Pathways
to Improving Health
Understanding and Managing Clients Who Challenge Us as Professionals — Completed
Wednesday, June 23, 2010
8:30 AM to 4:40 PM
Patients/clients who exhibit "difficult" behaviors often do not get the care they need and present with difficulties in social, vocational and self care activities. Substance abuse, personality and anxiety disorders and schizophrenia often result in acting-out, risk-taking behaviors leaving the person socially isolated, depressed and unable to avail themself of needed services. Inability to fully utilize mental health services creates further problems, not the least is the clinician's feelings of frustration as to how to help. This program will bring together leaders in the field of geriatric mental health to discuss how to work with patients/clients whose behaviors challenge us all. In addition to offering a deeper understanding of the internal world of these patients/clients, presenters will discuss how the clinician's feelings and reactions to these behaviors may contribute to difficulties in treatment and improved client functioning. Attendees will learn about how and why patients/clients use challenging behaviors to manage their feelings, what these behaviors may tell us about the patient's/client's needs, and how clinicians can manage their own feelings while improving their client's ability to function more successfully.
Participants will be able to:
- Discuss how clients use behaviors to manage their feelings.
- Recognize how client behavior can challenge professionals.
- Identify strategies to work with clients whose behaviors challenge us as professionals.
Morning Plenary Session 8:30 AM to Noon
Moderator
Patrick Arbore, EdD, Director, Center for Elderly Suicide Prevention and Grief-Related Services, Institute on Aging
Panelists
Jay Luxenberg, MD, Director of Medical Services, Jewish Home of San Francisco; Clinical Professor, School of Medicine, University of California, San Francisco
Medical Factors That Contribute to Making the Difficult Client Difficult
Presentation on medical factors such as psychiatric
syndromes, dementias, hearing impairment, urinary urgency and incontinence,
etc. and strategies to manage them. Will include a discussion of the importance
of access to care — how to find a physician that will make house calls,
etc.
Erlene Rosowsky, PsyD, Assistant Clinical Professor of Psychology, Department
of Psychiatry, Harvard Medical School
What Makes the Difficult Client so Difficult?
Difficult clients are those who evoke in us a sense of helplessness, hopelessness, inadequacy and rage; all the feelings they are feeling. Core concepts of the "difficult personality" will be introduced. These clients have limited resilience and thus the frequently occurring events in older age can be expected to exaggerate clinical symptoms.
Karyn Skultety, PhD, Director of Behavioral Health,
OnLok Lifeways, Institute on Aging
Complex Behaviors: Why We Lose Sight
of the Forest and Run Into the Trees
Often in our attempt to handle difficult
behaviors, we forget the basic rules of behavior and communication that
may make the most difference. The basic tenets of behavioral psychology
will be reviewed and applied to thinking through the ways we respond and
intervene with difficult clients. We will explore the differences in applying
these ideas to cognitively intact versus demented clients. Our reasons for
losing sight of the basics and the difficulties we encounter in making them
work will be explored.
Afternoon Workshops 12:45 to 2:15 PM
1A. Dangerous Behavior: Assessment, Intervention and Treatment of Suicide Ideation in Older Adults
Patrick Arbore, EdD, Director for Elderly Suicide Prevention and Grief-Related
Services, Institute on Aging
Older adults have the highest rates of suicide of any age population. Depression, alcohol abuse, dependence, isolation, chronic physical illness, anxiety and bereavement are significant suicide risk factors. One of the most difficult challenges that professional helpers and families face with older adults is chronic suicidal ideation. The goal of a suicide assessment is not to predict suicide, but to place a person along a risk continuum, to appreciate the bases for the suicidality, and to allow for a more informed intervention. How to respond to a suicidal crisis is a common problem. The professional helper can feel anxious upon hearing about a person's suicidal intent and communication can be blocked. Suicidal people are very sensitive to the underlying feelings of the helper.
Participants will be able to:
- Learn to differentiate geriatric depression from normal age-related changes or dementia.
- Develop skills to work with the depressed older person.
- Learn how to assess the older person's risk for suicide and how to intervene in a crisis.
- Learn about materials that are available to help educate older adults, their families and staff about late-life depression and suicide.
2A. Personality Disorders in Older Adults: Diagnosis and Treatment
Erlene Rosowsky, PsyD, Assistant Clinical Professor of Psychology, Department of Psychiatry, Harvard Medical School
This workshop will explore personality disorders in older adults and the difficulties they present for diagnosis and treatment. Research findings will be discussed, as will the affects of aging and how they might be anticipated to respond to challenges in older age. A conceptual model will be presented offering a way to understand these most difficult clients and which can inform the selection among treatment options.
Participants will be able to:
- Identify personality disorders in older adults.
- Understand how the aging process affects clients with personality disorders.
- Develop interventions to work more effectively with older clients with personality disorders.
3A. Problem Solving Treatment: An Evidence-Based Treatment for Depression in Older Adults
Patricia A. Arean, PhD, Associate Professor, Department of Psychiatry, University of California, San Francisco
Problem Solving Treatment is an evidence-based intervention for the treatment of depression in a variety of older adults populations, including those with physical disabilities, mild cognitive impairments, and low-income, minority older adults. This workshop will serve as an introduction into problem solving history, theory and practice.
Participants will be able to:
- Learn the history and background of problem solving treatment.
- Become familiar with the theory and rationale for treatment.
- Learn how to implement problem solving treatment with different aging populations.
4A. Thinking Outside the 'Black Box': Practical Considerations for Medication Management in Behaviorally Challenging Older Adults
Helen Chen,
MD, Chief Medical Officer, Center for Elders Independence and Clinical
Professor of Medicine, Division of Geriatrics, University of California,
San Francisco.
Despite FDA "black box" warnings about the use of psychotropic medications for behavioral management in patients with dementia, clinicians often face pressure from families, caregivers, and residential care facilities to "order a pill" to manage challenging behaviors. This workshop will provide an overview of commonly prescribed drugs, the evidence for their use, and strategies for how prescribing and non-prescribing members of the interdisciplinary team can collaborate to use these medications appropriately.
Participants will be able to:
- Outline the regulatory issues concerning psychotropic medications.
- Recognize and describe side effects of these medications.
- Apply a framework for effective communication regarding initiation or cessation of psychotropic medications.
Afternoon Workshops 2:30 to 4:00 PM
1B. Working with the Difficult, Resistant, Angry Older Client: Venting vs. Expressing
Patrick Arbore, EdD, Director, Center for Elderly Suicide Prevention and Grief-Related Services, Institute on Aging
Working with difficult older adults can add a great deal of pressure to professional helpers. When difficult people experience stressful situations, they often act out their feelings through anger and aggressive behaviors. Pushing, hitting, cursing, manipulating, biting, and screaming are just some of the ways in which difficult people vent their distress. According to Greenspan (2003) an inability to express and experience grief, fear and despair in a healthy manner can lead to depression, anxiety, addiction, irrational violence, and psychic numbing. In this workshop we will examine the causes of difficult behavior in older adults. We will also explore ways in which the professional helper can cope effectively with someone who is "acting out."
Participants will be able to:
- Review a definition of the emotion of anger.
- Understand the role of cynicism and aggression.
- Consider the role of anger in depression, suicide, bereavement and addiction.
- Learn how to confront an angry older person.
- Distinguish between healthy anger and anger that hurts.
2B. Understanding and Treating Anxiety Disorders in Older Adults
Erlene Rosowsky, PsyD, Assistant Clinical Professor of Psychology, Department of Psychiatry, Harvard Medical School
This workshop will present an overview of what is known about anxiety disorders in older adults. Special considerations, such as medical conditions, medications, and late life existential issues as they contribute to anxiety will be discussed. Treatments, as well as barriers to treatment, will be addressed.
Participants will be able to:
- Recognize medical conditions and medications commonly associated with anxiety in older adults.
- Understand the role of cynicism and aggression.
- Recognize certain typical presentations of anxiety.
- Appreciate the role played by personality in the manifestation of an anxiety disorder in late life.
3B. Developing Your Skills and Techniques for Motivating Clients: Behavioral Contracts, Agreements and Rewards
Karyn Skultety, PhD, Director of Behavioral Health, OnLok Lifeways, Institute on Aging
This workshop will discuss ways to motivate clients to change a behavior. We will review ideas from motivational interviewing and behavioral psychology that have helped develop techniques that lead to behavior change. Several examples of motivation from real case examples will be presented, including some involving behavioral contracts. We will discuss common pitfalls in coming up with rewards or motivation for clients and ways to avoid these.
Participants will be able to:
- Describe three basic ideas from motivational interviewing and behavioral psychology that apply to motivation.
- Define the key components in a behavior contract.
- Identify two common mistakes made in attempts to motivate clients and how they can avoid these in their setting.
- Develop at least one new plan to help motivate a difficult client to change his/her behavior.
4B. Successful Strategies for Dealing with Dementia Behaviors Without Drugs
Elizabeth Edgerly, PhD, Chief Program Officer, Alzheimer's Association Northern California and Northern Nevada
In this interactive session, participants will learn effective strategies for avoiding the challenging behaviors often exhibited by people with dementia. The presentation will address why behaviors occur and how to improve verbal and nonverbal communication with people with dementia. Learn approaches for avoiding problematic behaviors and situations will be discussed, as will approaches for avoiding problematic behaviors and situations, as well as approaches for addressing specific problems, such as wandering and aggression, when they manifest during personal-care activities.
Participants will be able to:
- Understand why difficult behaviors occur.
- Learn techniques for improving communication with people with dementia.
- Identify general approaches for avoiding challenging behaviors and situations.
- Learn skills for handling specific difficult situations, such as aggression during bathing.
4:10 to 4:40 PM Closing Session
Facilitator
Patrick Arbore, EdD, Director, Center
for Elderly Suicide Prevention and Grief-Related Services, Institute on
Aging
Mind, Body, Spirit: Pathways to Improving Health
