Category: Inpatient Clients

What do you imagine it might be like to spend a day doing psychotherapy in a nursing home?

Well, no, it would not be like that.

In some nursing homes, there are many patients from age 40 to 70, with disabling or sometimes terminal diseases and medical conditions, who might likewise suffer from major mental illnesses, a history of trauma, and/or substance use disorders. And all of this can play out in the social dynamics between clients and sometimes understaffed, overburdened, and maybe inadequately trained caregivers.

Staff persons often turn to behavioral health clinicians with complaints about the “behaviors” of clients. A key part of my work is to help staff persons see how “behaviors” might be trauma reactions, or manifestations of pain, or psychiatric disorders, or medical conditions, or simply responses to the style of approach used by that staff person.

Challenges to Nursing Home Psychotherapist

While I am protecting my clients’ basic confidentiality, as a consultant psychotherapist, I understand that I am not practicing in a vacuum. I am seeking to relieve the symptoms of my clients while helping the staff to better understand and respond to the needs and symptoms conveyed through sometimes troubled and troubling behaviors.

The 10 clients I met with on this particular day each had major medical and psychiatric needs, were facing the end of their life, were actively grieving. Many had histories of difficult personal relationships. The clients were all in their 60s and 70s. Many were socially avoidant and isolated, some tended toward paranoia, and were argumentative, while some experienced auditory hallucinations. Nevertheless, and almost to the one, all were lonely, fearful, and frustrated by a loss of control.

I encountered each of these individuals in the vividness and complexity of their situation, tried to help them gain new perspectives on their experiences, better recognize their available choices, and to consider alternate ways of thinking and acting. Therapy can support persons facing the end of life and can help them better appreciate the psychiatric nature of peculiar subjective experiences. It can also widen the focus of attention from their medical condition to their whole self.

Nursing homes provide settings for meaningful, challenging, and beneficial psychotherapy, and I strongly encourage therapists to consider practicing where the need is so greatly concentrated. Look, you are not going to find such dynamic cases in any other setting.

At the end of this day, I got in my car, and I felt tired and drained. But why, I wondered, should I interpret my tiredness as being heavy stress? None of the clients I saw that day would say the encounter had been stressful; they would each say it had been relieving and encouraging. The encounters ended with expressions of thanks, handshakes, and comments about looking forward to the next session.

As I drove home, I could look back in my mind’s eye at each client and see ways I had helped them or eased their burden on that day. Was the work stressful? Sure. But I chose to maintain perspective and balance, and take care of myself, while enjoying a rewarding sense of fatigue from a day’s good work.

Questions for Reflection and Discussion  
What is your first reaction to the author’s message about working clinically in a nursing home?

What personal and professional challenges would you anticipate in this setting?

What countertransference reactions might you have in this kind of work?  

A frustrated and depressed nursing home resident recently described the facility as “a place where unwanted elders can be exiled.” Through our therapy conversation in that session, he came to acknowledge that he did have problems with his memory and his health, and that his facility residence was reasonable — even though unwanted — and was not a rejection by his son. “I know he’s only doing what he thinks is right for me.”

The Emotional Plight of the Nursing Home Resident

Many residents of nursing homes view their predicament as a rejection, or an exile, or an imprisonment. Many blame family members for the situation and try to pull the heart strings of loved ones in efforts to get them “to take me home.”

Many adult children weep as they speak with me about the conflicts they feel over the placement of their mother or father in the facility. Daily care at home with family is desired by all, yet available to only a few.

The older person living in the nursing home may feel a loss of home, family, their former roles, and too often, their sense of the value of their life. Some older people feel not only cast out by others, but inadequate due to the infirmities of their advanced age and their medical problems.

As I speak with seniors in psychotherapy at nursing homes, I discuss the specific aspects of their situation and seek to place some of their experience in a broader cultural and societal context. For example, I talk of ways that “the Elder” has traditionally been venerated in human societies.

Whether sitting around a fire in the cave, or in a small tribe, or a simple village, it has been the Elder who others looked to for history, stories, and advice. The younger members of the tribe or clan or family came to the Elder to learn the lore and lessons of their people. Others listened to and memorized the stories told by the Elder, and those stories they passed along when they, in turn, became an Elder.

The older nursing home resident might feel adrift from their family and their former life, but the value and the lessons of their life endures, and the sharing of their personal stories — whether in life-review therapy, with family, or with others at the facility, is a key part of reclaiming and affirming the value of their experience.

I encourage residents to share their stories with me and others in their life. I point out and affirm the dignity and value of the person’s journey through a long life. I speak to seniors of ways the society has changed, and how elders might not socially be held in the respect that their lives deserve and have earned.

Some people have suggested that nursing homes ought to have daycare programs attached to them, for the mutual benefit of old and young. But I think that it might be more productive, and developmentally appropriate, to have programs for troubled teens associated with nursing homes. Then, a teenager might share her problems about a relationship, her parents, school, or a career choice, and the senior might be able to understand and share suggestions, relate anecdotes, and offer guidance that might be helpful and in line with the long history of ways younger persons have been helped and guided by the wisdom of the Elder.

“Okay, but I don’t know if I really am wise, and I have all kinds of problems,” an elderly lady said as we discussed these ideas one day. I point out that throughout the long history of human life, the Elder who others looked to and venerated, likely also experienced problems with balance, and with short-term memory, and with urinary incontinence; but that did not erase the value of what they could contribute to younger generations.

It is important to share the stories of one’s life. As we age, we might become less active, and we might forget some of the recent events, but we might retain long-term recall of long past events and situations and relationships — and the sharing of those stories can enrich the understanding and the development of the younger person.

A nursing home sponsored a program a few years ago in which all the staff wore a round metal pin labeled “I’m a Future Senior Citizen.” That program enhanced the awareness of younger workers about the aging process. We each may now be, or may later be, senior citizens. Aging does not invalidate the adventures and lessons of a full life. A key task for the elderly person is to share their tales, and that is as it ever has been, and should be. And one of the most valuable tasks a therapist can undertake with the elderly is to give them the opportunity to share their story. 

In the long-term care setting where I work, residents have a far greater amount of life experience than they do control and influence. This might contribute to many of them losing their sense of worth and appearing frail, or even foolish, to the younger workers entrusted with their care. Wisdom is the distillation of lessons learned from life experiences and evidenced in fleeting comments or responses rather than in detailed and articulate expressions. This wisdom, however, may be lost or obscured by cognitive impairment or language problems.  The idea for our Wisdom Project arose in the course of uncounted hours of psychotherapy, during which I was privileged to hear the lessons and insights derived from the long and often quite challenging life experiences of the residents with whom I have worked. I’ve found that all too often, these residents have feared that their invaluable life experience has gone to waste because they are no longer in what most would consider to be an active stage of life. Or that a young staff person might overlook the depth of background and knowledge still present in an otherwise faltering and frail man or woman under their care.  I developed a simple questionnaire for select residents—those who seemed most able to verbalize responses. I believed that gathering their thoughts would provide them with a sense of validation and empathy, which would, in turn, provide workers with a glimpse of the wisdom that is all too often obscured by their physical and cognitive frailty. The following are some of the questions I developed, and several select responses.  What have you learned from your life experience? I’ve learned to be more patient. I’ve learned to be quiet and listen to other people. It helps me to not be selfish. At the time you don’t think things matter, but they do. The choices you make are more important than you think. So, make good choices. I’ve learned to communicate with people. I was too shy and reserved and passive. I should have more strongly pursued my dream to sing. I learned to love. I think it is very important to have a good marriage. My ability to love has grown as I’ve gotten older. Hold close, but not too close, the ones you love. I learned that the important things in life are marriage, children, friends, and an active life. Those are the things that teach you appreciation of life. I learned how valuable it is to have a loving, caring family. Everything else comes second. I have learned that life is brutal; it is hard on your soul and body and mind. It is hard to comprehend why life must include illness and death, but life still has its bowls of cherries. You can’t answer the questions of life with simple answers; you need heart.  What does illness teach you?   Illness teaches you that you have to be strong. I try to understand the meaning of illness, medically and spiritually. It has made me stronger. I had to learn to rely on others. Before, I thought leaning on others was cowardly. When there is illness, you want to help, to remove suffering. But you cannot always do that. I should just talk to myself, and just turn my feelings around the other way. Learn to take better care of yourself. But you cannot rely only on yourself. You sometimes need others. Even when you are ill you can still help yourself, to a certain degree. Don’t expect people to do everything for you just because you are ill. Illness has taught me a lot about caring, about understanding, and soul searching. You learn how a person can endure the trials of illness. You learn that you don’t give up. Illness teaches you that you shouldn’t try to take on too much at one time.  Who taught you important lessons in life, and what did you learn from them? I lost my mother when I was 4 years old. I had to rely on my father and we became close. He taught me what to expect from life. He taught me not to believe everything you hear; you have to experience it for yourself to know if something is true or right. I had a doctor who pulled me through a bad part of my life. He taught me to take one day at a time. To deal only with today’s problems today. That helped me to not be overwhelmed by the problems I had then. My mother taught me that it is important to be honest and kind. To be kind and try to help; that is what matters. To be honest no matter how much it hurts: but it pays. My sister taught me to stand up for myself. My father loved us. He put his arms around us and provided and protected us. He taught me honesty and responsibility, and to be kind to others. I worked for someone once who taught me to keep going despite pain and problems. My mother taught me to work hard on my education and to prepare to take care of myself, and to take care of my appearance. My brother and I helped each other through hard times. That taught me a lot. My father taught me to always reach higher.  What would you like to teach others? Patience is one thing. You’ve got to have patience. You will be able to do many things if you believe in what you really like, and really put your mind to it. Have more faith in yourself. Don’t be afraid to ask for help; there’s always more available than you know. Learn all about finances and how to manage money. Be honest and don’t lie. It’s very important not to lie. To be kinder. Staff people should be kinder because your attitude toward a resident is noticeable, and it really influences how I feel. You should mix in with others. Get involved and stay active. If you take a job, follow through with it. Don’t drop short or give up on it. I would like to teach people how to listen to others. How to care and be kind and gentle.  What lessons or advice would you like to offer to the workers at the nursing home? Be more patient. Get in bed and try being a patient for a while. I want to tell the young women to not give away yourself too easily to men. It will lower your self-esteem. There are too many pregnancies and too few marriages for young women now. That means there are too many irresponsible and immature men. Don’t go sleeping around when you are young. Hold out for a better man. It is important to have a good marriage. Life is about more than their boyfriends, and cigarettes, and time off and on at work. I’m here as a patient. Do what you can for me. Just pay attention to me and do what you can for me. Make sure this work is what you want to do, being around sick people. If you just want it because there’s no other job, forget it. Have patience with the residents. Don’t always say I’m too busy. Listen more closely. Make time for individuals. If you’ve had a divorce don’t jump quick into many relationships. Stay within limits with your money. Buy a house or a car and save your money. Be more content with what you already have. 

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In the course of developing and implementing the Wisdom Project, I have learned how important it is to see the individual resident not just in their symptoms of today, but also in the story of their full life, and to help her or him find and affirm the lessons in that story. It is important to look respectfully at all a person may have been prior to the needfulness of now, and to be open to learning from the painfully acquired wisdom of each person.