In Australia, nearly one quarter of a million older people live permanently in residential aged-care homes (Australian Institute of Health and Welfare, 2015). This figure will rise with the growing number of older adults. Of those living in residential care more than half have dementia (Australian Institute of Health and Welfare, 2012) or symptoms of depression or anxiety (Australian Institute of Health and Welfare, 2013; Creighton, Davison, & Kissane, 2016).
However, mental health conditions such as depression often remain undetected (Davison et al., 2007) and untreated (Kramer, Allgaier, Fejtkova, Mergl, & Hegerl, 2009) in residential-care settings. Less than one percent of aged-care residents receive any kind of psychosocial treatment, despite the high prevalence of mental health disorders (George, Davison, McCabe, Mellor, & Moore, 2007). In a recent survey on the utilisation of psychological support in such settings, psychologists were not well-represented (Stargatt et al., in press). Of 81 residential settings surveyed throughout Australia, only 11 employed psychologists (mostly on a casual or part-time basis), and only one setting had a full-time psychologist.
Why is psychology so absent in aged-care settings?
The reasons for the poor representation of psychologists in residential aged-care facilities are multifaceted. Older adults have negative attitudes about seeing mental health practitioners, and so would not readily self-refer. Staff working in such settings may not be able to identify signs of poor mental health, and instead may relegate the apathy and poor motivation to normative signs of ageing. Staff may also not know whom to refer to. Psychologists are rarely provided training in geropsychology, and may believe that older adults who are physically frail, have dementia or chronic depression are not amenable to psychological interventions. Access to psychologists in residential care is further hampered by inadequate funding mechanisms for residents to access psychological services.
Psychology’s effectiveness in aged-care settings
Despite the challenges in providing access to psychological support for aged-care residents, evidence is building for the effectiveness of psychological interventions in treating late-life depression, anxiety and dementia in residential settings (Wells et al., 2014). Interventions such as reminiscence therapies, behavioural activation, cognitive behaviour therapy, and mindfulness-based approaches have been subjected to research trials.
In addition, the advent of computer-assisted interventions, such as virtual-reality applications, robot companions and screen-based augmentation of traditional one-on-one counselling have begun to reach the residential aged-care sector (Rehm et al., in press). Manualised and creative protocols are now available for mapping dementia-related behaviour, managing cognitive difficulties and addressing mood dysregulation (Bird & Blair, 2010; Paukert et al., 2013). Systematic research has demonstrated that psychological approaches are effective in treating behavioural and psychological symptoms of dementia (O’Connor, Ames, Gardner, & King, 2009a, 2009b), as well as reducing levels of staff stress and the number of medical consultations by visiting general practitioners (Bird, Llewellyn-Jones, Smithers, & Korten, 2002). The potential for psychology to make a positive contribution to the mental health of older Australians living in residential care is significant (summarised in Davison et al., inpress).
Foundational frame model of psychological support
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Mrs Jones – a case example illustrating Swinburne’s foundational frame model for working with older adults in residential-care settings who are not self-referred.
Mrs Jones, an 85-year-old widow, was referred for psychological support because she appeared depressed, and did not leave her room. She asked for meals to be brought to her room and was consistently brusque to staff. She resented being referred to a psychology practitioner, viewing the referral as yet another imposition on her autonomy. Theproblem on the referral note stated vaguely – “MrsJones stays in her room” – implying that the behaviour was problematic, yet not indicating in what way so.
Following the Swinburne foundational frame model for working therapeutically with residents who are not self-referred (see Bhar et. al., 2015 for more details), the early focus of treatment was on developing a relationship of trust with Mrs Jones (the rapport building phase). Using a measured approach, visits were kept short and light – more akin to a visit by a well-meaning friend rather than a practitioner, and over a period of months, trust was developed. Mrs Jones began to talk about her problems, describing a fear of falling if she left her room, and staying in her room because she felt safe there. Mrs Jones acknowledged that she was isolated and lonely, and had become a recluse, with nurses being the only people she saw on a daily basis. Mrs Jones did not feel engaged with the nurses despite their routine inspections and when asked why, she simply said, “Because I cannot remember their names”. Mrs Jones reported having difficulties with her short-term memory, and felt agitated and embarrassed when presented with situations requiring her to remember information.
The second step was to clarify the problem and treatment goals, and to intervene (the treatment intervention phase). The psychologist observed Mrs Jones walk from her room to the dining hall. Mrs Jones was unsteady and required the assistance of a walking frame but appeared able to retain her balance. She was able to share a history of agoraphobia. Using an exposure-based strategy, the psychologist assisted Mrs Jones regain her confidence walking down the corridor. After nine sessions, Mrs Jones was able to make the trip unaccompanied.
In addition, the psychologist used reminiscence therapy on a one-on-one basis to help Mrs Jones feel more confident and less depressed (see Bhar, 2014 for more detail on reminiscence therapy with older adults). Drawing on technology, the psychologist used Google Earth on an iPad to show Mrs Jones images of her childhood neighbourhoods, which Mrs Jones found engaging and prompted a conversation about her family and neighbours.
The treatment for Mrs Jones’s poor memory of names reflected the third phase of the foundation model (the collaborative care phase). In addition, the psychologist sought the support of staff to wear larger name tags and to identify themselves to Mrs Jones when they checked in to provide care. Instead of helping Mrs Jones improve her memory, the environment was adapted to accommodate her impairment, a strategy commonly used to assist individuals with dementia and cognitive impairment, and it worked remarkably well.
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Other innovative psychological support in aged-care settings
In addition to reminiscence therapy used individually (as in the case of Mrs Jones), group-based reminiscence interventions have enormous potential in residential settings for building social relationships. In one study, reminiscence therapy was found to be most effective when it was delivered in a group-based context (Haslam et al., 2010). The authors of that study suggested the positive outcome of the group was not solely due to the prompting of past pleasurable memories, but also to opportunities for socialising with others in the group.
Life stories have also been shown to be a promising intervention. For example, digital life-story videos of an aspect of the resident’s life – comprised of media such as photographs, video, music and voice-over – have been used to trigger positive emotions in residents (Subramaniam & Woods, 2016).
The role of psychologists can encompass more than just the direct care of residents. The role can morph into that of a case manager and advocate, enlisting other services to improve the wellbeing of residents. For example, Swinburne’s program in aged-care facilities identified that many residents under their care complained of loneliness. In order to service these clients, a ‘befriending service’ was established whereby a ‘befriender’ would visit on a weekly-to-fortnightly basis to participate in discussion and activity with the resident and establish meaningful engagement. Preliminary results indicate that residents report feeling better following visits, which was often verified by staff.
The scope of care can also extend to family and professional staff. Families are often left feeling a mix of emotions following the relocation of an older family member to residential care. The role of the psychologist in this case is to provide care to the carer. An example of this might be through a care support group program – where carers meet with mental health practitioners and a facility representative on a monthly basis to discuss their concerns (see article on p. 16 for more information about caring for the carers).
Also of note is that staff at residential facilities tend to have limited training in mental health literacy. A series of studies focusing on staff knowledge of depression revealed that staff have low levels of competency to identify signs of depression (McCabe, Davison, Mellor, & George, 2008). Staff education and support (e.g., development of a screening protocol) have the potential for improving staff knowledge (McCabe, Sarah, David, E, & George, 2008) and referrals to a psychologist (Davison, Karantzas, Mellor, McCabe, & Mrkic, 2012). The role for psychologists to provide education through formal workshops and consultation is growing, with some facilities recognising the benefits that come from such education in the form of better care for residents, better self-care for staff and more informed referrals to mental health practitioners.
Access to psychology services in residential care willimprove with the provision of adequately trained psychologists, improvement in funding mechanisms that allow residents to access psychological services through Medicare, and improvement in the mental health literacy of care staff. Given the growing number of older Australians and correspondingly, those living in residential care, psychologists will find greater opportunities to make a substantial impact on the lives of the older adults in these settings.
Acknowledgements
Acknowledgement is provided to Mark Silver and Rebecca Collins for their involvement in coordinating Swinburne's Wellbeing Clinic for OlderAdults.
The author can be contacted at [email protected]