Psychiatric problems are widely prevalent among nursing home patients. The authors spent 2 years as consultants to a nursing home head nurse during which they tried to teach her ways to deal with these problems. The authors noted that the consultation went through distinct phases. These phases and the factors by which they could be distinguished from one another are discussed in detail and illustrated with examples. Some questions are raised about advantages and disadvantages of long-term, continuous consultation.

Psychiatric Consultation in a Nursing Home A Two-Year Experience1 Leonard E. Freedberg, MD,2 and Cori S. Altman, ACSW 3 Many patients placed in nursing homes by their families, social agencies, and general hospitals have preexisting emotional difficulties or adjustment reactions at the time of placement (Stotsky, 1970; Stotsky & Dominick, 1970). Furthermore, in Massachusetts, as elsewhere, the chronically mentally ill are being taken from state hospitals and placed in nursing homes (Dietz, 1974). Problem patients common in most facilities include the psychotic, the depressed, the angry and negativistic, the assaultive, the senile, the apathetic, and the adult retarded. Nursing home personnel are not necessarily equipped to deal effectively with patients with these problems. One way of increasing the capacity of nursing home personnel to care for such patients is to provide professional mental health consultation. This paper will report the experience of a psychiatric resident and social worker as they consulted to the head nurse of one nursing home for 2 years. Background and Setting of the Consultation Over the last 5 years, the Geriatric Unit of the Massachusetts Mental Health Center has developed a community-focused program of mental health services for the elderly. Included in its comprehensive program are psychiatric consultation services to the 50 nursing homes in its catchment area (Gurian & Scherl, 1972). Mrs. X, the head nurse of one of these homes, has had continuous consultation from mental 1. The work described here was supervised by Bennet S. Gurian, MD, Director, Geriatric Unit, Massachusetts Mental Health Center, and the authors gratefully acknowledge his assistance. 2. Resident in Psychiatry, Massachusetts Mental Health Center, 72-76 Fenwood Rd\, Boston 02115, and Fellow in Psychiatry, Harvard Medical School. 3. Psychiatric Social Worker, Massachusetts Mental Health Center.

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health personnel for 5 years. This had been offered to her originally because of frequent transfers of patients from the home to the Massachusetts Mental Health Center. The hope had been that consultation would enhance Mrs. X's skills and enable her to deal with most problem patients within the nursing home. Before the 2-year experience described in this report, consultation had been offered by a succession of psychiatric social workers and nurses, each for I year. Generally, they had visited the home at unspecified times or had come when called for emergencies. The interest on the part of the authors and the needs and wishes of Mrs. X for continued consultation led to the decision to provide Mrs. X with this consultation team for a 2-year period. The home is rated as a level 2 (skilled) and 3 (unskilled) nursing home by the Dept. of Public Health. When the consultation was begun by the authors in 1972, the home had 120 patients, of whom about one-fourth were mentally retarded middle-aged people transferred from state schools where they had been long-term residents. Another fourth of the patients were former long-term state hospital inmates diagnosed as schizophenic in most instances. The remaining patients had been placed there by their families or non-state agencies and hospitals. About half to two-thirds of the patients were Jewish. The home is housed in a threestory yellow brick building. Patients live on the top two floors with the more difficult-to-manage ones generally housed on the second floor. The ground floor has a dining room, common room, O. T. area, kitchen, offices, chapel, and barbershop. The head nurse of the home, the consultee,

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has been there for 9 years. She hires and supervises the nursing staff, communicates with the patients' families, works with the medical doctors, interviews most patients before they are accepted, and sets the emotional tone of the home. Despite the somewhat sterile physical plant, she infuses some personal warmth. This is apparent in the eagerness with which the patients greet her and in the affection she expresses for them. Mrs. X had worked in a state mental hospital after completing her training but had no other professional experience with psychiatric patients. The format of the consultation was worked out with the consultee in the beginning and was deliberately designed to be more structured than had previously been the case. The consultants went to the home once each week for P/2 hours. The first hour was spent with a patient or patients selected by the consultee. Some patients were followed for several consecutive weeks while others were seen only once. The remaining half hour was spent with the consultee. She was called by phone regularly on the day prior to each visit and was asked about the patients that were to be seen. She alone was responsible for selecting patients or issues for discussion. If she were absent from the nursing home there would not be a consultation that day.

a year, having two consultants instead of one, and changing to a more structured form of consultation was to ask the consultants to think about whether they really wanted to do it at all. During the first few weeks she often arrived late for the consultations. She asked the consultants to see patients who had been in the home for years, who exhibited some kind of chronic and unpleasant behavior, and who had been seen by previous consultants. The consultants felt frustrated at times and wondered if the consultation should continue.

The Two Years of Consultation

The Problem-Solving Phase

In retrospect, the 2 years of consultation can be divided into Hazlett's and Rapoport's (1964) last three phases: beginning, problem-solving, and termination. Their preparatory phase during which the agreement was reached between the consultee and the Geriatric Unit that there be ongoing consultation had been completed before the authors' experience began. During the problem-solving phase, the bulk of the 2 years in time and work, three varieties of consultation took place. These included consultation directed at specific patients, at administrative problems, and at general issues. In each major phase and in each variety of the problem-solving phase, the kind of problem presented by the consultee, the nature of the help given, and the feelings of the consultants were distinctly different. These differences are illustrated below by specific examples.

The beginning phase blended into the problem-solving phase. The three varieties of consultation that went on during this phase are discussed separately for clarity although they were often combined in practice. Thus, on a given visit, the discussion might begin with a single patient but shift to a discussion of administrative problems and general issues.

The Beginning Phase

The beginning phase, as noted by Hazlett and Rapoport (1964), was marked by some negativism. The consultee's immediate reaction to losing the nurse with whom she had worked for

Example, Case I Mr. AB, a 63-year-old widowed Jewish man, has lived in the home for 7 years. He had originally been admitted when his wife died and he was unable to function alone. He had severe, progressive Paget's Disease which had grossly deformed his skull and caused nearly total deafness. He was isolated, lonely, sarcastic, and angry, but he was one of Mrs. X's favorite patients. The other patients called him names, and he responded in kind. On weekends he often defecated noisily in his pants or on the floor just outside of the bathroom. Various prior attempts to deal with the problem such as administering tranquillizers, changing his room, and regular visits by a male staff member had failed. The consultants tried to show Mrs. X that this behavior expressed anger, but she was disappointed since a concrete solution was not provided. Eventually, however, she became more understanding of Mr. AB's behavior and stopped asking the consultants to see him with hope of a "cure" in mind.

Variety I: Specific Patients

The first variety of consultation in the problem-solving phase was characterized by its focus on specific patients. The discussions were mainly restricted to the designated patients, and the consultee wanted to be told what to do. She seemed to expect the consultants to have an answer for every problem. The consultants felt pressed to make specific suggestions such as advising the use of psychotropic medications. The dependent aspect of the consultee-consultant relationship never disappeared entirely but, with time, became far less prominent. This variety of consultation is most like Caplan's (1970) description of consultee-centered case consultation.

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matches between the owner and Mrs. X, reported to the consultants by her, during which the owner pressured her to discharge certain patients, and she threatened to resign. The consultants helped the consultee to clarify what she wanted, e.g., to open her own mail and, later, the right to have in-service training, and supported her self-esteem by agreeing that her requests were reasonable. She confronted the owner, gained his cooperation on those two issues, and thereby was able to establish a more appropriate relationship with him.

Example, Case 2

Miss CD, a 72-year-old former state mental hospital resident, has lived in the home for 7 years. She had originally decompensated in her adolescence and thereafter led an isolated, highly dependent existence, living with her mother until her mother's death and then living in state hospitals. She had adjusted reasonably well to the nursing home at first, although she continued to be isolated. She decompensated abruptly when she was moved to a new room and given the bed of a patient who had died a few days before. She became withdrawn, refused food, lost weight, and muttered angrily about being brain damaged since her father hit her head when she was a child. A second room change was instituted by Mrs. X. The patient's sister visited, they argued, and the sister removed the patient's most prized possession, a picture of their mother. Miss CD deteriorated further, and the consultee asked the consultants to see her. The consultants suggested that physical causes of anorexia and weight loss be ruled out first. This was done, and the consultants suggested that Mrs. X discuss the patient's feelings about being moved and about her sister's behavior. The consultee went to the patient's room several times weekly, talked, and made observations about the patient's anger such as: "C, you seem to have been mad at me ever since I changed your room." The consultee reported to the consultants about her interaction, and the consultants encouraged her to continue. The patient expressed some anger openly, began to eat, and for a while was less withdrawn.

Variety 2: Administrative Problems As the problem-solving phase of the consultation progressed the consultee gradually began to talk about administrative problems. She discussed her difficulties with medical doctors (who sometimes did not see patients about whom she was concerned as quickly as she felt necessary), with patient's families (some of whom blamed her or the home for their relative's deterioration), with the staff (some of whom worked poorly together because of personality differences), and with the home's owner (with whom she was engaged in a long-standing struggle for control). During this variety, most like Caplan's (1970) consultee-centered administrative consultation, the consultants felt less pressed to offer specific advice. As the consultants came to appreciate the delicacy of the consultee's position vis-a-vis the various individuals mentioned, she began to assert herself more definitively.

A problematic aspect of this variety of consultation was the consultee's occasional introduction of material about her personal life. The consultants disagreed about the meaning and handling of this. One (LF) felt that it distracted from the professional nature of the relationship. In line with Caplan's (1970) thinking, that consultant felt that the consultee should be respectfully but definitely discouraged. The other consultant (CA) felt that the consultee was able to make better use of the consultants' expertise after "testing" their interest by sharing something personal. That consultant felt that the consultee should not be discouraged as long as the work continued. The consultants steered a middle course, and the consultee gradually introduced less personal material in the sessions. Variety 3: General Issues Consultation around administrative problems dominated the scene for many months and blended with variety 3 in which general issues were discussed. The consultee shared her thoughts and feelings about changes in the nursing home,4 aging, society's and family attitudes toward the elderly, and dying. During this variety of consultation the consultants felt closest to the consultee, seemed to learn as much as they taught, and worked through some of their own feelings about these difficult issues. The consultants felt that they were involved in a mutual problemsolving effort that benefited them, the consultee, and the nursing home. Example, Case 3 The consultants arrived one morning and learned that a patient, Mr. EF, whom they had never met, had died during the night. The consultee asked the consultants if they would like to view the body. Mr. EF was a 90-year old man who had gradually wasted away over the preceding year. He had no close relatives or friends. The consultee had liked him and was sad because he had been lonely toward the end of his life. She explained that she usually preferred to have patients die in the hospital because other patients became so upset whenever someone died in the home. An exception had been made in Mr. EF's case by.

Example

On several occasions the consultee mentioned the fact that the owner opened mail addressed to her and that he sometimes failed to deliver it to her. As the consultants encouraged her to amplify and explore this topic, it became clear that the mail problem symbolized the mutually gratifying and' upsetting power struggle between the consultee and the owner. Other evidence of this struggle included hour long shouting

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4. For instance, over the 2 years the proportion of state hospital patients increased from a fourth to a half, and there were fewer Jewish patients in residence.

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agreement with his doctor. The consultee also discussed the discomfort experienced by staff members who dealt with dying patients; she had noticed, for example, that they avoided these patients. The Termination Phase

The final phase was termination. More than a month was devoted to it in an effort to examine and to summarize our experience. The consultee's immediate reaction to approaching termination was to express her disappointment that the consultation was ending and her warm feelings for the consultants. The consultee stated she had learned to tolerate her own limitations and those of the home with more comfort, that she had improved her ability to assess and to deal with difficult patients, and that she had won more respect from the home's owner. Asked to be critical, she stated that the consultants were always "cool" so that she often felt self-conscious about her own emotionality. There were also implicit indications that Mrs. X had negative as well as positive feelings. She again resorted to referring patients to the Massachusetts Health Center prematurely and without prior consultation. Example, Case 4 One of the consultants (LF) was called by the Health Center clinic to see a patient, Mr. GH. He had been sent to the clinic by Mrs. X with a request for admission to the hospital because he had wandered from the nursing home. This behavior had shown itself infrequently and had been present for at least 2 to 3 weeks. She had neither spoken to the consultants about the patient, nor informed them that she was sending him to the clinic. Any efforts she had made on her own to understand and resolve the problem had failed. Although he was not admitted to the hospital, Mrs. X arranged to have him transferred to another nursing home, still without having asked the consultants to see him.

Other evidence of difficulty around ending the consultation was that the consultee wanted to focus largely on personal matters at several of the last meetings. In this instance both consultants agreed that to do so exclusively was not helpful to the work of termination. The consultants also were aware of both positive and negative feelings in themselves. On the one hand they felt gratified because they had worked hard and learned so much; on the other hand they wondered whether the consultee would be able to integrate and make future use of what she had grasped. Conclusion

As Hazlett and Rapoport (1964) point out, it is hard to assess the full impact of consultation. This difficulty is corroborated by others

(Goldberg, Latif, & Abrams, 1970). The authors of this communication are most certain of the increase in their own knowledge of and ability to deal with the emotional problems of nursing home patients. There were few transfers of patients from the nursing home to the Massachusetts Mental Health Center during the period of consultation described here. Mrs. X has expressed her own sense that she had benefited, and the consultants hope that she has developed an increased capacity to solve problems on her own. Evidence for such growth is Mrs. X's ability to terminate with the consultants without arranging for further continuous consultation as had always previously seemed necessary. An advantage of long-term, continuous consultation is the development of maximum rapport between consultee and consultant to facilitate a free-flowing exchange of ideas and feelings. With this exchange the consultation described in this report became more comprehensive and meaningful. The main disadvantages of longterm, continuous consultation are its "cost" in terms of efficient use of limited numbers of trained professionals and the potential danger of fostering dependency in the censultee. Summary

This paper has described continuous consultation over a 2-year period between two mental health professionals and the head nurse of a nursing home. It has been shown that such a consultation goes through stages distinguishable from one another by the content of the individual meetings, by the attitudes and expectations of the consultee, and by the responses of the consultants. References Caplan, G. The theory and practice of mental health consultation. Basic Books, New York, 1970. Dietz, J. Mass. Plans to Phase Out Mental Hospitals in 5 Years. Boston Morning Globe. Boston, Feb. 8, 1974. Goldberg, H. L, Latif, J., & Abrams, S. Psychiatric consultation: A strategic service to nursing home staffs. Gerontologist. 1970, 10, 221-224. Gurian, B. S., & Scherl, D. J. A community-focused model of mental health services for the elderly. Journal of Geriatric Psychiatry. 1972, 5, 77-86. Hazlett, C. H., & Rapoport, L. Mental health consultation. In Bellak (Ed.), Handbook of community psychiatry and community mental health. Grune & Stratton, New York, 1964. Stotsky, B. A. The nursing home and the aged psychiatric patient. Appleton-Century-Crofts, New York, 1970. Stotsky, B. A., & Dominick, J. R. The physician's role in the nursing and retirement home. Gerontologist. 1970, 10 (1:2), 38-44.

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Psychiatric consultation in a nursing home: a two-year experience.

Psychiatric problems are widely prevalent among nursing home patients. The authors spent 2 years as consultants to a nursing home head nurse during wh...
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