Older Adults and Psychiatric Rehabilitation

In our youth-obsessed world, there is an unspoken assumption that when it comes to older adults and mental health, the recovery train has already left the station. After all, older people are stuck in their ways and are not able to make changes. They don’t have the same growth potential. They won’t participate in programming designed to encourage progress and movement. They are accustomed to a service delivery model focused on symptom relief and maintenance of status quo, rather than one intending to foster hope, develop and achieve goals, and move forward.

But nothing could be further from the truth. While it is true that older adults are accustomed to old-school models, this is not the same as entrenched, mired, or stuck. In fact, when provided the chance to think differently, many older adults eagerly gravitate to new opportunities.

Psychiatric rehabilitation services are well-suited for older adults who may need “developmentally appropriate” services designed to help them strengthen their skills to better achieve recovery and full community integration.

While older adults may prefer psychiatric rehabilitation options when offered, the model does need to be adjusted slightly to meet the needs of an older population. For example, in psychiatric rehabilitation, there is a lot of focus on vocational skills and employment. While this is certainly a life domain for people in their prime working years, older adults may not uniformly be seeking work. Some in fact, have already worked for a lifetime and are now retired. The concept of “work” needs to be broadened slightly to incorporate volunteering, mentoring, or off-the-books employment. Rather than focusing more narrowly on competitive employment, the emphasis is on “productivity.”

Cognitive health is a major issue for seniors. Older adults with mental illness are aware that the cognitive impacts associated with their illness may be compounded by natural declines due to aging. This is a source of great anxiety, and people are eager to prevent further additional loss. Activities designed to keep the brain active, or even reestablish neuronal connections are vital. These can range from more formal cognitive remediation to more activity-centric board games and other efforts to keep people thinking and connecting with each other.

Another difference is the focus on physical health. For a younger population, physical health is important, but is not considered a “life role.” But for older adults with declining health, and sometimes developing cognitive problems (such as dementia), physical health takes on an expanded importance. Psychiatrists working in these programs need to be savvy about the ways psychiatric medications may interact with other medications. They need to consider the fact that older bodies may be more sensitive to even small changes in medications. Other involved health professionals need expertise in aging issues as well. In fact, the need for multi-systems coordination is especially strong when working with older people. This translates into close communication between medical, psychiatric, behavioral health, social service, and allied health professionals. It also means that issues such as transportation, home care, and accessibility supports need to be part of the conversation.

Finally, social interactions take on renewed importance in this population. While all psychiatric rehabilitation incorporates a focus on social skills, with older adults connecting is essential. As people age, their family and social circles naturally decline, as people pass away or move. We know that many older people live increasingly isolated lives. This is particularly the case for people with mental illness. So programs need to provide lots of opportunities not only to develop skills, but to practice using these skills in social contexts with others in the group, to help form new social circles that can provide support and connection with others.

In New York City, psychiatric rehabilitation services are the focus of program models such as PROS, clubhouse, and psychosocial clubs. In different ways, each of these approaches works with participants (or members, in the case of the club programs) to develop new skills, re-kindle their passions and interests, and become active participants in their communities.

When New York City’s Service Program for Older People (SPOP) decided to convert their continuing day-treatment model into a PROS program in 2013, the big question was “can psychiatric rehabilitation work for the older/geriatric participant?” Now, a year later, the answer is yes. Participants seem to be thriving, making unexpected and exciting progress. Participants report that they like the smaller, more focused groups. They are now attending groups that speak to their needs, so they are more engaged, verbal, and energized, even those previously considered disinterested or limited. In fact, participants have been so excited by the new options available that they have begun attending more groups than anticipated.

In PROS, participants are asked to select a “life role goal” as a focus for services. At SPOP’s PROS, participants select the same array of life role goals as participants in other (younger) programs. Participants want to improve family relationships, move into better housing, become more involved in vocational activities.

And participants are achieving these goals – a 59-year-old known for her frequent hospital visits and stays is a less frequent hospital patient and has found a job as a personal assistant/dog sitter. A 66-year-old woman who described herself as isolated and “extremely lonely” has begun to attend a local senior center every afternoon after her time at the PROS program (community integration). A third is in the process of developing a more intimate relationship with a person he likes. In fact, 20% of participants have already made significant progress towards their recovery goals.

Perhaps most exciting was the program’s first graduation: Jose is an 81-year-old widower who spent many years in continuing day treatment. When he started the PROS program, he said he wanted to improve his relationship with his two sons who live in Peru and in California. He had not seen either in many years, and even phone contact was sporadic. Through his work in PROS, he increased his contact with his sons to twice weekly phone conversations. Equally impressive, Jose increased his work hours from 8 to 28 hours a week to save enough money to visit his family. Recently, Jose was able to use his savings to go to Peru to visit with his son for three weeks. With his self-confidence greatly improved and symptoms under control, Jose graduated the program a few weeks ago.

Another model featuring psychiatric rehabilitation in New York City is the psychosocial club. Like PROS, most psychosocial clubs are open to people of all ages. But there are a group of programs that specialize in working with older adults. Jewish Board of Family and Children’s Services’ Club Pride is one of these programs. Like other psychosocial clubs, Club Pride combines socialization and recreation opportunities with more goal-focused psychiatric rehabilitation, through groups and individual work with members on issues such as coping with depression and anxiety, goal setting, WRAP planning, and the stress of recovery. The staff includes both professionals and peers, and serves members from age 55 to 96 on a daily basis. Members focus on enriching four aspects of their lives: health, home/residence, purpose, and community.

At Club Pride, social interaction plays a key role in fostering recovery. Through activities, groups, and simply being together, club members develop new friendships that help reduce isolation, normalize common feelings and experiences, and create new support systems.

Sometimes, newcomers to Club Pride are taken aback by the expectation that they should have goals. Their years spent on symptom management and in day treatment programs provided them with messages of surviving, rather than thriving. But they soon appreciate the potential of recovery and recognize the opportunities that are being presented.

Lee is 94-years-old and says being a Club Pride member has made her feel reborn. Before, she explains, her family treated her like an old, depressed woman, parked in the corner. With both her children and grandchildren grown, she felt depressed and without purpose. Coming to Club Pride, Lee initially replicated her self-isolating behavior. But through the interventions of staff and other club members, Lee emerged from her shell. Today at the Club, Lee leads community meetings and current event groups. Lee’s recovery can be observed outside the program as well, as she is equally engaged in activities at her residence.

Before Mary, 59, came to Club Pride, her trajectory was far from promising. Her identity centered around her experience of bipolar disorder and her hospitalizations, and her estrangement from her daughter. But through her active engagement at Club Pride, Mary has reconnected with her family, and frequently attends Club functions with her daughter. She recently volunteered to serve on JBFCS’ Adults with Mental Illness Committee, and she says her goals now are applying to college and getting a job.

It is an exciting time in behavioral health. Recovery is the expectation for all, not just a select group. This means that many older adults, for the first time, will be asked questions like “have you thought about getting a job?” “Any interest in going back to school?” “Is there someone you would like to ask out on a date?” “Are you satisfied with where you’re living?” The response may be one of welcomed surprise, and excitement about the future.

Robert Franco, MA, is Director of the PROS Program at SPOP; Izabelle Hakim, LCSW, is Director of Club Pride at JBFCS; Nicole Ness, LCSW, is Supervising Recovery Counselor of the PROS Program at SPOP; and Naomi Weinstein, MPH, is Director of the Center for Rehabilitation and Recovery at The Coalition of Behavioral Health Agencies.

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