’s only to say that it will be another half hour before the resident can expect help. The immediate acknowledgement of the need and getting a time frame can be very reassuring.
2. Create a communication system that simplifies follow through. Have you watched, as I have, the nurses at the desk get bombarded with simultaneous requests? There are too many disruptions in the daily workflow in a nursing home to keep track of everything without a system in place. Train staff to use reminders and other techniques as part of their daily routines. Identify and remedy areas where tasks are falling through the cracks (such as scheduling medical appointments recommended on consults or sharing information from shift to shift). If a pattern of omission is identified, it’s a systems problem rather than the fault of a particular nurse or other staff member.
3. The resident council meeting is an excellent venue for showing residents that they are listened to and their concerns are being met, counteracting the perception that what they value doesn’t matter. It’s important to identify actionable requests during the meeting — and then act on them. Otherwise, the meeting contributes to learned helplessness.
4. Providing a suggestion box offers a way for those in the LTC community to have an impact on their environment. Making it optionally anonymous allows community members the chance to contribute without fear of reprisal. Even an anonymous suggestion can be acknowledged in staff, family, or resident council meetings or via a message board. The people living, working, and visiting your facility often have great insights they’re not sharing with you. As an added bonus, community members will be encouraged to bring more good ideas to the administration.
What techniques has your facility used to empower residents and reduce learned helplessness and depression?
Eleanor Feldman Barbera, PhD, the author of The Savvy Resident’s Guide, is an accomplished speaker and consultant with over 16 years of experience as a psychologist in long-term care. This blog complements her award-winning website, MyBetterNursingHome.com, which has more on how to create long-term care where EVERYBODY thrives.