Category: Inpatient Clients

Standing With Clients in the Twilight of Life

Posted on by Psychotherapy.net Team

Chris had advanced cancer, and only a short time left to live.

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Connecting at the End of Life

Chris was in his 70s, and he felt full of regret as he approached the end of his life; he felt afraid of dying, and disappointed in himself. He believed he’d damaged and lost all the key relationships in his life — who would want to be near to him now, he wondered?

In the course of our weekly therapy conversations, Chris came to realize ways his selfishness had hurt his personal relationships, and he came to recognize that his supposed preference for a solitary lifestyle had become an excuse or rationalization for his estrangement. He thought, though, that he was now paying too dear a price for his errors: dying alone in a nursing home.

Chris lacked a formal religious faith, yet he had spoken of his vague sense of a life beyond this one, and he expected to again see the loved ones who had already passed away. One morning when I came to his room, Chris was sitting on the edge of his bed crying.

He looked up and said, “Talk to me, Tom, I’m scared.”

I pulled a chair up close and looked at him and spoke quietly.

“Chris, when you first came here, you told me you thought you had wasted your life and burned all your bridges. You thought that you’d made all the wrong choices, and had neglected relationships, and that you would die alone.

“But you have been surprised by so many things that have happened during the past few months. Your son came from the west coast to see you and decided to stay here with you till the end; and you thought you had lost him. You hadn’t spoken with your sister for years, yet she and her husband have become regular visitors to you here.

“Many friends you had long lost touch with have reappeared, and you didn’t know how they found you or learned you were ill. Look around the room, Chris, and see all the gifts and cards and flowers you have received from people you thought would not know or care that you were ill. So many unexpected hands have reached out to you, Chris, to help comfort you as you prepare to move on from this world; you never expected such tenderness and reassurance.

“You have spoken lovingly of your parents and grandparents and aunts and uncles, and how you look forward to seeing them again on the other side. So, here you are Chris, poised between this world and the next. You have been loved by many over the past few months, even when you had believed yourself to be unloved. Many hands have been extended to you in this world to help you on your journey, and you anticipate many hands to greet you when you arrive in the next world.”

His quiet sobbing subsided, and he gave a big sigh and said, “Okay, okay, thanks, I feel better.”

A few days later Chris quietly passed.

Nursing homes, typically less formal than outpatient settings, have been special places for me as a psychotherapist, especially when I encounter people with major or terminal illnesses. I commonly engage in exquisitely poignant therapy conversations about life and coping, and about dying and grieving. Clients facing the end of their lives often feel a need to speak openly about their fears, hopes, doubts, and beliefs. Meeting their needs often involves bold entry into topics sometimes avoided or not considered as part of treatment. But it can be profoundly touching and rewarding to meet clients directly in the midst of their most vulnerable moments.

Questions for Reflection and Discussion

What are your reflections on the type of clinical work this author describes?

In what ways do you embrace or avoid working with the elderly or dying client?

What are some clinical challenges that might accompany working with this population?  

Finding Ways to Communicate with Clients About Their Symptoms

Posted on by Psychotherapy.net Team

Some nursing homes tend to have few, if any, residents with major mental illnesses. There are other facilities that have many residents with a mental illness, and those are the nursing homes where I prefer to work.

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Many of the clients I see for psychotherapy have a long history of mental illness. Few, though, report having been educated in helpful ways about the symptoms of their condition. When education has been presented, it may have been in technical language that might be perplexing or off-putting for the client. Finding ways to communicate effectively and sympathetically with a client requires artful attunement to the inner experiences of that person.

A 50-year-old lady with a diagnosis of anxiety, described her symptoms as “sweats, shaking, very nervous, and feeling pulled away from things.” A 72-year-old lady movingly described depression as “a heavy something that weighs on your brains, and you can’t think beyond that feeling — until someone helps bring you out of it.”

Asking someone to describe the symptoms of a mental health condition can be a helpful way to begin the process of deepening and clarifying their self-understanding. It can also be helpful to use some of the language and concepts of the client as a starting point, while avoiding sole reliance on technical jargon about mental illness. I’ve found that many clients have developed a defensive deafness to such language, anyway.

Helping Clients Understand their Symptoms

One way that I approach conversations with clients about their conditions and symptoms is through an exploratory series of questions:

How do you know when you are experiencing depression, (anxiety, bipolar symptoms, difficulty telling the difference between things real and unreal)?

How do others know when you are feeling depressed (anxious)?

Do you sometimes feel depressed, anxious, or have mood changes, or have maybe unreal experiences and others don’t notice?

What might others need to pick up on to recognize when you feel depressed, anxious, or afraid?

In general, individuals experiencing anxiety and/or depression may be interested in and receptive to education and discussion about their symptoms.

Yet many persons with a schizophrenic illness might deny the condition and rationalize the symptoms — due to stigma and shame, and due to limited capacity for logical reasoning. “I don’t have schizophrenia, I’m psychic; I get psychic attacks,” suggested Martha, who, nonetheless, is sometimes willing in therapy to directly acknowledge her schizophrenia, and her peculiar experiences as being symptoms.

Therapeutically educating a client about symptoms of schizophrenia might start with distinguishing things that are subjectively real from those that are objectively real. We might discuss inner perceptions and beliefs that may be real subjectively but may not be objectively real. Some already feel as though they live in a separate and inward world, somewhat apart from others.

Recently, I have begun experimenting with using a Venn diagram of three overlapping circles to illustrate differences between subjective and objective experiences. The first circle, on the right, is labeled as the client’s inner, or subjective world. In that circle are listed several of the specific symptomatic experiences already discussed in therapy, that the person might confuse as being real. The second circle, on the left, is labeled as the outer, or objective world. The overlapping middle circle represents the client and me in therapy, looking into each world to make connections and distinctions. Here is a compilation of some selected items from the right-hand circle for five clients: psychic attacks, mind-boggling thoughts, curses and accusations made by voices, paranoid thinking, anger, depression, anxiety, my make-believe world, messages received from the TV or radio or unseen persons. The list in the left-hand circle would include the facility, medical and psychiatric diagnoses, and related care and treatments.

I draw arrows to show, for example, how the experiences in the inner world circle are symptoms of the psychiatric diagnosis in the outer world circle, and how medications and psychotherapy from the outer world circle are intended to address the symptoms. Clients have shared poignant responses to lessons learned from this approach.

Cameron said, “This helps me understand mental illness. I feel relieved when we talk like this. I get it mentally, about what’s going on.”

Betty said that “Nobody ever told me this. It makes me understand what’s going on in my head better.”

“That means we’re on the same page, I appreciate that,” suggested Martha. “You understand what it’s like for me.”

Richard said, “Sometimes I think it’s real, and sometimes I don’t; it’s hard to tell. It relieves my mind when we talk about it.”

Donald said that “I’ve gotten a lot more mature and rehabilitated talking to you, Tom. I just don’t know what to say sometimes. It’s a big thing for me to get up to this level of reality. It’s your words that make me feel I’ve turned.”

For multiple reasons, it can be difficult to educate people with schizophrenia about the psychiatric nature of their subjective experiences. I had the impulse to try the Venn diagram with one client, and his response encouraged me to try it with a few others, as well.

***

I don’t use this approach with all clients, as some may be too delusional at the time to experience benefit. The people I have tried this with each showed some willingness to question the validity of their unusual subjective perceptions and beliefs. So far, I have only tried this approach with these five clients, and I have been pleasantly surprised, and touched, by their responses. Other therapists may wish to experiment, as well, with this simple, yet promising technique.

Questions for Thought and Discussion
What is your reaction to this therapist’s approach to explaining symptoms to clients?
What methods have you used to help clients understand their psychiatric symptomatology
With which clients might this approach be effective? With which others might it not?

Psychotherapy with Dissociative Identity Disorder

Posted on by Psychotherapy.net Team

“I call them the persons of my mind, my “pers,” Robin said, in reference to the split personalities she experiences due to trauma. “I talk out loud to them and I find it therapeutic, but I try to be careful because I know it can bother my roommate, and other people,” she said.

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The Long-term Consequences of Trauma

Robin had suffered severe trauma years earlier, and subsequently was diagnosed with Dissociative Identity Disorder, with associated psychotic symptoms (voice-hearing and delusions).

She currently resides in a nursing home, where she receives care and treatment for a painful chronic medical condition that she keenly understands may be a terminal one. She also receives psychiatric medications, and she meets with me for psychotherapy.

Robin is intelligent and articulate, and able to think in rational and logical ways. The psychotic and dissociative features have a common origin in her traumatic experiences. Addressing split personality issues is only a part of the scope of our therapy conversations, yet will be the focus of this blog.

Robin had experienced much psychiatric care over the years, and she was fluent with professional terminology. I did not begin to directly address the split personalities, or pers as she calls them, until a trusting therapeutic rapport had been well established, and only after she had initiated comments that were directly including the pers in our conversation. We then began to discuss the therapeutic goal of reintegration of the personality fragments into the self, and to include the pers in conversations.

Robin would tell me how the pers were listening to and reacting to comments I was making, and she would convey questions they raised. “They like the way you talk to me, and to them,” Robin said.

Robin would sometimes mentally gather the pers so they might participate in our sessions. I would speak in a teaching way about the trauma she previously experienced, about the fragmenting impacts of trauma, and about ways that dissociative features could have a protective effect — at least at the time of the trauma. I would explain that the so-called split personalities were actually all parts of Robin, and that one purpose of therapy was to help them all come together again as one person.

“There is only one Robin,” I said. “There are no other persons or personalities inside of you that are not Robin. Parts of you, Robin, might be experienced as if being separate — but only because of the psychologically explosive impact of trauma. The task of healing is a gathering up of the parts into the whole — of learning to recognize and identify with those thoughts and feelings and memories that have seemed peculiarly different, due to shattering troubles.

Some pers would argue or complain to or about Robin because, “they feel frustrated being stuck in this nursing home, and they want to be out in the world doing things. They get mad at me because I can’t easily move or walk.

“I can feel the pers moving in my body, and sometimes others come in and enter the pers, and I can feel them in my body, and I don’t really know who they are or what they want,” Robin remarked.

We would talk about the pers as aspects of Robin’s own feelings — that she feels frustrated being ill, and restricted to the nursing home, for example. We spoke of how the “others” were Robin’s as-yet unfamiliar, or unconscious, thoughts and feelings, and that her bodily sensations were ordinary visceral elements of emotions (but feelings numbed by suffering for Robin or pushed away from awareness to the point of seeming to be other than self).

When her subjective experiences were considered as unfamiliar elements of her own thoughts and feelings, Robin could glean new understandings about the complexity of her reactions.

When providing psychotherapy to someone with dissociative identity disorder — like Robin — I have found it important to keep in the front of my mind, and for the client, that this is one person; one unfortunate person, yet one quite resilient and remarkable person. Robin suffered great misfortune, yet she has been quite resourceful in her coping and her capacity for growth. Her well-being has been served by our careful, gentle, and sustained reconsideration of her internal experiences, with the aim of “bringing it all back home,” as Bob Dylan said, or returning the many parts into the one whole.  

The Challenges and Rewards of Therapeutic Work with Brain-Injured Clients

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Over the course of my career, I have worked with many people who sustained brain injuries. In the 1980s, I worked in a brain injury rehab program set in a nursing home, then in private practice during the 1990s. For many years since, I have been an employed psychotherapist in nursing homes.

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In my experience, those who have acquired a head injury typically display irritability and quick flashes of verbal anger — aspects of “organic personality change.” The individual may be more impulsive, acting prior to thinking about likely consequences, might show less awareness of social boundaries, and have problems with short term memory. Sharing some of their stories will offer you a glimpse into some of the challenges and opportunities I’ve experienced in working with these clients.

Case Illustrations of Clinical Work with Brain-Injured Clients

Douglas

One of the clients I met while working at an in-patient brain injury rehab program was Douglas, who was in his early twenties, and was injured riding his motorcycle while intoxicated. Anger management was a focus of therapy; he often expressed anger over being injured, and at his father for bringing him to the rehab program. One additional task of therapy was to assist him in formulating a new sense of personal identity — as he was not who he had been, and not yet who he was becoming, but was feeling lost and overwhelmed somewhere in the middle. Another goal was to strengthen his motivation to maintain sobriety in the future.

During a psychotherapy session one day he unexpectedly said, “Getting a brain injury was probably the best thing that could have happened to me.”

“Tell me why you say that, Douglas,” I asked.

“Because otherwise I don’t think there was any way I could have stopped drinking.” But that attitude and outcome are not achieved by all people.

Brandt

During the time I was working in private practice, I also provided psychotherapy and consultation with a statewide head injury program in Massachusetts. That was where I met Brandt, who had an alcohol use disorder, and, over time, had acquired three different brain injuries because he was not able to stop drinking.

Brandt had his first head injury on a construction job site when he was under the influence of alcohol. To others in his life, Brandt appeared to have a friendly and outgoing personality. Yet the overly friendly, and often tactless and joking manner he displayed represented “changes of personality” associated with frontal lobe executive dyscontrol due to his first brain injury — when a piece of work equipment struck him in the forehead.

Because of his frontal lobe dysfunctions, Brandt found it difficult to anticipate or perceive likely consequences of his actions, and he might brush off or disregard cautions and advice offered to him by me or others in his life.

His second injury occurred when he had been drinking one night with friends. They ran out of beer, and Brandt jumped into his Volkswagen Beetle and sped off to buy more. He drove too fast around a curve in the road, the car rolled over and he was ejected from the car. He landed unconscious on the ground in the dark.

Brandt awakened and lifted his head, and immediately in front of his face was a gravestone. He had landed in a graveyard! How could there have been a more pointed and dramatic message about where his drinking would lead him? Nonetheless, he continued drinking until he had a third brain injury that resulted in significant disability, and he was moved into a group home for daily care.

Mrs. Kelly

During the period when I worked in private practice and was offering head-injury-related consultations, I went to Chicago for a co-presentation at a brain injury conference. I spoke about brain injury from a professional point of view, and the co-presenter, Mrs. Kelly, talked about the personal experience of living with a brain injury. Driving home one day, Mrs. Kelly had been struck and injured by a drunk driver.

During our presentation, Mrs. Kelly spoke of the life losses and challenges that had resulted from her injury including relearning to walk, talk, conduct daily tasks, the gains that resulted from her rehab, and from the continuing support of her husband, who had accompanied her to Chicago who was always in her company.

I spoke of the common goals and aims of brain injury rehab, and about the work of individual therapy, group therapy, and family or marital therapy following a brain injury. During our talk, we also shared a particularly poignant background to our shared experiences, because Mrs. Kelly had earlier been one of my teachers in high school. Using her characteristic humor, Mrs. Kelly once said to me, “I used to get mad that I keep forgetting things; but then I realized, why get mad, in a few minutes I’ll forget what I was mad about.”

Rose

My mother-in-law, Rose, became ill with dementia and spent the last months of her life in a nursing home close to where we live. She and I sat in a small dining room during a visit one day a few years ago. A nurse’s aide across the room spoke irritably to a female resident in a wheelchair.

Rose watched, and when the aide left the room, she shook her head and said, “I hate it when they talk that way. She spoke to her like she was a has-been. She’s not a has-been, she’s a have-been.”

“That’s such a wise and beautiful thing to say, Rose,” I remarked.

Ronald

Around that time, I had long been working as an employed psychotherapist in nursing homes, and I was then seeing Ronald for psychotherapy in a different nursing home from where Rose resided. Ronald had been a scientist working at a prominent institute in California, and he drove a red convertible sports car — but sometimes too fast, and he sustained a brain injury in a collision.

What remaining family he had was in the Boston area, and so he found himself at a nursing home outside of Boston. Ronald was depressed and angry. He mostly stayed in his room, reading and listening to classical music. He would make derogatory comments about the other residents and the staff.

I told Ronald the story of the wise comment by my mother-in-law, and I challenged him to conduct a scientific experiment over the coming week: to go about the unit and research who the other residents have been in their lives.

The next week as I walked onto the unit, Ronald approached me holding a small notepad. Referring to notes he’d written, and pointing to different residents, he excitedly recounted things he had learned about them.   

***
 

Conducting psychotherapy with brain-injured clients has typically involved some modifications to my typical approach. It has been important for me to remain alert to the psychological consequences of organic brain dysfunction. My approach with these particular clients has been more educational and directive as opposed to my typical non-directive one; teaching about the effects of the injury and providing behavioral guidance and specific suggestions for social functioning. The information I provide in treatment is more concrete, and offered in smaller bits, with frequent repetitions to aid retention and recall.

I have found it to be enormously gratifying to work with these clients and encourage my colleagues to welcome rather than avoid these opportunities. It allowed me the chance to work with clinicians who taught me to appreciate the psychiatric effects of medical conditions. The work also allowed me opportunities to make a positive difference in the lives of persons who had been severely injured, and in the lives of some family members who had been devastated by the injury to their loved one. 

Therapy as a Means of Balancing Loss with Acceptance

Posted on by Psychotherapy.net Team

Arlene felt dismayed by the arrival of her 71st birthday. “It’s not the same as when I was young and carefree, now that I’m getting older,” she said during a psychotherapy session at a nursing home. She has a long history of schizophrenia with mild autistic features, obsessive features, social anxiety, and a chronic yet stable blood condition. Arlene mostly stays in her room, wears hospital gowns, and dresses only on rare occasions, such as when a family member takes her for a shopping and lunch outing.

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Nurses point out to me that she sometimes refuses her meals or her medications. “I always take my medicine if I know the nurse who is giving it to me,” Arlene said. When approached by a new clinician or caregiver, she might clam up, make few or no remarks, or raise her voice and order the person to leave her room, due to paranoid thinking. Arlene clarified to me that she was not purposefully avoiding eating, and that she had no intentions of harming herself or worsening her medical condition. “I’m embarrassed to say it, Tom, but it’s my teeth. They’re broken, you see, and it can hurt if I eat something tough. I just look at the food they bring me, and right away I know if I can eat it or not,” she remarked. “Oh, no, I don’t want them to know about my problem with my teeth.”

After further discussion, though, she agreed that it might be helpful if her care providers understand the reasons for her occasional avoidance of meals. Arlene allowed me to speak with other team members at the facility, and then worked with nursing and speech therapy on the types and textures of foods she might better tolerate and enjoy, but she did not want to have dental care.

Therapy as a Road to Acceptance

In psychotherapy one day, Arlene said, “I thought I was depressed because I’m stuck in a nursing home, and that’s true. Then I thought I’d be happier if I went to a different nursing home, but then I would miss my nurse Jane and my aide Jamie, and the other people and things I like here. Even my fan on the table there, I love that fan. So, I decided to look around and notice the things I do like, and let it be good enough.” I spoke with Arlene about the wisdom of her idea, and about ways we might seek to implement that outlook in her daily life.

Arlene had touched upon a wise and simple conundrum of human life. If you substitute the words nursing home in the above quote with family, marriage, relationship, school, home, job, car, town, etc., you notice the universal applicability of the idea of letting what one has be good enough. Why is it so hard, so much of the time, for many of us to simply look at the things and people we do have in our life and let it be good enough? Is the purpose of psychotherapy always to aspire for more than one already has, or to accept more reasonably and gratefully the people and things and abilities one already has?

Many clients I work with in nursing facilities refer to the well-known Serenity Prayer, and some post it on the wall of their room, as they strive for serenity, courage, and wisdom. The ability to distinguish between what can and cannot be changed might be impacted by cognitive deficits, as well as by psychological denial, or simply the anguish of tolerating an unacceptable situation that must be borne.

Some of the clients I work with in nursing homes suffer from severe medical illnesses or major disability conditions, in addition to psychiatric and mood disorders. They might understandably wish for a return to how things once were in their lives, yet not be able to attain those wishes.

Martine, for example, asked a hundred times why she could not go home from the facility, and a hundred times staff and her husband, Mike, answered her questions with careful explanations of her current conditions and needs (dementia, incontinence, fall risks, bipolar illness, and emotional dyscontrol), yet to no avail, as she would persist in the ineffective mental loop of questions and refusals — or inability — to absorb the answers.

Psychotherapy did help Pamela come to tolerate and accept her needs for daily care at the nursing home. She initially suffered a depressive reaction to the loss of her home, her former roles, and a reduced sense of control over her life. But over time she came to recognize and reconcile to the situation as it was, rather than as she might wish it to be. “As long as I know my kids are okay, I can be okay with this place,” Pam said.

Walter, who is debilitated by the effects of Parkinson’s disease, had suffered many losses in his life and was now learning to adapt to residential care. “I’m lucky to have what I do have. It’s not as wonderful as what I did have before, but I’m still lucky,” he said.

A Requiem for All That Was Lost

Education about medical and psychiatric conditions must be balanced with emotional support to assist understanding and tolerance of the knowledge, and guidance to learn to adapt to changes and limitations.

Many clients focus intently on What This Isn’t. “Living in a nursing home, being dependent on others for daily care, isn’t what I want, what I expected at this time of life or what I can easily tolerate,” they might say. All those things, I point out in therapy, may be true, but intense and sustained attention on the disappointments might simply magnify the realistic distress associated with the situation. To help moderate some of that distress, I therapeutically suggest attending as well to What This Is. While this is not home, and the others are not family, this situation is safe, a place of shelter, with meals, medicine, nursing care, rehab, and some socializing with others.

During a recent therapy conversation with Arlene, I referred to her prior remarks about letting her situation be good enough. “Oh, I said that? I don’t remember,” she said. Progress in therapy with my clients might involve small steps towards goals, or might simply be aimed at sustaining reasonable stability, depending on the disorders and capabilities of the nursing home resident.

Therapy is sometimes provided to persons with fully intact mental and physical capabilities, yet other times psychotherapy is needed to help individuals with varied degrees of impairments and functional limitations, who still need to find ways to cope, tolerate losses and limitations, and still be themselves — even under adverse and challenging conditions.

Meaning and a sense of purpose and security are needed not only by those most self-sufficient, but by all people — even, or most particularly, those groping their way through circumstances they don’t want yet cannot overcome. Psychotherapy can provide a relationship for addressing those existential human needs.

Sometimes psychotherapy can be viewed as striving for the highest and best of human capacities. Yet it can also be a humble undertaking, joining in the depth of troubles to help someone get through a day that will be difficult for them.

Questions for Thought and Discussion

How does the author’s notion of acceptance resonate with you personally? Professionally?

What might you have said to Arlene, or the others mentioned in this essay when they expressed their losses?

How do you work with elderly clients around loss and acceptance of “what is?”   

Psychotherapy With Non-Verbal Clients: Blending Empathy and Flexibility

Posted on by Psychotherapy.net Team

Psychotherapy with Non-Verbal Clients

Hello, Jane.

My name is Tom.

Can you hear me? Blink once if yes, or blink twice if no.

One blink.

Is your name Jane?

One blink.

Is my name Tom?

One blink.

Is my name George?

Two blinks.

Is your name George?

Two blinks.

Jane is fully paralyzed, and can only communicate by use of eye blinks — one for yes, and two for no. Her yes/no responses had been tested by the speech therapist and were deemed to be reliable. By responding to a series of my comments and questions, she could indicate her answers, and gradually build up a conversation about her thoughts, feelings, and concerns.

Consequent to a brain stem stroke, Rachel became paralyzed from the neck down. Her brain functions are intact, and she makes facial expressions, but cannot speak or move her body or limbs. Rachel communicates with a clear plastic board with black alphabet letters and numerical digits. I hold it up and watch her eyes carefully and methodically scan the board, and then say aloud each letter she selects by looking at it, as she builds words and sentences. Rachel can have thoughtful and meaningful conversations in psychotherapy, or with others — if someone is willing to make the effort to use her method of communication. In our first conversation Rachel communicated, “We should do staff in-service training, Tom, because they don’t always use my letterboard.”

Roger sustained a severe brain injury, and he was only able to move his right thumb, yet he would lift his thumb once for yes, and twice for no, and with that method, Roger could generate basic communications.

Doris was deaf for most of her life and was a skilled signer and reader of lips. She came to the nursing facility after a stroke. I don’t know how to sign, and I wear a mask at the facility, so I would write my questions and comments, and Doris would read them and give verbal responses.

Mark had been in a persistent vegetative state after a brain injury. He eventually made a surprising recovery, regained his speech, and moved about in a wheelchair. Mark explained to me that during the period when he was outwardly unresponsive, he had been aware of others speaking around him, yet he could not let them know. During that period, he also experienced an exact recurring sequence of twelve dreams, which he was glad to now be able to share with me.

Combining Empathy, Creativity, and Flexibility in Psychotherapy

In psychotherapy, I commonly attend to the specific content of what a client is saying, as well as what may be left out or avoided, what might be hinted at or signaled indirectly. I listen to the tone and pace of a client’s speech, and to gestures and body postures that also communicate meanings. I follow the attention of the client, how one establishes or breaks contact, and if the client is speaking directly to me as they search for new understanding or might be repeating comments they have made to others, or even if they might be speaking to an internal audience more than to me. I pay attention to what the client inwardly attends to and ask questions or make comments to guide their attention to what they might overlook, minimize, or avoid. This approach becomes more critical when working with clients like these with medical or disabling conditions that affect their ability to communicate verbally.

While practicing psychotherapy in nursing facilities, I might work with a client with intact cognitive and language skills, or sometimes with someone with a brain injury or a neurological condition. The individual might even be a non-verbal communicator, which as I have learned, does not preclude meaningful, empathic communication.

Some of my clients use non-verbal methods of communicating such as gestures, or a letter board, or an electronic device for spelling or voicing their typed comments. I may need to extend my patience and concentration when working with a non-verbal client. If an individual can only offer yes/no responses, it is important to clarify and confirm the accuracy of their responses. When documenting the conversations, I might state that I said or asked this, and the client indicated or selected that to limit assumptions or misunderstandings about precise communication with the client.

When working with a non-verbal client it is, ironically, the non-verbal communication that is lessened, as the client and I are focused more on the concrete words or meanings being generated than on the manner of communicating.

Social communications are an essential human need. A reduced ability to communicate or the loss of speech can be profound, and when added to an acquired disability condition, communication can be that much more difficult, especially between therapist and client. When a person most needs to talk about their situation, they might be unable to speak, or quite limited in their ability to communicate — if others do not effectively assist their abilities with some augmentative type of communication method. A person might lose the ability to verbalize speech, yet they do not thereby lose their need to communicate. Psychotherapy with a non-verbal client is possible yet may require adaptation of methods, therapeutic approach, and attitude.

***

I have been especially moved by the challenges faced by people with one or another barrier to ordinary human communications. I feel proud of the courage these individuals display as they grapple with enormous communication problems — those that others might overlook.

Some clinicians and health care providers might think it is not effective to attempt psychotherapy with significantly disabled persons or clients with an absence or impairment of speech. But my clients have many times expressed their appreciation for being helped to develop and refine methods of communication through speech therapy and psychotherapy.

It has been important to help my clients think about and prepare ways they might more successfully communicate with others, and not only with their therapist. For example, Rachel could have a card posted in her room or attached to her wheelchair that explains her need for help to communicate, and brief instructions for how to help. Or I might coach a client to practice sharpening the point of their messages so they more quickly convey their needs or requests before a listener might lose patience and end an interaction.

Psychotherapy can still be a dialog even when it is not a typical verbal conversation. A client can still be helped to find and use their personal “voice” even if it is not a spoken one.

Using Psychotherapy to Heal a Lifetime of Pain and Shame

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As a child, Darlene would change to lower-watt light bulbs in the small bathroom attached to her bedroom so that the light would be dimmer. “How can you see anything in here?” her mother would ask in dismay. But Darlene preferred to brush her hair, and later apply makeup, in subdued lighting.

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As a young adult Darlene had lived for several years in a state psychiatric facility. One day the psychiatrist and a nurse sat with her and suggested that she apply to nursing school. She thought she was in trouble when the doctor asked to speak with her, and was surprised when he spoke of her potential — and the possibility of her living outside of the hospital. Darlene became a licensed practical nurse (LPN), got an apartment, and enjoyed a career working at a state school for persons with developmental disabilities.

Darlene had weathered a very brief and turbulent marriage that ended when her husband was physically abusive to her. “I don’t know why I ever married him,” she said. “Partly, my parents thought it would be good for me, and partly I was at least hoping I’d be loved.”

Now, as an elderly woman at the nursing facility, she mostly stays in bed, and typically prefers that the shades be down. While she attends a few group activities, Darlene feels relieved when she can finally get back into her bed and the low-lit security of her room.

Therapy as Sanctuary

One day as I sat next to her in her room during a psychotherapy session, Darlene asked that I raise the shades because she could hear it was raining outside. “This is the only time when I feel good, when the weather outside matches the weather inside me," she remarked.

Dim and dreary weather conditions had always matched Darlene’s moods, and provided a sort of comfortable retreat for her, whereas sunshine and groups of people could be anxiety provoking for her. Her Poe-like melancholy was matched by an attraction to poetry, and she would recite to me verses of poems she had long memorized.

Darlene also had a lifelong struggle with bipolar illness that mostly involved depressive episodes, and rare manic periods with grand persecutory delusions (“I’m being nailed to a cross, everyone’s looking at me!”). Oh, what could be more distressing for Darlene than to be under the glaring and judging eyes of others!

As she aged, Darlen suffered from macular degeneration with progressive loss of sight. She ate meals sitting up in bed, and often felt increasingly frustrated and embarrassed by the messy results. She was helped when her meals were changed primarily to finger foods, and she could be guided by touch more than by sight.

Dignity in the Shadow of Shame

Darlene also experienced problems with bowel and bladder incontinence. The need for someone to witness and attend to her humiliating problem felt horrible and shameful to her. She inadvertently made the matter worse, though, by her ineffective effort to clean or hide the results of a bowel accident — causing a staff person to come to me stating that Darlene was “playing with her feces.” After a conversation with Darlene, I could explain her predicament and her sense of shame to the staff, and they were then more helpful with keeping her clean while protecting her dignity.

One day at the nursing facility as I was pushing Darlene in her wheelchair through the hallway, we encountered a new female resident who loudly exclaimed, “Darlene, Darlene, it’s me, it’s Ellen!” With a panicked expression, Darlene looked at me and said, “Get me out of here, now!” Darlene explained that she knew Ellen and that they had both lived at the psychiatric facility at the same time. Darlene did not want anyone to know that she had once lived there, because she felt it was yet another source of shame.

Over the course of several therapy sessions, Darlene and I explored her reactions, and her underlying thoughts, feelings, assumptions, and beliefs as they related to her encounter with an old friend who had resided along with her at a chronic care psychiatric hospital many years ago.

We focused on reframing her story of time at the hospital from one of self-perceived shameful illness to a story of triumph. We discussed ways she had achieved many significant and meaningful successes: through her trust in her psychiatric care providers while at the hospital, through her education and attainment of a nursing license, with her subsequent career providing valued care to her patients, and by living in an apartment on her own during her working career.

Darlene was praised for the many triumphs in her life story. We spoke of how others might be impressed by and applaud her achievements, rather than look poorly on them, if she might be willing to share her story, to raise the shades, and let in the light!

Questions for Thought and Discussion

In what ways does Darlene’s story resonate with you personally and professionally?

How might you have addressed Darlene’s dilemma of encountering her “old friend?”

What clinical experiences have you had with the elderly and how have they impacted you?  

Effective Nursing Home Psychotherapy: Blending Skill And Heart

Posted on by Psychotherapy.net Team

“My mother literally made gin in the bathtub; it was part of how she made money. She also had men ‘guests’ in the apartment, and unfortunately, she didn’t always protect me from them.” Daphne remarked as she spoke of her childhood in Brooklyn, New York.

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Daphne was now 84 and resided in a nursing facility. She used a wheelchair, and spoke in a raspy voice due to polyps on her vocal cords. As a result, she would not sing one note, since she knew it would never again sound like it had when she was younger. But she would laugh, and she would share her stories, and she was always curiously asking about the stories of other people, even mine.

On Her Own Terms

We often sat for psychotherapy in a small TV room in her unit. The room was about 8 feet wide by 10 feet long; just space for a loveseat, one chair, her wide wheelchair, a small TV on the wall, and a window looking out at the woods behind the facility.

During one session Daphne was speaking about the ironic balance of shyness and confidence of a performer. “How about you, you seem calm, but do you feel shy or do you feel confident?” she asked. I explained that when I was younger, I went to acting school, partly because someone wrongly suggested to me that taking up acting was a way to overcome shyness. Daphne laughed, and asked, “Well, so how did that work out, anyway?”

Daphne had a regal quality, along with her charmingly refreshing genuineness. Her issues in therapy were related to acceptance of aging and reduced functional independence, tolerance of the loss of her singing voice, and easing of suffering due to abuses experienced in her childhood. Daphne was intolerant of anything phony. She’d seen too much in her life, and seen through the disguises of so many persons. I could not have “played the part of a therapist” with Daphne — hiding behind a veneer of neutrality — my choice was to meet her on the terms she expected of authentic sharing, or nothing.

She roared with laughter as I told of the nausea and fear I’d experienced before a stage performance, and my delighted excitement during the performance. That pattern continued with each show — dread in anticipation, and elation while acting — and no, I certainly never got over being shy, I explained, as she threw her head back and laughed.

“So, why did you give it up?” she asked. I did not think it would be a successful, or tolerable, career — I could hardly tolerate putting myself through those ups and downs, so I went back to school to get a master’s degree to practice psychotherapy. “Well, didn’t you still have those same ups and downs in your new career?” she asked with her bright and penetrating gaze.

Actually, I would sometimes give talks or make presentations at professional conferences, and would experience the same nauseating apprehension, and then the same enthusiastic enjoyment while at the podium. ”Of course, I knew it!” she laughingly stated. “Let me explain to you why that happens,” she said.

Personality and Talent

“That’s the difference between personality and talent. Your shyness and your anxiety about putting yourself in the spotlight, that’s personality. But the joy and enthusiasm you felt when performing, in one way or the other, is talent. Talent and personality are not the same thing, but so many performers harm themselves because they never understand the difference.” Daphne wisely explained.

Daphne used examples of famous performers who confused their personality with their talent, and who got caught up in the projections of fans who thought that their personality ought to match their talent, and who developed problems because they could not, and should not, blend the two things that were categorically different.

Sometimes in psychotherapy, my clients are vulnerable and in need of guidance, strict boundaries, and a straightforward application of therapeutic techniques. In nursing facilities, I sometimes work with residents who have diagnosed mental disorders, and who need formal and conventional psychotherapy. Yet sometimes the residents I see in therapy don’t have a psychiatric disorder, but may instead wrestle with real-life problems such as illness or loss, and who may benefit from a less formal educational and supportive approach.

Daphne was of the latter; wise and resilient, she lived vibrantly, even when she was less able to function on her own. Her wisdom, her humor, and her curiosity about the lives of others were key strengths, and they found a place in our therapeutic conversations.  

Therapy in the Shadow of Death and Its Remarkable Privileges

Posted on by Psychotherapy.net Team

Concerns Converging on Loss
 

“So, the doctor told me that it is cancer, and that there's nothing they can do. I just hope I have a little more time; my biggest hope is that my sons will reconcile with each other.”

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“The doctor came to my room to see me. He held my hand and said, 'I'm sorry you have cancer, and I'll do everything I can to keep you comfortable.' And he said, 'From everything you've told me about who you expect to meet when you leave, I think that should be the best comfort for you,' and the doctor was right, my faith is a comfort to me.”

“My daughter, my beautiful daughter killed herself. There's just no answer to explain it.”

“Don't say goodbye, I'll see you in heaven; I've been there before (near-death experience) and it's beautiful.”

“Oh, Tom, can you see this client today, her son just died; they think it was a drug overdose.”

“They're all gone, my parents, my wife, my children, everyone; I'm the last one left. I don't know why, but I'm still here.”

“This is the third time my mother is in hospice. I wish she would die, but then I feel so guilty for wishing that. Then I wish she would get better, but I don't think she will; it's all just so difficult and confusing.”


Walking with My Clients
 

Over four decades, I’ve provided psychotherapy to residents in nursing facilities. I have worked with many thousands of clients, most of whom have died. I have been privileged to accompany so many on the last steps of their journey through this world. All persons die, and virtually all persons have lost someone, or many others dear to them. I have likewise been privileged to provide companionship to so many amid of their grieving. Speaking with someone with a terminal illness or someone grieving is a weekly, if not daily, or even several-times daily part of psychotherapy in a nursing facility.

Sometimes I know in advance, and can have sessions in which to work reflectively with the client as they approach the end. Other times I come to the room of a resident and their belongings are gone, and inquire of the nurse and am told they died. Sometimes, I receive an email telling me the sad news before I arrive, and sometimes a staff person will console me, “I know how close you were to her.”

For many clients who have a terminal illness, it is a comfort and relief to speak frankly in psychotherapy about matters of death and dying. The person's family members, and even some caregivers, might tend to avoid the topic, perhaps due to personal discomfort.

Staff persons might encourage continued socialization, yet the dying individual may be occupied with the internal work of preparation. A nurse asked me to “talk to” a dying resident because she thought her TV show was inappropriate. The resident was sitting up in bed while a television show for toddlers was quietly playing. While the resident sat facing the TV, she was clearly looking inwardly.

As I quietly kept her company between brief bits of conversation, I noticed how the TV show in the background provided a soothing backdrop. This particular resident, like others close to death, needed to pull away from the ordinary things of this world and reflect on their life, their relationships, and their eternal future. My father was lucky to die at home. As I visited him weekly towards the end, he would each time give me a book or another item of his. I thought of how I pack up when I am preparing for a journey. He was unpacking as preparation for his journey.

Sometime around 12 to 15 years into my 40-year career, I started to experience burnout; a result of too much trauma and human suffering. For me, it was a deepening of religious faith that allowed me to once again fall in love with psychotherapy and learn to practice without being harmed by it.


Of Greeting and Bidding Farewell
 

Some dying individuals are comforted by their faith, and some struggle with doubts. Everyone will have some fear of death, yet I notice how each person has their own kind of fear as they near it. For many of my clients, the fear is of God's judgment. Clients often voice worries about their mistakes and misdeeds in life — yet I regularly see how narrowly a person might look at their life experiences and influences, and how harsh and disproportionate is their judgment of themselves.

Many of my clients have been rejected by so many in life, they doubt there is a God, or let alone a God awaiting them with kindness and understanding. I feel a tenderness for each of my clients, yet often in therapy, sometimes as a client most severely chastises themselves, I feel a loving kindness in me that does not seem to begin in me. I notice a gentle feeling of wanting to reach out and touch their cheek, or a reassuring largeness of understanding that surrounds all the good and the bad of that person’s life, and I simply hold those ideas or sensations as aspects of my bringing a therapeutic presence to their suffering.

I have worked for many years in particular facilities; maybe 10 years in one, or 18 years in another. As I walk through the halls, I often think of the individuals who previously stayed in those different rooms, recalling their personalities and the challenges of their life.

Psychotherapy in nursing facilities is often a process of greeting, uplifting, supporting, and of saying goodbye. It can encapsulate and intensify the general experiences of life and death one might encounter in other settings or ordinary living. I am grateful for this work. When the time comes to retire, I will continue to see in my mind's eye the many people I have worked with and to thank them for their trust when they were most vulnerable.

 

The Encounter at the Doorway

Posted on by Psychotherapy.net Team

Francis Thompson was born on December 18, 1859, and died on November 13, 1907. He is the author of the great mystical poem “The Hound of Heaven.”

I fled Him, down the nights and down the days;
I fled Him, down the arches of the years;
I fled Him, down the labyrinthine ways
Of my own mind; and in the midst of tears
I hid from Him, and under running laughter.
 

So begins the first verse of the poem that is considered a spiritual autobiography of Thompson’s attempted flight from God, and the gentle and persistent presence that always pursued him no matter how much of a mess he made of his life. Francis Thompson was often homeless on the streets of London and addicted to Laudanum (alcohol with a tincture of opium).

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One day Francis went to the office of Wilfred Meynell at the Merry England magazine. At his desk, Mr. Meynell saw the office door open slightly and close, then open and close again. In the doorway, Francis had no shirt beneath his coat, bare feet in his broken shoes, and a soiled and wrinkled manuscript in hand. He was scared. Thankfully for Francis Thompson and for the history of English literature, the impeccably dressed Mr. Meynell looked beyond the surface of Thompson’s broken-down appearance. He read the manuscript with mounting astonishment, helped Francis get into a hospital, and gave him a job. Francis relapsed into addiction several more times between periods of rest and recovery at a monastery in the countryside and bursts of literary productivity, until his death that resulted from the effects of addiction and tuberculosis.

I have personally witnessed dramatic and counter-intuitive ways in which demographics have changed in skilled nursing facilities over the past several years. The general population may be aging, yet the trend nationally has been one of younger adults increasingly being admitted to nursing facilities. A dearth of funding for home-based services, and a lack of available and appropriate residential programs for psychiatric and substance abuse issues are among the factors that contribute to these changes, and those that most directly impact the clinical work I do with these populations.

In the nursing facilities where I work, I have encountered relatively young residents with complex medical and psychiatric and substance use disorders. I can attempt to prepare for these doorway encounters, as did Mr. Meynell all those years ago when first meeting Francis Thompson. But as Meynell’s first impression of Thompson was skewed by his streetworn and drug-addled presentation, so, too, might be our own first impression of a younger person whose substance abuse and psychiatric history has taken a toll on their body and mind. Their need to be seen fully as a person is no less than was Thompson’s when he first appeared in Meynell’s doorway. And, like Thompson, each of the residents who present in my clinical doorway is so much more than their respective psychiatric and substance abuse histories.

Every person wants his or her life to turn out well. The person with a substance use problem yearns to be recognized as someone who wants their life to turn out well, and who needs the help of others to rebuild that life. The person we meet might be a creative genius, but that doesn’t matter; they are always an individual human person of infinite value.

Residents I spoke to with a history of addictive illness have offered insightful comments that have guided me in my clinical role at these various nursing facilities.

“Staff make negative assumptions based on a person being homeless and self-medicating,” according to Casey. “It’s hell out on the streets; you get overcome and paranoid sometimes, and you use again,” Rod said. “Don’t tell them ‘Just get off drugs,’ but help them to get a job, a home, and social contacts,” he added. “You know, they once had a job and they were in society once; they need programs to help get back in society.” Casey said that staff should realize that for the newly admitted resident “their body is going through a metamorphosis because they are not drinking or using drugs.”

Trent pointed out that “you’re not relaxed and calm when you come into a nursing facility.” He suggested that too often caregivers have a negative attitude: “You’re busy and irritated, and it makes me irritated and angry.” Trent suggested that “it should be up to the patient if they want to talk about it [addiction].” “Too much pressure and they close up. You feel pressured by people always on your case, and telling you what to do, when you have to figure out what to do; it can be overwhelming, and you can clam up and want to be left alone,” he said.

The individual with a substance use illness will “need a little love; something like a Big Brother program for grown-ups,” said Rod. “Help them get to a place where they can at least have hope,” he said. “It’s going to take love and patience to help them rebuild themselves.” Casey suggested that nursing facilities might offer practical and age-appropriate group activities, and not simply Bingo or crafts. She suggested bringing in persons from the community to offer life skills training on how to budget, how to use the internet, how to interview for a job, how to prepare food, find an apartment, or apply for disability income. “You’ve got to help open doors to encourage people to want to do better: Give someone a reason to get up in the morning; you’re never too old to love to do something new,” she said.

I think we cannot reasonably say, “Let someone else deal with this; I’m not trained or qualified to deal with this kind of problem.” The residents I spoke with pointed out occasional shortcomings of the inpatient addiction treatment programs where they sometimes fruitlessly sought help. Frank was impressed by the practical advice and suggestions he heard during his first alcohol detox admission. He was surprised to hear the same points during his second admission, and then disappointed to find during repeated subsequent admission that “they just talk from the textbook, and they don’t really have something new to say to you.” Frank spoke of a 19-year-old woman who had been through 30 detox admissions—citing the evident insufficiency of the specialized treatment offered. The residents spoke to me about the perceived limited knowledge and understanding of some professionals with specialized credentials for treating persons with addiction. The residents stated that they could encounter negative judgmental attitudes and unhelpful advice as often in specialized in-patient treatment programs as in skilled nursing facilities.

In my own experience working with these residents, I have found it important to encourage fellow clinicians and nurses to acquire additional training and certification, yet not discount the array of skills, knowledge, and personal qualities that they already bring to bear in the service of these residents. Residents with addiction and/or psychiatric disorders tend to have developed acute BS-detectors; they observe us with an X-ray type of vision. The person with an addictive illness has a refined intuitive ability to notice the underlying attitude of the nurse or clinician who encounters them. That capacity typically emerges from the deep emotional wounds of shame that accompany an addiction. The person with the addictive illness feels under a cloud of suspicion and judgment from the first encounter. We should strive to receive that person with a wise and open heart, as well as with a wily awareness of the risks of manipulation that can also be an unfortunate part of the picture. We cannot hide or disguise attitudes of fear or revulsion or judgment from the awareness of the persons we meet and work with.

***

The encounter at the doorway is a two-way process: I encounter my personal attitudes and values and beliefs about illness, addiction, and homelessness as I also meet with a person in need of kindness and patience and practical encouragement. My own genuineness and authenticity and humility have often made the critical difference as I greet the other at the doorway of despair or new opportunity.