Advocacy Plan
Loneliness among the elderly is often seen (Djukanovic, Sorjonen & Peterson, 2015), yet I think is one of the least addressed issues. While research confirms that depression, anxiety, illness, and loneliness exist among this population (Cockayne et al., 2011; Djukanovic, Sorjonen & Peterson, 2015; Herbert, Callahan, Ruggero, & Murrell, 2013; Karimi, 2010; Serrano Selva, 2012), it appears to be addressed through medication and therapy only. After talking with my immersion population, I learned that counseling staff—whether LPC, psychologist, or psychiatrist—do not work on site, rather a psychologist visits the location every month or so to do evaluations. Since mental and physical health issues are so prevalent, what can we do to ensure the elderly are getting the attention they deserve even if their place of living isn’t?
Since reminiscence therapy has such a positive effect on the wellbeing of the elderly (Karimi et al., 2010; Serrano Selva et al., 2012), my plan for advocacy for the elderly is inspired by this therapy and Ohio Dominican University’s “Adopt a Sister” program. In this program, undergraduate students and people in the community have the opportunity to “adopt” a Dominican Sister of Peace from the retirement and nursing home on campus. In this role, students spend time with their Sister, going to movies, playing board games, or simply talking. Similarly, my plan for advocacy of the elderly involves getting the community involved—hence my image inviting people to be an ally for the elderly. I think being an ally for them is also represented in this image in that there aren’t enough people willing to give their time to do so. People in this population have reached out to me after my initial contact with them, asking me to bring more people or asking if we would be willing to come back and plan more activities with them. Thus, my plan for advocacy is reaching out to nursing homes and assisted living places and, hopefully, developing a program in which people can volunteer to spend some of their time with the residents on a weekly basis. Since this was such a successful program at ODU, I think it’s possible to reach out to them for assistance in developing more programs.
I genuinely feel this can be done, and I hope the image shows that I believe it can be done, we simply need the people to do it. This image also shows that I think that there aren’t enough people invested in the lives of older individuals, which I believe exacerbates their physical and mental health issues by telling them they are not an important piece in society. However, I think this image also shows that I feel we can change that. Surprisingly, I have not always been interested in serving this population, but through signing up for volunteer opportunities—even when I was uncomfortable—they are now a population I am very passionate about. This said, my image also says I think we need to push ourselves to get involved in these possibly uncomfortable situations. It is ok to feel uncomfortable at first! People in this demographic could also have a nostalgic connection to this image which is why I chose it.
Although I know there are several systemic issues within nursing homes, I have learned that it is possible to make a difference in this community without being overwhelmed by these issues. This image also represents that I have learned I cannot simply rely on myself to be able to make a difference. In all the wonderful opportunities I’ve had within this community, I could not have done it without the support and help from others. From the community, I realized they feel very similarly. Those that I have interviewed talk a lot about the administration, communities, and people help them feel at home. Additionally, they always mention how students and volunteer groups make them feel happy and involved in their community, even when they are not as mobile as they used to be. The elderly will always play a part in my life and advocacy and I hope others hear the call to action to be a part of older individuals’ lives—they want you!
Servant Leadership
The elderly can suffer from depression (Cockayne et al., 2011; Djukanovic, Sorjonen & Peterson, 2015; Herbert, Callahan, Ruggero, & Murrell, 2013; Karimi, 2010; Serrano Selva, 2012) loneliness (Djukanovic, Sorjonen & Peterson, 2015) and physical illnesses (Cockayne et al., 2011), and some of the best therapies include interacting with others through reminiscence (Karimi et al., 2010, Serrano Selva et al., 2012). Through servant leadership, the elderly could share their stories, possibly experiencing similar benefits as those who do talk and reminiscence therapy, and increase their social wellness. The elderly I have talked to shared that they simply want some youth through talking with others that are younger than them. In my visits with them, the nursing home and retirement home members wanted to share their stories with me, but also hear about my own experiences. Since the research shows that the elderly experience loneliness that impacts their physical health (Cockayne et al., 2011) it is important that servant leadership take the form of social interaction. Additionally, since many older adults experience lack of meaning in life after retirement, it is also important to incorporate activities that produce a sense of importance in their lives. Thus, my plan for servant leadership is creating an interactive activity and music making.
In my work with the Dominican Sisters of Peace, they expressed a love of music and helping others. Many of them said they used to play instruments, and many lived in other countries for more than two decades doing community service. These things considered, a servant leadership activity could be forming a small band or orchestra in which the Sisters could learn new music and be able to feel a sense of community with others (along with playing beautiful music). Similarly, since almost all the Sisters have been trained in choral music, a great activity that we are in the process of planning is caroling. They said it would be great to interact with others while creating something beautiful they could be proud of. All this took was reaching out to Ohio Dominican University to ask if I could give my time to the Sisters! Now, when I want to have a nice day with the Sisters, all I have to do is ask the director of activities (who is a Sister herself!) what days work best for them, which is how I have set up the activities I’ve done this year and the choral event for Christmas.
That is not to say that a time-intensive plan is needed to impact the elderly, who are a very underrepresented group, even in counseling. The simple “get to know you” activities my volunteer group did last month made the Sisters feel welcome and open to discussing their interests. In all, servant leadership with this population could be as simple as organizing an activity where everyone involved could make music, art, or play games. The most important thing to them was interacting with others in meaningful ways to socialize and share interests.
Having worked with the Sisters and other nursing homes for several years, I feel very connected to this population. At times, I feel a bit disheartened that people in younger generations do not consider the elderly a worthwhile population to engage with—as even the counseling literature shows. Yet, the more people I bring to volunteer with me, I see their attitudes towards older generations change, giving me hope others can change too. Little do some know that by simply listening to elders’ experiences, it is possible to make a difference. This image represents what I feel and think is possible: anybody can make a difference! I think even something seen as a small action, such as asking someone their favorite song, acknowledges that the elderly and any other group can have similarities. In order to change the narrative around being elderly, we need more than just one group interacting with the elderly and this image shows that.
Since I have started working with the elderly, I have learned a lot about the population and even about myself. I have learned that, although we grew up in very different times, we have so many similarities, such as being family oriented and enjoying a good romantic comedy movie. In being parts of diverse volunteer groups, I also learned that the elderly are very accepting—something that goes against stereotypes of the elderly. Again, this image shows that I have learned anybody can help and be accepted by this group, all we have to do is take the first step.
Strengths-Based Needs
The articles show that the elderly have many challenges to overcome, from depression (Cockayne et al., 2011; Djukanovic, Sorjonen & Peterson, 2015; Herbert, Callahan, Ruggero & Murrell, 2013; Karimi et al., 2010; Serrano-Selva et al., 2012), to physical illnesses (Cockayne et al., 2011), to loneliness (Djukanovic, Sorjonen & Peterson, 2015). Although I agree they face all these issues, few articles show the positive side of growing older such as wisdom and life experience. Some therapies that can acknowledge these positives are life review and autobiographical retrieval practice (Serrano-Selva, 2012). Not only do they allow for reflection on positive moments and growth in life, but also channels the positive parts of growing older into an effective treatment for affective disorders (Serrano-Selva et al., 2012).
I feel very optimistic about the future of elderly care and I think that is represented in the picture. Many senior “day cares” are now opening their doors to children, so the elderly and youthful can spend their day together. In a Seattle nursing home, there is a permanent separate day care within the home and the children and elderly spend their day together—everyday! When asked about their experience, nursing home patients say that they enjoy having the kids around to play with and simply enjoy their presence. To learn more about this arrangement, follow this link: https://www.youtube.com/watch?v=3LGSfgOi9UU.
I think the idea of combining childcare and elderly care is a great idea, as captured by the image above. I would expand this to say people of differing ages, such as middle schoolers up to college students could not only help the elderly but learn a lot from them. The only issue I see with this is in nursing homes with residents in need of serious medical attention, as having children on site may pose a risk to the residents. However, since some physical conditions worsen with higher levels of depression (Cockayne et al., 2011) which can be seen with loneliness (Djukanovic, Sorjonen & Peterson, 2015), perhaps having youth at the home would actually improve the health of residents.
Overall, I have learned a lot about this topic, from reading about the effects of loneliness on depression and illnesses (Cockayne et al., 2011) to experiencing being a youth in a nursing home. Since graduate school has started, I have visited a nearby nursing home a few times to spend my evening with the elderly. In that short amount of time, many residents remarked that they loved having youth around to talk to. This was something I never considered as a factor in the elderlys’ lives. In my experience, they liked having youthful people around to tell their stories to as well as hear how times have changed from a youths’ perspective. I have changed in that I have already planned another visit to the nursing home—and plan to visit more after that visit too. Seeing as the elderly are such an important, yet underrepresented population in society, I urge more young people to go out into the community and make someone’s day better by simply being a great listener.
Systemic Challenges
The readings I gathered on the elderly show that they benefit from any type of therapy, just as younger people do (Herbert, Callahan, Ruggero & Murrell, 2013). Older individuals can develop depression and anxiety, yet it is less recognized by practitioners (Djukanovic, Sorjonen & Peterson, 2015). In addition to depression and anxiety, co-morbid depression and cardiovascular disease produce more intense symptoms (Cockayne et al., 2011). Reminiscence therapy can help alleviate depression specifically in the elderly (Karimi et al., 2010) and life review can be a helpful tool in improving depressive symptoms (Serrano et al., 2012). These articles show the environment some elderly are in: almost entirely in nursing homes with undiagnosed mental illness and loneliness that drastically effects their physical health. Having volunteered in nursing homes and retirement homes, I saw physical illness, mental illness, and questionable staff behavior. I agree that the elderly are just as capable in making changes in their lives as younger people; however I also agree that staff and professionals are likely to see depression or loneliness as simply a part of being elderly rather than a treatable condition that, once treated, can improve quality of life. Thus, if we don’t recognize the elderly as being capable of change and deserving of help, we won’t see an improvement in the health and wellness of the elderly population or nursing home environments. This image captures that the elderly can suffer from depression, poverty, abuse, and loneliness which can be read about in the articles mentioned previously. I still feel deeply connected to this topic and population—even more now that I have explored the issues within this population. At the same time, I am angered that these issues exist in the first place. I recognize that I can use this passion to make a difference in the counseling of the elderly. Based on the image above, I think there are many issues within the elderly population and nursing homes that are not being addressed; however, this image doesn’t show the positivity I think can be created if people within the counseling community (and all communities!) stepped up brought the mental health, physical health, and wellbeing of the elderly to the attention of nursing home staff, families, and the elderly themselves. This image shows that I now recognize and understand the health issues the elderly go through, but also the systemic issues such as poverty that I hadn’t considered. Through this activity, I learned that one of the unrecognized populations in poverty are also the elderly—it has brought to mind the idea that my parents may feel monetary pressure in the future. I have changed in that I want to advocate for my own family and those who think they don’t have a voice due to their age with even more diligence than what I came into this program with.
Annotated Bibliography
Cockayne, N. L., Glozier, N., Naismith, S. L., Christensen, H., Neal, B. & Hickie, I. B. (2011). Internet-based treatment for older adults with depression and co-morbid cardiovascular disease: protocol for a randomised, double-blind, placebo controlled trial. BMC Psychiatry, 11(10), (1-10). http://dx.doi.org.proxy.lib.ohio-state.edu/10.1186/1471-244X-11-10
According to the literature, co-morbid depression with physical illnesses such as cardiovascular disease (CVD) produces more debilitating symptoms than previously thought (p. 1-2). The bidirectional relationship between depression and CVD may cause worse outcomes of the disease and there is no current research on interventions to treat the two conditions together. To determine if an online counseling treatment could benefit men and women from ages 45-75 with CVD and depressive symptoms, 260,000 people were given an initial questionnaire, the response rate being 18%. The following description is the protocol that the study would undergo if approved. Those that meet the elimination criteria have the opportunity to create a profile where they will receive assessments, consent, and counseling. Among these assessments are self-reported CVD history, self-reported depressive symptoms according to the Kessler-10 score of 16 or above, and the Patient Health Questionnaire (PHQ-9) (p. 3). Participants will be randomly assigned to receive either counseling through e-couch(an online program) or an active health program called HealthWatch.After baseline, 3, 6, and 12 months, depressive symptom data will be measured using the PHQ-9 (p. 6). Cognition will also be measured using a battery of online tests called CogStateusing the same time scale as previously mentioned. Subjects will also take assessments to measure sleep quality, anxiety, illness perception, physical activity level, and alcohol use. Once the data are collected, they will be analyzed using a mixed-model repeated measures test (p. 8). If accepted, the clinical trial could help several aging people who do not or cannot get help for depression and CVD via conventional methods. Acceptance of this study could also open the doors to future studies for CVD, depression, and/or the link between the two (p. 8-9).
Djukanović, I., Sorjonen, K., & Peterson, U. (2015). Association between depressive symptoms and age, sex, loneliness and treatment among older people in Sweden. Aging & Mental Health,19(6), 560–568. https://doi-org.proxy.lib.ohio-state.edu/10.1080/13607863.2014.962001. DOI: 10.1080/13607861003801037.
Mental health in older adults is an expanding problem that is associated with suffering, decreasing quality of life, and even mortality (p. 560). There is conflicting evidence from the literature about which age group has a higher prevalence of depression, and there is evidence that suggests there are no differences in the rates of depression among men and women in the older populations (p. 561). Loneliness is a possible factor in depressive symptoms in both older men and women; however, men who were lonely tended to be more depressed than women (p. 561). Previous studies even show that the elderly’s depression is undertreated. This study’s purpose is to examine the possible relationship between loneliness and depression as it relates to sex. Participants were selected through a Swedish register that indicated ages of 65-80, and they were sent a 53-item questionnaire that discussed mood, health, stress, demographics, lifestyle, and such. There were 6659 respondents. Participants then took the Hospital Anxiety and Depression Scale (HAD) to identify emotional state, anxiety, and depression. A score of 8 or greater indicates the possible presence of a depressive disorder. Loneliness was measured by one item (“do you ever feel lonely?”) with four alternative options (yes often,yes sometimes,no seldom,andno never). They were also asked to report if they had sought medical care in the past 3 months and what prescriptions were they taking. Data was broken up into three age groups, 65-69, 70-74, and 75-80, and analyzed using Pearson’s Chi Square test and Student’s t-test. The results showed that depression was seen in 9.8% of participants and more depressive symptoms were in men than women; however, more women reported loneliness than men. More than 25% of participants reported they often or sometimes felt lonely. As other studies found, this study found a relationship between loneliness and depressive symptoms; however, this relationship decreases as age increases. Even though 60% of participants had met with their general practitioner within 3 months of taking the questionnaires, they were never treated for depressive symptoms, suggesting that one of the issues with receiving adequate care is that physicians are not screening them for affective disorders. Additionally, few people met with psychologists or other professionals. Overall, treatment of these symptoms involves screening, possible medication, and connecting people with proper resources and therapy.
Herbert, G. L., Callahan, J., Ruggero, C. J., & Murrell, A. R. (2013). New analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program: Do different treatments reflect different processes? Psychotherapy Research, 23(5), 514–525. https://doi-org.proxy.lib.ohio-state.edu/10.1080/10503307.2013.800949
Past research has focused on how client/counselor bond, client interpretation of sessions, and client/counselor personal traits influence therapy outcomes; however, this study focused on how different therapies affect session outcomes. They use the phase model of psychotherapy (remoralization, remediation, rehabilitation) to describe client treatment progress, where remoralization is thoughts on how therapy will change themselves, remediation is decreasing symptomology through counselor-directed strategies, and rehabilitation is adaptation into their life roles (p. 514-515). Past literature has shown that these phases can occur in a number of different sessions; however, no study was able to give reliable, specific details on phase progression (p. 516). Since treatment role or type was not considered, in previous literature, it is necessary to examine data to see if treatment type has an effect on patient improvement. The current study used data from The Treatment of Depression Collaborative Research Program (TDCRP), which was a clinical trial that looked at the differences between Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT). The authors argue that CBT is more remediation focused, whereas IPT is more rehabilitation focused; thus, they hypothesized that patient phase changes would be different according to the type of therapy and that the number of sessions would be different, with CBT having more (p. 517). The TDCRP data was collected from 1982-1986 and ended with 119 participants that took part in 16 sessions of either CBT or IPT. Participants were assessed using the Schedule for Affective Disorders and Schizophrenia, and the Beck Depression Inventory, and all participants (ages 21-60) were asked if they received an eighth grade education (p. 517). The participants were split into two groups, one group receiving CBT and the other IPT. Analyses were conducted to determine if there was a significant difference between groups and if each phase change (remoralization, remediation, rehabilitation) occurred in both therapies at the same time (p. 518). The results showed that almost half of the participants in both groups went through the remediation phase by treatment 4. The other half of both groups achieved remediation at week 8 of treatment. Overall, participants in the IPT group showed slightly higher remediation rates by the fourth week of treatment than those in the CBT group and rehabilitation was about the same (50%) in both groups by the fourth week, with IPT gains being slightly larger (p. 520-521). Thus, there are no significant differences in treatments as they relate to transitioning from phase to phase. This finding suggests that any treatment can be used in any counseling setting for younger and older adults alike to achieve significant change in affect.
Karimi, H., Dolatshahee, B., Momeni, K., Khodabakhshi A, Rezaei, M., & Kamrani A. A. (2010). Effectiveness of integrative and instrumental reminiscence therapies on depression symptoms reduction in institutionalized older adults: An empirical study. Aging and Mental Health, 14(7), 881-887. https://www.tandfonline.com/doi/abs/10.1080/13607861003801037
The literature on reminiscence therapy shows that it may produce significant positive effects with regard to depression; however, several studies show inconsistent results (p. 881). According to literature reviews, the shortfalls of reminiscence therapy are contradictory results, lack of therapeutic theory base, and confounding variables, and these are some of the main reasons that the therapy still lacks a theoretical base (such as psychodynamic, Adlerian, Rogerian, etc.) (p. 881). It has been argued that until reminiscence therapy finds a theoretical base to follow, it will continue to yield contradictory results in the research field (p. 882). The current study investigates the differences between integrative reminiscence (integrates past and present, conflict resolution, gives a sense of meaning, and yields acceptance of self and others) and instrumental reminiscence (remembering past plans, goal-directed pursuits, and drawing from life-experience to solve current problems) in reducing depressive symptoms in illiterate older adults (p. 882). Participants were recruited from an Iranian nursing home if they had lived there for more than 6 months, were not on medication for depression (or were on medication for at least 3 months), were able to speak and understand Persian, and scored a 5 or higher on the Geriatric Depression Scale-15 (GDS-15). Thirty-nine participants were randomly selected and matched in terms of gender and depression scores and placed into three groups: integrative reminiscence, instrumental reminiscence, or social discussion (in which participants discussed topics of Iranian laws, physical health, relationships, and so on). Each group went to six weekly sessions that lasted 90 min each; due to the subjects’ illiteracy, a nurse helped complete homework worksheets that were given at the end of each session to keep the participants thinking about what was discussed in group (p. 883-884). The data were analyzed using an analysis of covariance (ANCOVA) and post hoc tests (p. 884). The results showed that those in the integrative reminiscence group had significantly lower depression scores than those in the control social discussion group, that there was no statistically significant difference between the instrumental and control group, and that the two reminiscence groups did not differ from each other (p. 884). These findings suggest that the best way to alleviate depression symptoms in older adults is through integrative reminiscence; however, a limitation of this study is that almost all the adults were illiterate and from Iranian culture, and it is possible that the instrumental reminiscence theory was not adapted enough for this group (p. 885). Additionally, there was a small sample size.
Serrano Selva, J. P., Latorre Postigo, J. M., Segura, L. R., Bravo, B. N., Aguilar Córcoles, M. J., López, M. N., … Gatz, M. (2012). Life review therapy using autobiographical retrieval practice for older adults with clinical depression. Psicothema, 24(2), 224–229. Retrieved from http://proxy.lib.ohio-state.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2012-08486-007&site=ehost-live
Previous research with older adults has shown that life review can help alleviate depression and increase feelings of well-being (p. 224). However, depressed older adults may have trouble retrieving autobiographical memories (personally experienced events) (p. 224). When compared to nondepressed individuals, depressed individuals recalled general memories or events that occurred over long periods of time. This is important because some literature showed that memory specificity is tied to psychological improvement in therapy. This study hypothesized that older adults who received autobiographical memory retrieval practice would experience a better mood, decreased negative symptoms, decreased hopelessness, and greater life satisfaction (pg. 225). Thirty-seven participants were recruited after taking the Mini International Neuropsychiatric Interview (MINI) and receiving a score that indicated major depression, and subjects were split into two groups: the control group (n = 19) received a placebo (supportive therapy), and the experimental group (n = 18) received life review therapy (p. 225). The participants then took the Geriatric Depression Scale (GDS), the Beck Hopelessness Scale (BHS), the Life Satisfaction Index A (LSIA), the Quality of Life in Depression Scale (QLSD), and the Autobiographical Memory Test (AMT). Data were analyzed using the chi-square test and t-tests (p. 226). The results showed that those who received life review therapy had significant decreases in MINI and GDS scores; however, these scores were not significantly different from those who received support therapy (p. 228). Additionally, using longitudinal projection, those who could retrieve more specific, autobiographical memories show decreased levels of depression, suggesting that the number of memories recalled is important to well-being. Improvement in depression was positively correlated with the final score on the AMT (p. 228). Unfortunately, a limitation of this study was the small sample size and that there were differing baseline scores for depression across the control and experimental groups (p. 228). Regardless, these findings suggest life review is an important part of psychotherapy and should be implemented to increase positive affect and overall well-being in older clients.