Counseling and therapy services should be available to every person with dementia (i.e., those with diminished memory, neurological health and cognitive ability), if he or she wants them. But not all long-term care facilities offer such services.
They should for two reasons: to support them in making sense of their lives, and to support them in making sense of themselves in their present condition and experience.
Many psychologists who practice in long-term care facilities base their work on the medical model of treatment. In this model, hierarchy in the relationship is essential in order to observe the client as the subject of inquiry. The psychologist focuses on using his or her own expert knowledge to make treatment decisions for residents.
Residents are considered to have deficits and dysfunctions, and the psychologist is called in to “fix” them. This form of treatment often does not view the client as an expert about his or her own life. It views clients as lacking information and the ability to make decisions about what is best for them. Regarding dementia, those using this approach assume that there is little or nothing you can do for the patient. They tend to focus largely on assisting the family and long-term care providers.
In contrast, those psychologists who utilize person-centered therapy base their work on collaboration with residents in a joint endeavor to bring about positive change from the residents’ view. The counseling relationship is based on discovering who the person is and what she or he is thinking and feeling about what is happening in their lives.
In therapy, we assume that a person with dementia “is making an urgent request to make sense of Self – to make sense of the past as it has affected the present and how the past has collided with the brick wall of the future” (D. Lipinska, 2009, a noted author in the field). According to psychologists who utilize person-centered therapy, therapeutic relationships with residents emphasize:
• Unconditional acceptance.
• Responding with empathy.
• Generosity of spirit – giving the benefit of the doubt; not making premature and often inaccurate assumptions.
• The belief in human development as occurring throughout life.
• The spiritual dimension of experience.
What does the psychologist providing person-centered therapy do? She provides opportunities for people with dementia to tell their stories and to be listened to in psychotherapy. She also provides them with an opportunity to make sense out of the world in which they live now and to grieve the losses they have suffered.
What happens in therapy? The assumption is that older adults continue to develop in the emotional, social and spiritual dimensions of their lives up to the point of death. Story-telling is a way for individuals to become known to themselves and to others. They gain a sense of their own worth as their stories fill them with status and importance in the relationship.
What are the outcomes in person-centered therapy?
• Defeat of the three most common plagues in long-term care: boredom, helplessness, hopelessness.
• Reduced anxiety and depression.
• Enhanced feelings of being heard, worthwhile, valued, respected.
• Increased desire and ability to express how they are feeling during the session without needing to wonder if it is appropriate to do so.
• Experiencing forgiving and resolution.
• Feeling of being taken seriously and empowered to be themselves within their relationships at their home.
What are the implications for families when choosing a long-term care provider?
Assuming the provider offers psychological services, the first implication concerns the issue of power and influence in therapy.
Here there are two choices. Does the psychologist utilize a “power over” strategy based on the medical model to induce compliance among residents living in the facility? Or does the psychologist utilize an “empower to” strategy to invite collaboration with residents regarding their own care? The second implication concerns the issue of “resistance” versus “protection” on the part of the resident. Consider the following. Does the psychologist understand that residents hold a lifetime of beliefs, decision-making and choices to which they may be wedded strongly? Does the psychologist encourage residents to honor their past choices? Does he or she enable residents to trust their own instincts about their care? Does the psychologist understand that residents may need to protect themselves and their position (i.e., appear “resistive” to care) in the new world of long-term care until they better understand and trust that new world? Does the psychologist understand that residents have the right to say “no” to a particular treatment? Does he or she understand that residents may need to say “no” (i.e., appear resistive to care) before they can say “yes” (i.e., comply with treatment and care)?
In conclusion, families who are considering long-term care for a loved one, and families who have already placed a loved one in long-term care, should consider the choices now available to them. Does the facility offer psychological services to all residents? Do the psychological services offered at the facility emphasize person-centered therapy? Do you believe your loved one might benefit from psychotherapy that facilitates a search for meaning in her current situation? Does your loved one know that these services are available?
Dr. Judith Rand is a licensed psychologist in Arizona and provides person-centered psychological services to residents at home in a long-term care facility in Phoenix and on an outpatient basis for Ahwatukee Foothills residents. Contact her at (480) 399-6100 or J_RandPhD@msn.com (please put “Person-Centered Therapy” in the subject line). Her Web site is www.thefamilyprosperityinstitute.com.