Mental Health Services
for Elderly in Their Homes
by Shelley F. Diamond, Ph.D.
Summary
This report describes a two-year mental health program
for 200 culturally diverse seniors living in private apartments
in a residential community. Successes and limitations of the
program are outlined, including specific factors that
contributed to outcomes.
Introduction
Rates of psychopathology in seniors over age 65 have
been estimated at 13-20%, and many conditions are
underdiagnosed, especially depression (Druss, Rohrbaugh, &
Rosenheck, 1999; Jeste et al., 1999; Unutzer et al., 1997). Mental
health services are typically underutilized and access is poor
(Bartels, Horn, Sharkey, and Levine, 1997; Mental Health Report of
the Surgeon General, 1999). Fewer than 3% of older adults report
seeing a mental health professional, lower than any other adult
age group (Olfson & Pincus, 1996). Barriers to treatment include
physical mobility issues, financial constraints, and lack of
awareness of the benefits of psychotherapy (Yang & Jackson,
1998). Innovative programs do outreach to the elderly in the
places where they live (Yang & Jackson, 1998).
Methods
Staff at a residential community for seniors perceived the
need for mental health services and contacted the Institute on
Aging. A pilot mental health program was set-up under the
umbrella of an established Well Elder Program (in which a nurse
is available for minor medical check-ups and consultations).
A psychologist was assigned to come to the apartment
building for four hours a week. She conducted psychoeducation
workshops for residents and staff, did individual psychotherapy
sessions with residents in their own apartments, and
coordinated care with other professionals. The psychologist
received special training on issues related to doing
psychotherapy in a person's home, where traditional boundaries
of the therapy office do not exist.
Due to concerns that seniors would have fears about a
psychologist suddenly becoming part of the community, a plan
for consistent but low-key exposure was put into effect. The
psychologist was introduced to the residents at a group meeting
by the building manager, social worker, and Well Elder nurse.
For the first two months, the psychologist attended holiday
events, birthday parties, and weekly gatherings over morning
coffee. She introduced herself to as many people as possible,
socializing informally, handing out contact information,
explaining that she would be available every week, and
answering questions about services. A casual matter-of-fact
style was used, emphasizing the importance of health in both
body and mind for successful aging, and de-emphasizing mental
illness.
The psychologist then presented a number of
psychoeducational lectures on relevant topics, including Stress
Management, Relaxation Techniques, Chronic Pain and Illness,
Memory Loss, and Life Changes and Transitions. At the end of
each presentation, she answered questions and explained that
residents could schedule private follow-up sessions in their
apartments to discuss personal issues. At the end of each
presentation, at least one or more residents scheduled a private
appointment. At the same time, staff began to refer people for
services and follow-up intake interviews were conducted in
residents' apartments.
In between private sessions, time was spent in the
common areas of the building, making informal contact with
whoever was there, exchanging names, expressing concern
about residents' well-being, and offering informal consultations.
Gradually, there were more residents interested in services than
could be handled by one person. A social work intern began to
do the intake interviews and pre-doctoral interns began seeing
patients.
The psychologist also attended building staff meetings to
help staff deal with the difficult behavior of some residents. This
role as consultant was critical to help staff feel supported, and
2
to increase their understanding of residents' behavior. Careful
thought was given to issues of confidentiality and privacy,
sharing information with building staff only when necessary.
A nonprofit foundation gave minimal monthly financial
support. Insurance was accepted and a sliding scale was
available. As more and more people without financial resources
requested services, the foundation began to subsidize
psychotherapy fees. At any one time, approximately half the
residents seen in weekly psychotherapy had subsidized fees.
This program was economically feasible within the context of a
mental health training facility that focused on a geriatric
population. Given the low level of Medicare reimbursement,
individual psychologists would likely need grant money to
sustain their practice.
Results
Over time, there was a growing acceptance of and
receptiveness to mental health services. By the end of two
years, the traditional stigma associated with mental health was
greatly reduced. Word of mouth spread that the mental health
clinicians were people with whom they could safely talk when
they needed help. Residents and staff openly welcomed the
psychologist upon her arrival at the building each week, many
acknowledged her in the halls and elevators, and felt
comfortable asking her questions in public or in a private room
available to all residents. By the end of the two years, there was
enough need for several clinicians to come to the building to do
individual psychotherapy sessions.
Psychological concepts needed to be demystified with
nonclinical language. Cultural differences needed to be
accepted and flexible attitudes maintained. Creativity was
essential in contacting residents with hearing impairments who
could not use the telephone, did not hear knocks at the door,
and/or could not hear conversational speech.
Examples of situations in which services were needed
included: a psychotic episode in which a resident had to be
hospitalized, neglect that required reports to Adult Protective
Services, dementia that involved a capacity declaration and
assignment of conservators, depression and suicidal ideation
3
due to chronic pain, hoarding that created a fire hazard and
caused the resident to fall, and post-traumatic stress.
Less severe issues included concerns about memory loss,
bereavement or grief over losses and changes in their lives,
fears of gossip among neighbors, social isolation, family
conflicts, depression and/or anxiety due to chronic medical
conditions, disabilities, and/or lifestyle restrictions, medication
issues, and a wide range of other stresses and concerns typical
for an elderly population.
The successful evolution of the mental health program can
be partly attributed to the slow and gradual start-up of services
in which residents were gradually exposed to the concept of
mental health needs in psychoeducation classes open freely to
all, and individual psychotherapy for a fee offered as additional
option. Residents were probably also influenced by building
staff, who all strongly supported the integration of mental health
services and encouraged the psychologist's participation in all
aspects of the community from the beginning.
Other critical factors in the program's growth included
maintaining a consistent, visible, informal, reliable, friendly
presence in the building on a weekly basis. Participation in
social events demonstrated a willingness to become a part of
the community. Psychoeducation presentations gave residents
an opportunity to get questions answered before making a
commitment to psychotherapy.
Since there were a large number of non-English-speaking
residents, interventions would have been improved by having a
more linguistically- and culturally-diverse staff of clinicians. A
couple of psychoeducational lectures were translated (into
Mandarin and Russian) but there were not enough trained
bilingual clinicians to see residents in individual psychotherapy
sessions.
Other limitations included problems arranging sessions
with residents who were suspicious of all strangers and/or had
memory loss which interfered with their ability to remember
appointments or follow conversations.
Conclusions
The two year pilot program demonstrated the need for
mental health services in independent living apartment buildings
4
for seniors, and also showed the potential for success in
delivering effective care and treatment.
The program seemed to be helpful to most residents in
acknowledging and reinforcing their strengths and abilities, and
facilitating medical and/or psychosocial services when needed.
Training to conduct psychotherapy in home visits was critical.
References
Bartels, S.J., Horn, S., Sharkey, P., Levine, K. (1997). Treatment
of depression in older primary care patients in health
maintenance organizations. International Journal of Psychiatry
and Medicine, 27: 215-231.
Druss B.G., Rohrbaugh, R.M., Rosenheck, R.A. (1999).
Depressive symptoms and health costs in older medical
patients. Am. J. of Psychiatry, 156: 477-479.
Jeste, D.V., Alexopoulos, G.S., Bartels, S.J., Cummings, J.L.,
Gallo, J.J., Gottlieb, G.L., Halpain, M.C., Palmer, B.W., Patterson,
T.L., Reynolds, C.F., and Lebowitz, B.D. (1999). Consensus
statement on the upcoming crisis in geriatric mental health.
Archive of General Psychiatry, 56: 848-853.
Mental Health: A Report of the Surgeon General. (1999). U.S.
Department of Health and Human Services, Rockville, MD.
Olfson, M., and Pincus, H.A. (1996). Outpatient mental health
care in nonhospital settings: Distributions of patients across
provider groups. American Journal of Psychiatry, 153: 13531356.
Unutzer, J., Patrick, D.L., Simon, G., Grembowski, D., Walker, E.,
Rutter, C., Katon, W. (1997). Depressive symptoms and the costs
of health services in HMO patients aged 65 years and older.
JAMA, 277: 1618-1623.
Yang, J.A., and Jackson, C.L. (1998). Overcoming obstacles in
providing mental health treatment to older adults: Getting in the
door. Psychotherapy, 35: 498-505
5