Assisted Living Decisions in Psychotherapy
For individuals in the U.S. & U.S. territories
Assisted living decisions are often thought of as merely residential choices, but they reflect a host of considerations: Finances, healthcare, and concerns about new and unknown environments are key elements to consider during this complex process.
In this video, Claudia Drossel demonstrates an approach to therapy with caregivers and their loved ones in which the therapist's role is to put the clients' personal history and values in context as they explore the best care options for the clients' circumstances.
In this session, Dr. Drossel works with the daughter and caregiver of an elderly woman who has recently experienced a medical crisis. Although the client is not yet aware of her mother's prognosis, she struggles with an urgent need to take action immediately to protect her mother. Dr. Drossel guides the client toward being a more effective advocate for her mother as they discuss assisted living options that are supportive and in line with her mother's needs.
The approach illustrated in Assisted Living Decisions in Psychotherapy has origins in a contextual framework. It assumes that a person's cognitions, emotions, and behaviors can be understood in the context in which they occur. Assisted living decisions generally occur in the context of loss: Adults — just like you and me — are losing their ability to independently manage challenges of daily life due to cognitive or physical decline, or both. Routines and divisions of labor that have been established over decades are breaking down.
When individuals experience cognitive and physical decline, they are not only trying to cope with a significant loss of skills but also with changes in their relationships and day-to-day interactions. Their own attempts to compensate for losses may be ineffective and may strain relationships even more. Not surprisingly, in addition to the psychosocial difficulties brought about by cognitive and physical decline, the mere mention of assisted living may lead to conflict within families.
In a time of profound loss and uncertainty, the approach illustrated here works by identifying preferences and values that have guided the person's life so far. Given chronic illness, what activities are still working for the person and match the person's overall life direction? For example, if he or she tended to a garden, how can engagement in planting, growing, nurturing, and harvesting be preserved? What activities are not working anymore? Can a modified prosthetic environment support these longstanding activities, or is there a need for replacement activities that carry similar meaning?
The process of identifying and addressing facilitators and barriers to living a values-oriented life — situational, emotional, physical, cognitive, and behavioral — is called a "functional analysis" and is a key part of the contextual behavioral science approach. The goal of this analysis is a person-environment match. Transitioning successfully from independent to assisted living requires discovering viable ways to maintain important relationships, to live one's values, and to honor one's preferences in the presence of chronic disease.
Frequently, the substantial loss of skills is matched by family members', spouses' or friends' growing concerns for the person's safety. A sense of urgency can lead to an abrupt role shift when significant others assume caregiving responsibilities and preclude participation in choices "for the person's own good." Sometimes significant others are eager to force a decision, any decision, in an understandable yet impulsive attempt to escape from a very stressful experience. Lopsided interactions can become an unworkable battleground, a lose/lose situation in terms of successful transitioning to assisted living as well as cultivating the personal relationship.
An alternative is also illustrated with this DVD: It shows how to slow down caregivers' decision-making process and how to refocus caregivers on promoting mutual respect and trust, by considering the person's history as an active, competent agent in his or her life. This approach helps caregivers notice futile care strategies and build the psychological flexibility to genuinely interact with the person whose skills are failing, in the service of a long-term, amenable solution.
Claudia Drossel, PhD, holds doctoral degrees in experimental psychology from Temple University's Brain, Behavior, and Cognition Program in Philadelphia, Pennsylvania, and in clinical psychology from the University of Nevada, Reno, where she focused on researching, practicing, and disseminating the contextual approach to dementia care.
From 2005 through 2010, Dr. Drossel was the associate director of the Nevada Caregiver Support Center, a state-funded, evidence-based, consumer-directed service program for individuals with dementia and their families, recognized in June 2008 by the U.S. Administration on Aging as a "Program Champion."
Based upon clinical experience and research, Dr. Drossel coauthored (with Susan M. McCurry) a practical manual for providers, Treating Dementia in Context: A Step-by-Step Guide for Working With Individuals and Families (2011).
Dr. Drossel is currently an advanced fellow in mental illness research and treatment at the VA Mental Illness Research, Education, and Clinical Center, where she continues her work to enhance quality of life for individuals with neurocognitive disorders and their families by promoting health-related behaviors and preventing excess disability (i.e., more disability than predicted by the neurocognitive disorder alone).
Functional analysis – a tool for assessment and intervention
- McCurry, S. M., & Drossel. C. (2011). Treating dementia in context: A step by step guide to working with individuals and families. Washington, DC: American Psychological Association.
Prosthetic environments and person-environment fit — seminal papers
- Lawton, M. P. (1974). Social ecology and the health of older people. American Journal of Public Health, 64(3), 257–260.
- Lawton, M. P. (1990). Residential environment and self-directedness among older people. American Psychologist, 45(5), 638–640
- Lindsley, O. R. (1964). Geriatric behavioral prosthetics. In R. Kastenbaum (Ed.), New thoughts on old age (pp. 41–60). New York: Springer.
- Hayes, S.C. (2008). Acceptance and commitment therapy. In Systems of Psychotherapy Video Series. Washington, DC: American Psychological Association.
- Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.
- Miller, W., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.
Assisted living decisions
- Kane, R. L. (2011). Finding the right level of posthospital care: "We didn't realize there was any other option for him." Journal of the American Medical Association, 305(3), 284–293.
- Kane, R. L., & Kane, R. A. (Eds.). (2000). Assessing older persons: Measures, meaning, and practical applications. New York: Oxford University Press.
- Kane, R. L., & West, J. C. (2005). It shouldn't be this way: The failure of long-term care. Nashville, TN: Vanderbilt University Press.
Contextual behavioral science
Assessments of older adults with diminished capacity
- Psychologists in Long-Term Care
- APA Division 20, Adult Development and Aging
- The Gerontological Society of America
- Adapting Psychotherapy for Working With Older Adults
Bob G. Knight
- Depression With Older Adults
Peter A. Lichtenberg
- Interpersonal Psychotherapy for Older Adults With Depression
Gregory A. Hinrichsen
- Parenting Our Elderly Parents
Patricia J. Pitta
- Treating Alzheimer's Disease Through Caregiver Family Therapy
Sara Honn Qualls
- Clinical Geropsychology
Edited by Inger Hilde Nordhus, Gary R. VandenBos, Stig Berg, and Pia Fromholt
- Emerging Issues in Mental Health and Aging
Edited by Margaret Gatz
- A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context
Edited by Steven H. Zarit and Bob G. Knight
- Interpersonal Psychotherapy for Depressed Older Adults
Gregory A. Hinrichsen and Kathleen F. Clougherty
- Making Evidence-Based Psychological Treatments Work With Older Adults
Edited by Forrest Scogin and Avani Shah
- Medical Adherence and Aging: Social and Cognitive Perspectives
Edited by Denise C. Park and Linda L. Liu
- Mental Health Services for Older Adults: Implications for Training and Practice in Geropsychology
Edited by Bob G. Knight, Linda Teri, Paul Wohlford, and John Santos
- Neuropsychological Assessment of Dementia and Depression in Older Adults: A Clinician's Guide
Edited by Martha Storandt and Gary R. VandenBos
- Psychology and the Aging Revolution: How We Adapt to Longer Life
Edited by Sara Honn Qualls and Norman Abeles
- Treating Dementia in Context: A Step-by-Step Guide to Working With Individuals and Families
Susan M. McCurry and Claudia Drossel