Psychological Well-being in Long Term Care

Psychological well-being is a subjective point of view defined as person’s cognitive and affective evaluation of life. The dimensions of well-being include a balance between positive and negative affect. Affect is a psychological term for emotions. Negative affect involves such emotions as anger, fear and depression. On the other hand positive emotions include such things as joy and happiness. How much time in any given day we spend feeling depressed needs to be balanced with time feeling happy. If more of our day is filled with positive emotions than with negative we have a sense of subjective well-being. Well-being is also dependent on how well we meet our fundamental human needs. That includes basic needs like food, shelter and safety. There can be no sense of positive well-being if we feel hungry or fear for our safety. However, given that those needs are met higher level needs like autonomy and self-esteem become important to our sense of well-being. It also seems very important to our sense of well-being that we have a purpose. For the oldest among us it is just as important to have goals even though it may be necessary to limit those goals as we age. Careers are behind and there is increasing limitation on the pursuit of wealth. However, those with a sense of positive well-being continue to set goals and pursue those goals. Activities also seem very important as dimensions of psychological well-being. There may be some constriction in the options available; however, activities within the framework of current skills can make a great difference. For example, one patient of mine in a nursing home and only the use of his upper body. However, to help of his family he arranged an entire world all within the reach of his own arms. Finally, optimism and hope are essential elements for a positive sense of well-being.

Paul Baltes of the Max Plank Institute for Human Development in Berlin and his wife Margaret Baltes of the Free University of Berlin have conducted extensive research on what they characterize as ‘Successful Aging’ and they have proposed that success is in part dependent on the selection process in which strengths are optimize in older people learn to compensate for losses in appropriate ways. For example, they become more discriminating in the choice of activities while which to spend their time and energy. Interactions with family become increasingly important in that may restrict themselves to a few real friends other than a large number of acquaintances. Optimization involves building resources needed to cope through self-education and continued learning. For example memory skills training can help in compensating for some of the losses that are associated with aging. Compensation involves doing whatever is needed to mitigate limitations and losses. Visually impaired older people use reading machines which magnify the written word. If they cannot read that can begin to listen to audio books. To avoid falls they can learn to use a walker, a wheelchair or a cane. To the extent that quality care processes facilitate selective optimization and compensation residents in long term care are more likely to experience a positive sense of well-being in spite of losses.

Chronic Illness and LTC

Our healthcare system is based on an acute care model. One germ and one cure. The doctor and technology are in control and the patient is the passive recipient of pharmacological miracles and technology triumphs. However, according to the Centers for Disease Control and Prevention, 70% of all deaths in the US are due to chronic disease and the top four are cardiovascular disease, cerebrovascular disease, cancer and COPD. Of those over the age of 65 it is estimated 85% have one or more chronic diseases. If you are a psychologist working with geriatrics in Long Term Care you are working in the context of chronic conditions. LTC is no place for the Cartesian myth that the mind and body are separate. Rather clinical success depends on en embodied mind.

So what is a chronic disease? A chronic disease does not have a single cause, specific onset or stable symptoms. The course is marked by exacerbations and remissions in symptoms. Unpredictability is the rule. Treatment requires biopsychosocial interventions with coping, self-management and palliative care.

There are four types of chronic illnesses (Sperry, 2006):

· Life-threatening diseases such as fast growing cancers, stroke or heart attacks.

· Manageable diseases like diabetes, hypertension, osteoarthritis, chronic sinusitis

· Progressively disabling diseases like Parkinson’s, lupus, RA and multiple sclerosis

· Those not life-threatening but with waxing and waning course like fibromyalgia and chronic fatigue syndrome

Other important distinctions between acute and chronic illness include (Cummings et. al., 2005):

· Acute illness onset is abrupt and CI is gradual

· Acute illness is time limited and CI is indefinite

· Acute illness tends to have a single cause and the causes of CI are multiple and changing

· Acute illness prognosis is accurate and the prognosis in CI is uncertain

· Technology is effective in acute illness and indecisive in CI

· There is a cure for acute illness but rarely a cure for CI

· Uncertainty is pervasive in CI

· Professionals have the important knowledge in acute illness and both the patient and professionals have complementary knowledge in CI.

Patients who are told they have a chronic illness usually start with a crisis as they try to answer questions like these:

· Will I be incapacitated?

· Do I face a life of pain?

· Can I make the changes they ask?

· Will I be dependent and a burden?

· What will be the impact on my family?

· Will I be able to do the things I enjoyed?

· Will we be wiped out financially?

· Will I be isolated and alone?

· Is this all my fault?

· Is there a God?

· Will I live?

Since cures are rare in chronic disease the best outcome we can expect is adjusting to the illness and disability. There seems to be a pattern that most patients follow. There seem to be phases of recovery that most patients share.  Patricia Fennel (2003) who authored Managing Chronic Illness: Using the Four Phase Treatment Approach, describes four phases:

• Crisis
• Stabilization
• Resolution
• Integration

Kenneth Sharoff (2004) who practices in Maryland and who authored Coping Skills Therapy for Managing Chronic and Terminal Illness describes five phases:

• Crisis Phase
• Post-crisis Phase
• Alienation Phase
• Consolidation Phase
• Synthesis Phase

Both agree that patients may move through the phases at different rates and that patients may return to an earlier phase. In fact without intervention a patient may return often to the crisis phase.

During the crisis phase patients must mobilize support, learn to manage discomfort, preserve a sense of identity and begin to learn how to deal with suffering. The diagnosis is associated with unstable emotions. The best approach for the psychologist during this period is to engage in crisis intervention with the patient and the family. Educational efforts or lifestyle change tends not to take during the crisis.

During the post-crisis or stabilization period the patient may very well try to return to pre-illness patterns and failure in that may lead to a return to the crisis phase. The basis goal in this period is to restructure life patterns and perceptions so they can move on with the illness as part of their life. Sharoff (2004) identifies a phase called alienation during which there is a high level of anxiety and anger that expresses itself in bitterness. However, not all patients seem to go through such a phase.

During the consolidation or resolution phase the patient must learn to manage limitations and find meaning. They must develop a new sense of self that is acceptable in spite of the illness and must develop a philosophy of life.

In the final phase of integration or synthesis the patient must meld the old self with the new self and yet as Fennell (2003) says: “…to experience a complete life in which illness is only one aspect…”  The person must unify the illness with a healthy identity.

In that context what is the goal of our intervention? According to Len Sperry (2006) “…the goal of Biopsychosocial therapy is to achieve integration of the chronic condition as part of a healthy sense of self…the highest level of wellness possible while living with a progressively degenerative or life-threatening illness.”

One of the most frequent reasons for failure and frustration in combining Behavioral Medicine with psychotherapy is bad timing and poor teamwork. By considering the phases of chronic illness we can improve our timing and by recognizing the importance of all three domains we can improve our teamwork.

In no area of healthcare are the skills of psychologists needed more than in the area of chronic disease. Psychology can play a major role in addressing the crisis in healthcare costs, that will become steadily worse in the decades to come. Only when medicine recognizes the role of emotional and cognitive factors can we improve the services to a sufficient extent that there is less demand for the most expensive services.