Conferences 

 

 

 

My presentation was Friday in stream five: Graceful Aging Holistic Approaches in Social Work with Seniors (a great title btw!). Feel honoured to be alongside the presenters in this stream.

 

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​​ABSTRACT

They Need Us to Think Differently: Senior Friendly Psychotherapy

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The current cohort of advanced seniors are often not familiar with psychotherapy, nor seek it, however psychological distress for this group can be high. Men aged eighty-five and over in Australia have the highest rate of suicide and a report by the Australian Institute of Health and Welfare revealed in 2013 that more than half of care home residents in their study had depressive symptoms. Current models of psychological practice, irrespective of modality, are limited for an advanced senior population because they do not consider generational nuances. They assume literacy with the purpose of psychological intervention, client motivation and a degree of comfort in psychological help seeking. Moreover, traditional models of psychological practice emphasize pathology and can assume an expert role. Such approaches can be alienating, uncomfortable and disempowering for an advanced senior population. Two models are suggested to guide the clinician. The Flexicare Model aims to improve relevancy, comfort and accessibility of psychotherapy for seniors by seeing informal engagement as foundational to formal encounters of multimodal intervention, advocacy work and evidence-based interventions for specific issues such as complex grief and trauma. Informal engagement is covertly therapeutic through life story consultation, reflective listening skills and the identification of abilities or values. The Senior Friendly Service Delivery Matrix is a four-part multi-systemic model. It starts by offering an innovative approach to engagement. Then it suggests ways to adapt interventions to suit a range of physical and cognitive limitations. Third it questions the status quo of programs around consent and evaluation. Finally, it explores how clinicians can guard against subtle forms of ageism and examines society’s relationship with death and decline. Together these models ask us to think differently about how we practice psychotherapy with older adults, especially those in residential care, to maximize good mental health outcomes and quality of life.

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PRESENTER BIO

Felicity Chapman is an Accredited Mental Health Social Worker in South Australia who has specialized in work with advanced seniors for fifteen years. Her book, Counselling and Psychotherapy with Older People in Care: A Support Guide through Jessica Kingsley Publishers, was a nominee for the 2019 Australasian Journal on Ageing Book Award. Currently she works in and coordinates the Your Story program through Summit Health CONNECTcare which delivers psychological services onsite to aged care residents across the Adelaide Hills region.

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SESSION SUMMARY
This presentation is for anyone interested in the wellbeing of advanced seniors living in the community or in care. You will learn about the Flexicare Model and the Senior Friendly Service Delivery Matrix. You will be able to identify the barriers to engagement and know how to overcome them by using five guiding principles and life story interview techniques. You will also learn about the ‘mental health and neurological spectrum’ and what three criteria are essential for making assessments regarding suitability. Expect unconventional ideas around obtaining consent, defining therapeutic effectiveness and the use of outcome measures. Together, we will unpack what it means to be truly senior friendly as we re-think policy and practice across multiple systems. Therapist self-care is covered which will include learning how to protect yourself against the Mickey Mouse Mindset. More broadly you will be invited to think critically about our society’s relationship with death and decline and whether positive ageing has a negative side. This presentation is for anyone passionate about ageing well. It seeks to create a better world for your mother, your father and your future self. It also seeks to ‘bring sexy back’ in how we listen to and respect our elders.
 

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They Need Us To Think Differently:

Senior Friendly Psychotherapy

10th International Conference on Social Work in Health & Mental Health

 

TRANSCRIPT

First, I’d like to acknowledge the traditional custodians of this land. The land we’re on today and the land that I live and work on in South Australia, my home. I pay my respects to the Elders past, present and emerging. I also pay my respects to the Elders that I’ve had the privilege to work with, the advanced seniors, because really they form the backbone of this presentation.

 

I’d like to share a little story with you about one of these seniors. Mary (not her real name) was 91 when I first visited her. This is an excerpt from my book Counselling and Psychotherapy with Older People in Care:

 

““I’ve always been so positive!” she implored to me that first day, her face contorted with embarrassment and despair. She listened patiently, but eyed me suspiciously, when I told her about staff feeling concerned and how our programme could help. It was clear that she knew little about counselling, but enough to see it as a threat. As Mary sat stiff and sore on her floral chair, with her hallmark colour of purple dancing all around the room, I could see that she was in a dilemma. Would she feel more like a failure being involved in this counselling thing – likely to just highlight her weaknesses – or more alienated than ever before from an identity of positivity if she tried battling on all by herself? Would she mind giving it a go, I asked. “I don’t know,” she said. Reluctantly, she agreed but much later confessed, “I really wasn’t sure about this at first.””

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This is a few paragraphs on:

At our final session – the twentieth one – she summarized her experience of a year in therapy by writing, “An amazing journey from a deep hole of despair and hopelessness, not wanting to live, to a life well worth living with bonuses. [I now] have more confidence and self-worth.””

 

Mary hadn’t been seeking therapy. Would she have signed a consent form that day?  I don’t think so. Then none of that healing would have happened. Now I realize that people who are currently 60 are probably not going to be as unfamiliar with therapy in thirty years’ time as the current cohort of 90 year old’s, but right now, it’s those like Mary who need us to think differently.

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They tend to be very uncomfortable about the notion of therapy or find it confronting to admit that they’re not coping. Yet even the most sensitive therapy, the most benign consent form or psychological measure, assumes a level of comfort in therapy and encourages problem identification.

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Mary didn’t want help but she responded to it when it was presented in a way that kept her dignity intact and gradually – little by little – built up an experiential understanding of this therapy thing.

 

But it does take a bit of flexibility to manoeuvre around these barriers!

 

With that in mind I came up with this model. As you can see in the legend it has two main elements: informal and formal engagement. Now even though as counsellors we might take a friendly and very informal approach to our work. The reality is that what we end up doing can be quite formal or, as I like to say, explicit. Especially if there are expectations from funders or accreditors that draw heavily on the medical model or a one-size-fits-all approach to mental health.

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Think of Mary. The focus of my first few sessions was just on connection. It wasn’t on formal consent, on completing a K10. And it wasn’t even on goals or explicit intervention.

And then we started dancing! We danced between informal and formal engagement, with the latter becoming more of a focus as we went on. We eventually delved quite deeply into loss, depression management and experiences of trauma that dated back to her childhood. I’m very grateful that there wasn’t – and still isn’t – a session limit in the program I work in because time was needed to build trust and comfort and then address the multitude of issues that bubbled to the surface. Time was also needed to help Mary prepare for the conclusion of our therapeutic relationship.

 

If you’re interested, The Flexicare Model is in the handouts available for this talk. In this handout you’ll also find another excerpt. This one shows the difference between a worker coming in on a more formal or explicit level compared to an informal or implicit one which can be especially helpful in those initial sessions. In my book I offer five guiding principles to invite seniors into a therapeutic context:

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* Dignity: How can we build them up? (Not in a patronizing or

inauthentic way.)

* Choice: How can we help them feel like they are in control of

the process?

* Value: What is it about their conversation that speaks of important

values?

* Trust: What opportunities are there to reaffirm their trust in us?

* Permission to talk: How can we comfortably invite them into

conversation?

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These are the things I look at fostering.

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It’s a bit similar to a trauma informed care model of building trust, empowerment, collaboration, safety and choice.

 

To illustrate what I mean by implicit and explicit I’ve created this table. The main point is that informal or implicit work can be just as valuable as formal or explicit work.

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Consider the story of Alan. The other month, at session #2 when asked how he was going he replied, “Couldn’t be better!” Later I wanted to check in and see if progressing with therapy was relevant for him. He didn’t answer me directly. Instead, he asked me to take down the wedding picture of he and his wife. He explained how, just recently, he’d visited her in hospital. She reached over and kissed him on the cheek. Then died in his arms.

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I can tell you that neither of us had dry eyes after that! I held his hand, with his permission, as he told me his love for her. At the end I asked if he would like to chat again some time. “Oh yes!” he said. “I appreciate our chats very much.”

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Let me ask you: Was therapy happening here? He wasn’t acknowledging distress. On the contrary, he “Couldn’t be better!” There were no therapy goals; no evidence based explicit work. Just moving with Alan in the way he wanted to. He didn’t want to define our work as therapy. Just chats.

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Like a wildlife photographer we wait patiently for that special moment to affirm identity, values or segway into deeper work. Maybe explicit and evidence based work. But if we stay at the informal and implicit then that’s fine by me.

 

I want to touch briefly on assessment. Assessing for suitability is very important and these are the three criteria that guide me: interest, need and capacity.

 

With regard to capacity this diagram might help. I definitely don’t rule out all who have dementia because that is such a sliding scale but I am looking out for if it’s too progressed for therapy to be fruitful. Or if I need to refer to another service.

 

This is also in your handout. It’s what I believe being senior friendly is all about. We’ve already covered the upper two quadrants. Now I’d like to briefly discuss the bottom two. 

 

What if, instead of requiring signed consent, like is so common these days, we looked at things a bit differently? What about defining consent as their agreement for you to come back another time? What about being attuned to signs of discomfort in an ongoing way and checking in regularly if chatting feels relevant? When I first started in this work 15 years ago the focus wasn’t even on the resident. It was on their GP. If the GP didn’t believe therapy would be beneficial -even if the resident wanted it – then that was that. You can imagine what I thought about that!

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And what is this obsession with formal assessments and pre post tools? I appreciate that these issues might not be a concern for those folk in private practice. But for those of us in government funded programs I question how relevant or respectful it is to define progression according to a quantitative pre post score when wave after wave of loss is experienced during the course of therapy?

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The focus should be on whether they appreciated the opportunity to talk and not on symptom reduction. I love what my friend and colleague Julienne Whyte OAM says about this. She’s an accredited mental health social worker, runs a health service for rural communities in Victoria and is now our National President! She says that intervention for advanced seniors should be more about, “care not cure.”

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We’ve probably all heard of ageism. But anyone heard of internalized ageism? It’s where older adults feel worthless and have absorbed ageist or disempowering attitudes from our community. Like how the media seem to prize youth over age. It’s like how we can use words like geriatric, deficit, and can be glued to all that isn’t working instead of noticing the strengths, abilities and core values. I think we can reduce the risk of internalized ageism if we focus more on who the older adult is rather than what they’re not. A positive focus.

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But sometimes even a positive focus can be negative. I appreciate the positive ageing movement, but too many times a senior has confessed to me that they feel like a failure because they’re not being positive enough. You try losing all semblance of life as you know it. At times like this they need to be encouraged into self-compassion – holding the pain like you might a crying baby – instead of pepping themselves up with positivity.

 

Speaking of self-compassion. Us workers need that too! I have a chapter in my book called Caring for You the Psychotherapist. One strategy deals with what I call the Mickey Mouse Mindset and being aware of it can protect ourselves from subtle forms of ageism. The Mickey Mouse Mindset is a way that we and others might devalue our work because it relates to aged care.

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For example, our work on the surface might look like just a pleasant chat. No in session exercise or explicit intervention. So we might be lured into thinking of it as a bit Mickey Mouse. Not serious therapy. But if you consider the therapeutic intent behind everything – every look, every question and response – then you can bet your bottom dollar that serious therapy is taking place. And re-defining effectiveness can help too. No matter how big or bad the story you can feel satisfied that you’ve offered a compassionate listening ear. Compassion satisfaction as opposed to compassion fatigue.

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Another way we can protect ourselves from subtle forms of ageism is our relationship with death and decline. It’s perfectly natural to want to avoid these things. From the moment we’re born the focus is on life and progression. But with all the emphasis on healthy ageing and medical technology it’s almost like we can defy death or that decline is somehow synonymous with failure.

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I think a more senior friendly healthy ageing approach is to fully accept that death and decline is, in fact, a part of life. So, our relationship with it is not one of avoidance or denial. But softer. Allowing for it and looking at how we can live with it or flow with it rather than fight against it.

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I wrote Counselling and Psychotherapy with Older People in Care because all I could hear were the voices from medicine or geropsychology. Now I want to point out that I know some amazing GPs and psychologists working with seniors. But what concerns me is the dominance of some ideologies I don’t agree with which get translated into standards of practice.

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I’m deeply proud of my social work roots. We look at multiple systems, power inequalities and how to create encounters that are dignifying and empowering. Older adults can be pathologized, patronized or ignored in our society. Even in mental health.

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Social work looks at people and situations in a unique way. Older adults need us to go beyond what’s the status quo. They need social workers to weigh in on what’s best practice for psychological care.

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Because WE think differently.

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