Overcoming Obstacles In Providing Mental Health Treatment To older Adults:

Getting In The Door  -  Posted March 2007

Janet Anderson yang                                                                  Cynthia L. Jackson

 

The Center for Aging Resources
Graduate School of Psychology, Fuller Theological Seminary

Older adults significantly underutilize mental health services relative to their numbers in the population. Barriers that impede their access include physical, financial, cognitive, emotional, and attitudinal issues. This article discusses strategies for overcoming these barriers, including physical adaptations such as in-home psychotherapy and telephone sessions, use of support groups, strong community outreach, and liaisons with other professionals. Adaptations that help to increase older adults' use of mental health services are discussed, including education about treatment, nontraditional "pursuit" of clients, and use of alternative terminology. Informed consent is discussed as a special issue.

   Older adults underutilize mental health ser­vices. Whereas approximately 13% of the U.S. population is over age 65, only 2 to 4% of patients in mental health outpatient clinics axe over 65 (Eisdorfer & Stotsky, 1977). This is so, despite the fact that overall rates of mental disorders do not seem to decrease in older age. Providing ap­propriate mental health services to these elders can increase their quality of life, help prevent premature institutionalization, and reduce overutilization of medical services. Drawing on their experience directing the Center for Aging Re­sources in Pasadena, California, these authors will discuss obstacles elders face in accessing mental health services and strategies to surmount these obstacles. The Center for Aging Resources is a community-based mental health clinic for seniors, with special programs designed to help them overcome the financial, physical, linguistic, cognitive, cultural, and psychological difficulties faced by older adults.

Barriers to Access

   Older adults in today's cohort of elders demon­strate many difficulties accessing mental health services, including physical, financial, linguistic, cognitive, and psychological (emotional and atti­tudinal) barriers (Newton & Lazarus, 1992). First of all, for many elders, physical condition pro­hibits them from traveling to a mental health clinic or practitioner's office. Between 12 and 30% of elders have chronic medical problems causing mobility impairments (Centers for Dis­ease Control, 1992; Parnes et al., 1993). An even greater percentage, though able to walk or drive, may find that keeping an appointment takes too much energy or causes too much physical pain to be worthwhile.

   Second, many elders live on a low income. Approximately 13% of adults over age 65 live below the poverty line. Although some elderly people have insurance that covers mental health services, increasing numbers of elders are joining health maintenance organizations (HMOs), that tend to restrict access to mental health treatment. In addition, many elders who may have financial resources will hesitate to spend them to "just talk."

Third, approximately 5% of adults over age 65 and 15-45% of adults over age 85 are diagnosed with dementia (Evans et al., 1989; Regier et al., 1988). While there is ongoing debate about the benefit of psychotherapy for moderately to se­verely demented individuals, certainly cognitive impairment presents some difficulties in ac­cessing psychotherapy and requires new ap­proaches to service provision. Fourth, at least four further psychological (emotional and attitudinal) issues interfere with accessing services. Mental health treatment carries great stigma for the elders of this cohort (e.g., Lazarus, Sadavoy, & Lang­sley, 1991). Today's elders developed their atti­tudes in the 1920s, '30s, and '40s, when being mentally ill usually meant being psychotic or sui­cidal. People who received psychiatric care were usually hospitalized and may have received elec­troshock treatments; psychotherapy as a treatment was not widely available. Many of these elders were taught by their families that negative feel­ings of sadness, fear, depression, or anger were either bad or weak, and that talking about them would be shameful.

   A second internal dynamic for today's elders is simply a lack of education about the effective­ness of psychotherapy. Having grown up in an era in which psychotherapy was not prevalent, they are often unaware that psychotherapy is an effective treatment for psychological problems.

   A third internal dynamic is the emphasis placed on independence, being able to take care of one­self. With many areas of declining independence and increasing needs for help from others, many elders fear that accepting one more service, par­ticularly mental health, will lead to further loss of independence and ultimately to institutionaliza­tion. This is not completely unfounded, in that once an elder enters the social service system, he or she may actually be pressured to move to a higher level of care.

   A fourth internal dynamic is a generalized sense of fearfulness experienced by elderly people who have become vulnerable. This applies partic­ularly strongly to victims of elder abuse and other crimes. Such elder victims maybe especially hes­itant to agree to anything new for fear that the unknown may bring violation of themselves or their property. This fearfulness may include a fear of signing any papers, which can interfere with standard mental health treatment procedures.

Strategies for Overcoming Barriers

   A number of adaptations to traditional service delivery are necessary to address adequately older adults' needs. One of the most needed physical adaptations of outreach and treatment is to pro­vide treatment in clients' homes. Because of the numerous and complex issues that arise in provid­ing psychotherapy in clients' homes, we will de­vote a section to addressing this need later in the article when alternative modes of treatment are discussed.

   Because of the financial bathers mentioned, providers of psychotherapy to older adults must be willing to accept Medicaid and Medicare insur­ance, or work to find other sources of government and foundation funding to underwrite the cost of services to individuals who lack adequate insur­ance.

   A discussion of providing psychotherapy to cognitively impaired persons is beyond the scope of this article. Research has begun on the effec­tiveness of psychotherapy with demented patients at various levels of impairment. The authors have seen significant improvement in the psychological and behavioral status of demented individuals through psychotherapy. In addition to facilitating behavioral interventions by the caregivers, we have found verbal psychotherapy with the cogni­tively impaired to be effective. An appropriate approach is validation therapy developed by Na­omi Fell (1982), which is poignantly illustrated in her videotape called Looking for Yesterday. This tape demonstrates Ms. Feil's approach to connecting with, understanding, and validating the internal world of the demented person.

   A number of adaptations to the traditional ap­proach to providing services must be made in order to break through the psychological fears and hesitations of many older adults. These can include community outreach, liaisons with com­munity gatekeepers,

"pursuit" of a client, change in terminology, educational interventions, rapport­ building techniques, altered informed consent procedures, and alternative modes of treatment delivery.

   Community outreach: Aggressive outreach may be necessary to enable this population to accept services. Many seniors, particularly in first-generation immigrant communities, will ini­tially reject the possibility of talking with a clini­cian or even a social worker. One strategy to overcome this is to send a nonprofessional out­reach worker into senior gathering sites, such as senior residences, senior centers, community cen­ters, and churches. Such an individual can spend time informally with the seniors and gradually develop relationships with them. By developing trusting relationships, an outreach worker can en­courage these seniors to begin to verbalize their needs. The authors have found that sometimes older adults may initially identify case manage­ment needs, or needs of their friends, rather than their own psychological needs. The outreach worker can then work as a bridge to the needed services, whether they are practical (e.g., legal, social, medical) or psychological. He or she will often go with them to their first appointments, will sometimes help with difficult paper work, and so on. Often, the seniors are first willing to receive offers of concrete help through the case management agency and later are willing to re­ceive our mental health service.

   Liaisons with community gatekeepers: Another aspect of community outreach that will facilitate access to services is working closely with com­munity gatekeepers. These may include social workers, physicians, pastors, senior center staff, police officers, attorneys, home health nurses and aides, and senior residence managers. Main­taining ongoing, active relationships with these agencies and individuals, both informally and through community networking meetings, pro­vides a forum in which the mental health provider can encourage the gatekeepers to identify elderly persons who are in need of mental health interven­tions. Where these gatekeepers have already de­veloped trusting relationships with their clients, the mental health provider can work with those individuals to demystify the psychotherapeutic process and help them to educate their clients to the benefits of psychotherapy. A joint first meet­ing to see the client can help to concretize the bridge from the trusted relationship with the gate­keeper to the mental health provider.

   Consultation with the gatekeeper can also aid the older adult. When, despite significant efforts, a senior is still unwilling to receive psychological services, the gatekeeper can be taught strategies to manage the mental health problem. These strat­egies are based on research suggesting that social contact, physical health, and religious connection are three of the highest correlates with mental health and lack of depression (Gelman & Peder­son, 1993; Lin, Hunter, & Harris, 1980; Phifer & Murrel, 1986). Some of these strategies are to:

Educate the gatekeeper about the positive ben­efit to the senior of maintaining an ongoing relationship.

Encourage the gatekeeper to help the senior increase and strengthen connections within so­cial and family networks.

Encourage the gatekeeper to help the senior find good medical attention.

Encourage the gatekeeper to help the senior connect or reconnect with religious faith.

   Pursuing a client: Once a senior has been iden­tified to be in need of mental health services, it often becomes necessary to determine to what extent to pursue the older adult. In a traditional mental health approach, professionals are trained not to call a patient directly, but to wait for the potential patient to call them. Seniors, however, can be particularly hesitant to initiate these services.

   This dilemma of how much to pursue a potential patient is illustrated by one of the programs at the authors' clinic, the Center for Aging Re­sources. Through a contract with the police de­partment, reports on all senior victims of crime in the city of Pasadena are referred to the crime victims program at this clinic. Each victim re­ceives a debriefing telephone call, during which the victim will often talk extensively about the trauma. When further counseling is offered, how­ever, the senior frequently gives ambivalent re­sponses as to whether he or she wants further counseling. For example, one client talked for 45 minutes during the initial call about her fears after a man broke in through her window. She would not agree to formal counseling, however. The clinician's approach is usually to offer to call the victim back in a week or so to check on how he or she is doing. The victim usually agrees to this follow-up call, as did the client previously men­tioned. When the clinician called back, the victim talked extensively about stress symptoms, such as nightmares, but again would not agree to formal counseling. A decision then had to be made about how many times to call the victim. The goal is that after several calls, the victim will develop trust in the counselor, and want to go on for more formal sessions in the clinic, in the victim's home, or sometimes over the telephone.

   Terminology: Another adaptation of the thera­peutic process concerns the language used to talk about the services. Elders in this cohort, as de­scribed earlier, carry many stereotypes about terms such as psychiatrist, psychologist, and men­tal health treatment. Rather than using sophisti­cated labels and professional jargon, simple, descriptive language is typically more effective. For example, the label clinician or counselor seems to be more acceptable than psychotherapist. A straightforward description of the process, such as, "I would like to come out to see you and talk with you about how you're feeling" or "I'd like to talk with you about problems you may have been feeling and see if I can help you solve some of them" is less threatening than the term psychotherapy.

   Before talking with the senior, it is helpful to talk with the referring person or gatekeeper, find out what language this individual uses, and use those terms. If the person says he is lonely or bored, these words will be understood more easily than depression; if she says she has nerves, this will be more acceptable than anxiety disorder; if the senior complains of bodily pains that the professional suspects are caused or worsened by psychological issues, it may be helpful to talk about feelings or stress that exacerbate the pain. It is important not to challenge the person by insisting on a formal label like depression, which may connote failure and shame. Talk about what the senior already accepts as a problem, using familiar language.

   Education: Many elders need basic education on the symptoms of psychological distress and the benefits of psychotherapy. They often do not know that the consequences of a major loss event (e.g., bereavement, relocation) can be boredom, fatigue, or loneliness; they do not know that stress can cause stomach aches and headaches or can aggravate arthritis. They often have not learned about how "just talking about it" will help. It can be beneficial for the clinician to tell the patient, based on experiences with others that, "Talking about your feelings of being bored can help"; "You can learn ways to have more energy"; "Let's consider things you might be interested in"; or "Talking about your feelings can help so you won't feel so alone with them."

   Analogies can help when educating these older adults. For example:

Psychological symptoms can be compared with a weight or burden: "Talking about your concerns can help you feel less weighed down by so many burdens."

A person's experience of distress can be com­pared with a pressure cooker: "Talking about your thoughts or feelings can help you let off steam like an old-fashioned pressure cooker, so you won't feel so pressured inside that you reach the point of exploding."

The process of psychotherapy can be com­pared with purging: "When you have losses or stresses in your life, they can leave you with a lot of uncomfortable or distressing things inside you. Counseling can be like cleaning purging those out."

Psychotherapy can be compared with wearing glasses: "When your eyesight gets worse, you don't think it is bad or shameful to use glasses to help you see better; counseling is a well­ established tool to help you think or feel better; it is not any more of a `crutch' than glasses."

   In providing education, it is important to give information about the length and nature of treat­ment, including where and when it will occur, how long it will take, and how it will be paid for.

   Rapport-building techniques: Once an individ­ual agrees to begin therapy, it is helpful to use approaches that bring quick, concrete help and lay the groundwork for a trusting relationship, that will facilitate work on the long-term, psycho­logical goals. Rapport-building techniques can in­clude the following:

Referring the senior to a case manager and arranging for a concrete need (such as getting a housekeeper) to be met.

Helping the client to reactivate a dormant in­terpersonal relationship.

Teaching the client progressive muscle or other relaxation techniques, and making an audiotape for him or her.

   Informed consent: One of the complicated is­sues that emerges in undertaking some of the above described adaptations to traditional psycho­therapy is the place and form of informed consent. Traditionally, a client comes to a mental health professional with an already established idea of what psychotherapy is and a willingness to sign a form that states he or she understands the nature of the process and the limits of confidentiality. These older adults are often reluctant to sign any­thing, however, particularly something that for­mally states they are engaging in psychotherapy. Although current standard practice among psy­chologists is to obtain written informed consent, many seniors, if pressured to sign forms with a stranger, will terminate the relationship.

   One approach to this is to develop funding streams in addition to traditional medical insur­ance, so that more services that are considered outreach rather than psychotherapy can be pro­vided, therefore eliminating the need for a signed consent form. Even within the area of outreach, however, mental health service providers are ethi­cally bound to assure that they do not force ser­vices on someone who does not understand and voluntarily consent to receiving such services. It is critical to assess regularly with the clients whether the services currently being provided are acceptable to him or her. Informed consent may be progressive, in that the elder is initially ver­bally asked if it is "okay" for the clinician simply to talk generally with him or her, and then later asked formally to agree to counseling. During the outreach phase, we try to teach the seniors what it means to talk about their thoughts and feelings. We assess their interest in it and try to assess and meet whatever needs we can on a time-limited basis.

   For certain purposes, a traditional informed consent rewritten into informal language can be useful. For our Center's psycho-educational discussion groups, described below, a form entitled ^"Support Group Agreement Form," rather than "Informed Consent," is used. It clar­ifies in simple language the guidelines of the group, the group's aim to discuss members' concerns, the clinician's limits in keeping con­fidentiality under certain circumstances (i.e., elder and dependent adult abuse, child abuse, homicidality, suicidality), and the expectations for members to maintain privacy regarding other members' issues.

Alternative Modes of Treatment

Telephone sessions: At times, telephone sessions are conducted. If a client lives in an environ­ment that is unsafe for the clinician to enter ­with an abusive family member or in a home with loaded guns, for example-therapy is better conducted by telephone, if the patient cannot or will not come to the clinic.

   Telephone sessions are also conducted when the patient has particular dynamics, resisting a face to face session in the home or in the clinic. For example, one man was the victim of a scam in his home. (Two men came to his door, suggest­ing he needed his roof fixed. They convinced him to walk around the house, pointing out parts in need of repair. While one man talked with him, the other slipped back, entered his home, and looked for money and jewelry.) After this scam, we contacted him through our crime victims' pro­gram. He was receptive to talking over the tele­phone. After two or three telephone contacts, when our clinician asked to come to his home or meet him at the clinic, he refused. He was hesitant to be seen by the clinician. Dynamics of shame as well as fear of dependency seemed to inhibit him. He was willing, however, to receive weekly 45-minute telephone calls, which we conducted for the program's set of 10 sessions.

   Psychoeducational groups: Another alternative mode of offering psychotherapeutic help is through discussion groups at senior residence buildings and senior centers. Catchy, somewhat upbeat ti­tles are given to the groups, for example, "Healthy Living," ^"Transitions," or "Living Well Discussion Group." Fliers are posted announcing a time and place for a discussion group. Topics are prepared for discussion on issues of interest to seniors, topics that include psychological content through which adaptive strategies can be taught, but that are not emotionally threatening. For ex­ample: Memory Improvement Reminiscence, Making Friends, Enjoying Your Grandchildren, Enhancing Wellness, Coping with Illness, Stress Reduction, Relaxation, Coping with Change, Learning to Live Alone, How to Sleep Better. Initially, the participants prefer a teaching format, but after the group gains cohesiveness, they be­come more open to processing their feelings and aging issues.

In-Home Psychotherapy
Opportunities and Pitfalls

   Using in-home psychotherapy as a treatment modality presents significant opportunities to overcome the barriers to treatment, but also cre­ates several potential pitfalls. A review of the literature reveals little discussion of the efficacy of providing in-home psychotherapy (Lipsman, 1996; Stoke, Kessler, & LeClair, 1996). More has been written about other types of in-home social services (Aneshensel, Pearlin, Schuler, & Roberleigh, 1993; Biegal, Bass, Schulz, & Mor­ycz, 1993; Burnette & Mui, 1995; Lawton, Pow­ell, Moss, & Dujamel, 1995; Malone-Beach, Zarit, & Spore, 1992; Noro & Am, 1997; Rabi­ner, 1992; Rabiner, Mutran, & Stearns, 1995; Stephens, Kinney, & Ogrocki, 1991; Wallace, Campbell, & Lew Ting, 1994) and about providing mental health services in other nontraditional settings, like nursing homes (Spayd & Smyer, 1996).

   The primary advantage to in-home treatment is accessibility. When a psychologist sees a client at home, he or she is able to engage an elder who cannot or will not come to the office. Sessions are not likely to be missed due to difficulties with transportation, and so on. The home may feel like a safe environment for the client, which may foster rapport-building. In fact, this may decrease the stigmatization for the client in regarding men­tal health services. Many older adults are, as dis­cussed earlier, reluctant recipients of psychologi­cal care and are unlikely to go to a mental health clinic. The psychologist can readily assess the home environment and obtain information about people with whom the older adult has significant relationships. In fact, family treatment may be more likely to occur.

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