The study of relationships between the mind, emotions, body, and spirit has existed for as long as man has reflected on his health. For most of this century, health related scientific research has been based on measuring and testing physical reactions or emotional reactions without a reliable vehicle for simultaneous measurement of both. This has impacted with present conceptualization of mind, body, and spirit that may be found in western institutions and cultural processes.
The dualistic concept of psyche and soma is reflected by treatment models that focus on curing symptoms. Western medicine has been significantly successful in treating symptoms that fall into the category of acute care needs, both in the body and in the mind. Medical, nursing, and other interventions directed toward the treatment of acutely ill people have served to escalate differentiation and specialization, which may be necessary in present acute care settings. The spiritual dimension is addressed by the professional, the chaplain, usually without partnership of health care practitioners, so that every dimension of a person's health appears to be addressed in fragments. It is the purpose of this paper to share our approach to nonacute health care delivery, and to report on one aspect of our work in this area.
The acute care approach is not always advantageous to the patient, and this is particularly true for the patient who is old. We sometimes believe that we are attending holistically as we continue to treat physical symptoms, to the neglect of the other aspects of a person's being-in-his-world. For example, Mrs. E is an 82-year-old widow, mother to a married daughter with whom she has been living for two years. She was brought to our outpatient mental health clinic because she wanders away from home, gets confused, and has become incontinent. Her son-in-law feels in constant conflict with both his wife and her mother because of Mrs. E's interference in his family life. Mrs. E's daughter reacts in a hysterical fashion that escalates her mother's confusion and feelings of loss of control.
A complete history and physical revealed nothing remarkable physically, yet we were reluctant to assign her a diagnosis of organic brain syndrome. Our treatment plan was twofold; we would address the needs of the family and we would attend to the needs of Mrs. E, and their common systems where they impacted negatively. We explained to the family how Mrs. E was causing an imbalance by remaining dissatisfied with what they could offer, and how they were partners in this by not setting reasonable limits. The familiy was encouraged to get a separate flat for Mrs. E nearby, and to see that she attended group sessions at the Mental Health Center twice a week, beginning the next day. The family cooperated, and before the move to a new flat, Mrs. E ceased to be incontinent. She was moved gradually over a two-week period, and a visiting housekeeper was hired for two hours, three days a week. In our group sessions Mrs. E took the opportunity to express her anger and to explore her fears. When she was able to explore some of the losses affecting her and the meaningfulness of her life overall, she stopped getting confused, stopped wandering, and decreased her dependency on her daughter and son-in-law. Without an overall look at this family system, Mrs. E might well have been admitted to a nursing home, with the family believing that there was no other alternative. The influences on a person's health, in this case on mental status, include the family or other significant relationships, the person's belief system, a faith or spiritual dimension, a values hierarchy, ascribed meaning of the illness, losses sustained, and others.
Modern psychosomatic illness posits that the human mind, body, and emotions work asa unit. As this unit ages, personal resources may become less accessible and more vulnerable to both internal and external environments. It is our opinion thai health related services to/with older adults are most effectively delivered when psyche and soma are viewed as two sides of the same coin. People who live to be very old and who can partially or fully maintain themselves have learned to cope with both internal and external stress; and some have learned how to use this stress as a source of motivation rather than as a cause of energy depletion.
When we look at frailty and disstress as partners, we also want to look at the care we provide to those who become dis-eased. Physical limitations have counterparts in emotional and sometimes mental conditions that serve as perpetua tors for each other, as demonstrated by Mrs. £. Exaggerated physical disstress may be considered in the service of the psyche for the person who has no other way available for expression of psychological, social, and/'or spiritual needs. Disorders in thought and judgment suggest to us the need to examine not only mental status and drug history, bu spiritual, nutritional, relational, emotional, and environmental stressors as well.1 Anxiety, fear, depression, sleep disturbance, forgetfulness, thought disturbances, and exacerbation of chronic disease processes can be overlapping component parts of a variety of physical illnesses such as heart disease, hypertension, pneumonia, anemia, malnutrition, diarrhea, and others. We have found in our own patient population that physical conditions are also expressed through the emotional and/or mental systems, and that the blocking of emotional expression can be, and sometimes is, manifested by physical distressas well as emotional distress. As providers of care in a physical care setting such as a home for the aged, we need to incorporate mental health concepts in our care of physically ill or disabled people, and to provide a milieu in which they can thrive emotionally as well as physically.2
We nave encountered medical, emotional, psychosocial, ethnic, and other problems of an aged population in a variety of treatment settings, in two different parts of the world. The senior author has worked with the team approach in the geriatric unit of a general hospital, in the psychogeriatric outpatient clinic of a community mental health center, and in a home for the aged, all in Israel. In our quest toward holism, we use a therapeutic team that may consist of a geriatric physician, psychogeriatrician psychiatrist, psychologist, nurse, social worker, physiotherapist, and occupational therapist. In our culturally diversified population in Israel, our treatment plans are sometimes traditional, sometimes ethnic, and almost always multilingual.
As a function of their obligation to be involved in community mental health, the staff of the psychogeriatric unit of the Community Mental Health Center in Jaffa, plus a nurse, formed an outreach program that was administered initially by the nurse. In a setting such as that with a small staff, the nurse's role may encompass any or all of those on our treatment team. Our nurse began by knocking on doors to find elderly people who were isolated and her outreach proved fruitful.
Our psychogeriatric unit staff acts as a team that shares the evaluation process and formulation of treatment goals. A physical history and assessment is done by the geriatrician, psychological assessment by the psychiatrist and psychologist, psychosocial assessment by the social worker, self-care needs by the nurse, and activities of daily living strengths/deficits by the physiotherapist and occupational therapist. While these divisions of labor appear categorized, there is much overlapping as each team member discovers aspects of personality that may not have been observable to another member. Together the treatment team shares responsibility for various aspects of patient care and for maintaining as far as possible their remaining in the community.
Families are activated, whenever possible, as an integral part of the patients' social system and as an extension of the treatment team. We provide information to the family about how they may live more satisfactorily with (or separate from) their older member, with respect to their own as well as the patient's needs and wants. The nurse may be the appropriate contact person to whom the family can come for personal as well as patient concerns; thus the nurse has an opportunity to practice both preventive and remedial interventions with the family.
The nurse and the physiotherapist, in addition to their traditional roles and functions in a home for the aged, participate with the psychiatrist in conducting group therapy. A major thrust of this modality is an emphasis on removing the patient from isolation perceptually, environmentally, and interpersonally. This approach with our patients is described elsewhere.3"6
To demonstrate the practical approach to treatment, Mr. G is presented. Mr. G is a 70-year-old divorced man who has lived in a nursing home for two years. He came to our attention when he began to complain of abdominal pain, refused to leave his bed, did not eat, refused medication, cried often, and expressed suicidal thoughts. During his two years at the facility, he made few friends and visited with his son oncea month in the facility.
A thorough physical examination ruled out organic disease. The social history, taken by the psychiatrist, nurse, and social worker revealed that Mr. C» was a survivor of a World War II concentration camp where he had lost his first wife and five children. Because he was unable to talk about this at length, each of the team heard parts of his history and were able to subsequently put together the fragments. He married again in Israel and divorced his second wife after the marriage of their son, two years ago. Although Mr. G was successful in business, he retired and moved into the nursing home when he left his wife. He began to feel that his life had no meaning or purpose and he got depressed.
The team formulated a plan to remove Mr. G from his self-imposed isolation, to help him sustain the triple losses of job, home, and marriage, and to facilitate his finishing the grief process that he had carried for 33 years. This plan involved the entire team as well as the nursing and social work staff, who undertook this with feelings of "overwhelming odds" and "oneday and one person at a lime." The attention given to Mr. G helped him to get to group therapy twice a week, where he eventually learned to share his past experiences and horrors with others who had also survived the Holocaust. He began to feel important to the other group members and to some of the staff, and then he reached out to people not in his therapy group. As he began to build resources in his environment, he was able to look back over the recent losses in his life and to feel that there was meaning in his existence, nonetheless. As he looked back over his life, he was able to sense his own historical significance and to realize that some of his wisdom could be shared with his grandchildren.
At the same time that the treatment team and staff worked with Mr. G, the social worker visited the family to enlist their cooperation. Without the threat of Mr. G's coming home to live with them, the family was able to hear some of this member's needs and to attend to them. During the family sessions, the need for Mr. G to have a feeling of belonging and contributing was accepted, and ways were worked out to visit him more often and to have him in the home regularly for short (two-hour) visits. As Mr. G was able to understand his part in being open to the needs of the young family, the integrity of the family was preserved. This was particularly noticeable within the developing grandparent-grandchildren alliance and appreciated by both parent.
During the time this family was seen, all of the treatment team members had contact both with the family living outside the facility and the member living in the facility. Each of the staff involved in the care of Mr. G felt good about his progress, and were available to the family when they visited him. The shift in responsibility from physician to team and staff seemed to be signifiant in the outcome of treatment.
While we do not advocate discounting the curing of symptoms, we have found in our patient population that attending more holistically to the varied needs of individuals facilitates the cure of symptoms. When we involve the family and staff in planning and treatment goals, we find that our interventions impact in a more effective way both for family, patient, and staff. Therefore, we believe that wholeness rather than duality is the conceptual base upon which satisfactory and satisfying attention can be given to the needs of out patients and their families.
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- 3. Ernst P, Reran B, Safford, F et al: Isolation and the symptoms of c hronic brain syndrome. Gerontologist 18(5): 468-474. 1978.
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