Insight into the coping mechanisms often manifested by aged persons will enhance the ability of health professionals to provide quality care for these persons. Coping or defense mechanisms may be viewed as those psychological processes that are used to defend one's self against anxiety and fear and that tend to provide some temporary security. Attempts to utilize these mechanisms ofteïi lead to being labeled as a difficult, uncooperative or non -compii ant person. Health professionals could assist the families or significant others to better understand and cope with their aged who exhibit these mechanisms.
Butler and Lewis believe that in judging the adaptations of the aged, it is important to remember that they deal with more stresses than any other age group.1 Therefore, health professionals and families must realize that to maintain the status quo in many situations should be viewed as a triumph. Also, as persons become increasingly old, the need for stability becomes more important for them, therefore, when they feel insecure they often manifest some coping mechanism.
The psychological stresses experienced by aged persons may originate in the external or internal environment. Assessments should always include data about both of these areas for planning care. In fact, a major part of the role of the nurse is to assist the aged in coping with his/her problems regardless of the origin of them. Conflict is an integral part of life for many aged persons. How the nurse and/or other health professional assist the aged to adapt and cope with these stresses and conflicts greatly influences the level of wellness the aged maintain. When these stresses and conflicts are unresolved, tension occurs and continues until resolution. Coping behavior becomes necessary to prevent the development of psychotic disorders. Ideally, the nurse should assist aged persons experiencing conflicts and stresses to develop the positive coping mechanism identified as insight before the more negative mechanisms emerge. The profound level of energy often utilized to display negative mechanisms could be channeled into more constructive behavior patterns with which to defend the ego.
Five coping or defense mechanisms, identified by Butler and Lewis, which are often exhibited by the aged will be discussed. These mechanisms in the order of discussion are: (a) Insight, (b) Reminiscence, (c) Denial, (d) Displacement, and (e) Projection.1 Insight - An intellectual understanding and emotional acceptance of the origin and development of symptoms. This new understanding will assist the person to avoid repetition of some of the behavior which precipitated conflict in the external environment and to gain understanding about bodily dysfunctions. Health professionals must be cognizant of the fact that insight can be helpful but also very painful.
In view of this, health professionals must make the determination of whether to promote insight into a situation which could promote despair. Families should also be involved in this process. Health insight may be promoted through the development of relationships which enhance a positive selfconcept and feelings of self-worth. The positive results of insight occur when they enable the person to look beyond bodily declines and gain meaning through other strengths and activities. When this occurs the person will be able to cope more readily with' his personal situation.1
Reminiscence - Often utilized among the young and old, the value of this behavior tends to increase as one ages. This behavior has been described as a method of holding onto the self while letting go of some personal situation.2 It has also been described as a part of the life review which allows the aged to put their life in order and/or derive pleasure from their past.1 Becoming involved with the aged as they reminisce is a helpful way of learning more about their past struggles, concerns, losses, strengths, fears and triumphs. Additionally, reminiscence promotes interaction, stimulates personal awareness, assists in meshing lives with those who have had similiar experiences and during this process selfesteem of the aged is enhanced.2 A therapeutic climate occurs for the aged when they feel that their memories are treasured in that a sense of personal significance is preserved.
Reminiscence frequently is prevalent after a loss and this is adaptive because it represents a natural healing process which is the basis for psychotherapy. Verwoerdt indicated that the purpose of reminiscence is not to recall facts but is used in an effort to achieve a sense of closure.3 In view of this, it is imperative that health professionals recognize reminiscence as a healthy process and encourage it as a therapeutic measure. By utilizing this process, the health professional may enable the aged person to gain hope and security.
Denial - This is often utilized as a means of defending the ego when losses occur.4 Denial may be manifested by the type of dress, refusing to take medications and/or to seek out health care. Behavior of this nature tends to act as a buffer which may be healthy at first to make a situation more tolerable until coping can occur. Stated another way, denial allows the person time to collect themselves and to develop less radical behavior.
The role of health professionals is to encourage the person to explore their feelings in a way that will support them until they decide to accept reality.5 The complete denial of loss and/or situation may indicate psychopathology which requires psychotherapy.3 A team effort including input from the family or significant others must be utilized to decide whether to force the person to accept reality.
Denial may be precipitated in the aged by their inability to transfer the decisions about their care and life, which sometimes occurs as a result of chronic health problems. In essence, denial is utilized as a means of coping until some resolution of the feelings about the decrements can be developed.3
Displacement - A behavior utilized to disguise the real source of anxiety by placing the blame upon another object or circumstance.6 It has been described as the process of ascribing one's own undesirable condition, thoughts or feelings to others.3
The health professional may recognize this behavior when the aged complain about the type of care or facilities available to them. This behavior may be considered as being displacement when the criticism appears to be unjustified by an objective observer. Health professionals should endeavor to discover the precipitating factors of this behavior and devise ways to make the situation more palatable. Families are often the recipient of these verbal attacks from their aged members, which is difficult for them to understand. Therefore, health professionals should be in the position to assist them to develop some understanding and acceptance of the behavior.
Projection - Viewed by many authors as being very similiar to displacement and discussed together, the behavior is seen as a need to allay anxieties by projecting to another the feelings that are uncomfortable emotionally. A person who has previously been very rigid and aggressive may find it very disconcerting to fail and/or experience a loss so he/she projects the basis for the change upon another.3 Since the person cannot admit to a loss and/or deficiency, he/she often complains bitterly about and attacks whomever is around, blaming them for the problems.3 This outburst may be against the person whose support is needed and it may create guilt and/or hostility in that person, who is often a family member. Often the attack is in the form of accusations of neglect and abuse. If the recipient of the attack retaliates, the situation will worsen, in that the person needing security and support will feel the suspicions about the lack of care are validated.
It is imperative that an atmosphere free of counter-aggression be provided. Measures should be implemented that would make the aged feel important. They should be encouraged to participate in activities that would promote personal satisfaction. The aged and their families should be offered the opportunity to explore relationship problems that exist. The health professional can contribute greatly toward the alleviation of this coping behavior by assisting the family in gaining insight into the basis for the untoward behavior.
When defense or coping mechanisms are observed, health professionals should assess the situation to determine if the behavior should be allowed to continue or if attempts should be made to alter the mechanism. That is, it should be determined if there is something more positive to offer the person. This determination requires much skill on the part of families and health professionals.
A very important task of the aged is to maintain ego integrity in spite of their losses. We as health professionals must assist them in building ego strength by eliciting past and/or present successes in an effort to aid them in remembering days of wholeness. The attainment of this goal requires much knowledge about the aged, their families, and the available resources.
- 1. Butler RN, Lewis MI: Aging and Mental Health: Positive Psychosocial Approaches. Saint Louis: CV Mosby Company, 1973.
- 2. Burnside IM: Nursing and the Aged. New York: McGraw Hill Company, 1976.
- 3. Verwoerdt A: Clinical Geropsychiatry. Durham, NC: The Williams and Wilkins Company, 1976.
- 4. Evans FM: Psychosocial Nursing. New York: MacMillian Company, 1971.
- 5. Hall JE, Weaver BR: Nursing of Families in Crisis. Philadelphia: JB Lippincott, 1974.
- 6. Butler RN, Lewis MI: Aging and Mental Health: Positive Psychosocial Approaches (ed 2). Saint Louis: CV Mosby Company, 1977.