The Power Of Relationships A portrait of the The Winchester Medical Center

Adult/Senior Outpatient Program

Brenda J. Johnston, DNP, PMHNP-BC, PMHCNS-BC

Objectives:

Discuss the value of “purpose” and the influence of interpersonal relationships on

health and wellbeing

Examine the impact of social isolation on the development of common mental illnesses

in elderly populations

Recognize the benefits of group therapy

Describe the services provided at the Senior Outpatient Program (SOP)

Select appropriate referrals for the SOP

Mental Illness and the Elderly

According to the World Health Organization (WHO)

More than 20% of adults older than 60 suffer from some type of mental or

neurological disorder

6.6% of all disability cases in older adults are due to mental health and neurological

disorders.

The most common neuropsychiatric disorders in older adults are depression, anxiety

and dementia.

(“WHO | Mental health and older adults,” n.d.)

No Health without Mental Health

Elderly persons with mental health problems have a higher incidence of:

Chronic illnesses

Chronic pain

Substance abuse

Neurocognitive decline

(American Psychological Association, 2017)

What Came First ?

Anxiety and Depression

Anxiety disorders affect 3.8% of the elderly population.

Depression is the most common mental health problem in older adults. According

to WHO, it occurs in 7% of adults older than 60 years. Symptoms of depression in

older adults include:

Fatigue

Sadness

Irritability

Social withdrawal

Weight loss and loss of appetite

Loss of self-worth

Fixation on death

(“WHO | Mental health and older adults,” n.d.)

Depression is a major risk factor for suicide.

In 2006, 14.22 of every 100,000 people age 65 and over died by suicide, higher than the

rate of 11.16 per 100,000 in the general population.

Non-Hispanic white men age 85 and over are at the greatest risk for suicide, with a rate

of 49.8 suicide deaths per 100,000

(CDC, 2006).

Neurocognitive Disorders

About 47.5 million people around the world have dementia, and it is estimated that number will reach 75.6 million by 2030. Symptoms of dementia include:

Memory loss

Depression

Irritability

Difficulty finding the right words

Inability to perform tasks and activities that require planning and organization etc.

(“WHO | Mental health and older adults,” n.d

Accessing Mental Health Care Services

Mental health problems in elderly individuals are frequently under-identified by

health care providers

Elderly people are often reluctant to seek mental health care

Stigma surrounding mental illness

Often present with symptoms that seem unrelated to a mental health problem

Access to services

The expense of mental health care

(Townsend & Morgan, 2017)

Signs that Indicate a Need for Help

May Include:

Depression

Social withdrawal

Severe anxiety

Suicidal thoughts

Sleep and appetite changes

Loss of interest in appearance

Hallucinations

Confusion

Cognitive impairment due to depressive symptoms

(Townsend & Morgan, 2017)

Risk factors for mental health problems include:

Physical health influences mental health and vice versa

Chronic pain

Diabetes

Heart and vascular disease

Strokes

Urinary and bowel incontinence

Polypharmacy

(Townsend & Morgan, 2017)

Risk factors for mental health problems (Cont)

Experiencing events such as bereavement

Loneliness

Financial instability

Lack of physical activity

Emotional distress

Neglect

Loss of independence

A lack of purpose

(Townsend & Morgan, 2017)

What is more Deadly than Smoking,

Alcoholism and Obesity?

Social Isolation contributes to increased risk of chronic diseases and can predict an earlier death

Loneliness increases the risk for the development of psychiatric illnesses such as anxiety, depression and neurocognitive decline.

(Holt-Lundstad, Smith, & Layton, n.d., 2010, Holwerda et al., 2014))

”The Atrophy of Social Life”

Why are we so Isolated? In 1930 two % of the

population lived alone. By 2000 ten % of the population lived alone.

Mega-houses with spacious fenced in back yards

Air-conditioners, refrigeration, televisions and technology

Mobility and less job security

Senior living communities

(Eitzen, 2004)

The benefits of social supports

Potentially reduced risk for cardiovascular problems, some cancers, osteoporosis, and

rheumatoid arthritis

Potentially reduced risk for Alzheimer's disease

Lower blood pressure

Reduced risk for mental health issues such as depression

How do our Relationships with Others

Improve Health?

Being nagged by your spouse to have better health behaviors

Having a sense that you are loved, cared for and listened to

Social relationships enhance a sense of personal control

Social ties inspires persons to want to live healthier lives

Supportive interactions with others benefit immune, endocrine, and cardiovascular functions and reduces the body’s response to stress which decrease ”wear and tear”

(Eisenberger & Cole, 2012).

Do Relationships always Improve

Health? There is a dark side:

Poor marriages can lead to poor physical and mental

health

High care-giving demands

Raising grandchildren

Negative social environments contribute to increase

substance abuse and other unhealthy behaviors

Smaller families increases care-giver burden

(Eisenberger & Cole, 2012).

Using Interpersonal Theory to Target

Mental Illness

Based on the assumption that

all mental health issues are

connected to interpersonal

struggles

Altering relationship patterns

improves wellbeing and can

lead to healing

(MacNair-Semands, 2015)

Yalom’s Therapeutic Factors

Yalom (1995) defined therapeutic factors as "the actual mechanisms of

effecting change in the patient" (p. xi).

Yalom identified 11 factors that influence the processes of change and

recovery among group therapy clients.

In the Context of Therapeutic

Environment

Therapeutic/Curative Factors

Instillation of hope

Universality

Imparting Information

Altruism

Substitute family

Development of socializing techniques

Imitative Behaviors

Interpersonal Learning

Group Cohesiveness

Catharsis

Existential Factors

(Yalom & Leszcz, 2005)

11 Therapeutic Factors

Universality

feeling of having problems similar to others,

not alone

Altruism

helping and supporting

others

Instillation of hope

encouragement that recovery is possible

Guidance

nurturing support & assistance

Imparting information

teaching about problem and recovery

Developing social skills

learning new ways to talk about feelings, observations and concerns

Interpersonal learning

finding out about themselves & others from the group

11 Therapeutic Factors

Cohesion

feeling of belonging to

the group, valuing the

group

Catharsis

release of emotional

tension

Existential factors

life & death are realities

Imitative behavior

modeling another’s

manners & recovery skills

Corrective recapitulation of family of

origin issues

identifying & changing the

dysfunctional patterns or roles

one played in primary family

Valley Health’s Senior Outpatient

(SOP)Behavioral Health Program

The Winchester SOP opened on December 11, 2013

Offers an integrated psychiatric and medical approach to mental health

and wellness, specifically designed for those aged 55 and up.

450 persons have received services

Winchester Medical Center SOP

Developed as a result of Valley Health’s Community Benefit Assessment

This assessment completed every 3 years, consistently identifies the top 2

needs within the Shenandoah Valley=

Mental Health and Substance Abuse.

Long waiting lists in the area and lack of services which provide specialized

outpatient psychiatric treatment for older adults

Valley Health developed the Intensive Outpatient Program model to target

adults 55 and over requiring intensive behavioral health support within a region in

which many retired individuals reside.

SOP Services

Winchester Medical Center also has two inpatient psychiatric units which serve adults

and senior adults who can receive a continuum of care after their discharge to the

intensive outpatient program

Services offered at the SOP

Medication management,

Group/Individual/Family Therapy-

Primarily Group Modality,

Psychiatric Nurse Practitioner, Psychiatrist oversight and direction.

Case Management

Types of Group Therapy

Cognitive Behavioral Therapy,

Interpersonal Process Groups,

Psychoeducation

Psychotherapy

Admission Criteria

Patients aged 55 and up with a mental health diagnosis

Someone who is experiencing an acute or chronic psychiatric episode who is requiring

intensive behavioral health support for at least 3-11 hours a week.

Intensive Outpatient Program (IOP) is defined as at least 9 hours of service and most

individuals begin at this level.

The Senior Outpatient Program

The Senior Outpatient Program has expanded over the last year to also serve adults under the age of 55

Collaboration with the patient’s primary care physician and other

healthcare providers are strongly encouraged to ensure the best

continuity of care.

Typical length of treatment is 6-8 weeks

Outcomes

Decreased hospitalizations

Improved physical health

Increased physical activity

Establishing a routine

Improved health behaviors

Decreased reliance on medications

Improved communication

Improved coping skills

Assessments and Referrals

Our clinical staff offers free, confidential assessments to determine if

behavioral health services are needed.

Referrals to our program may be made by the family physician, nurses,

mental health professionals, assisted living facilities and others concerned

about the welfare of their family member, friend or loved one.

Patients can also self-refer into the program.

Two locations: Winchester and

Woodstock, VA

Program operates 5 days a week

Patients receive an individualized treatment plan developed based on the

needs that have been identified.

Patients set realistic goals, learn healthier coping skills and participate

actively in their own recovery

Diagnostic mental health evaluations by a psychiatrist/psychiatric nurse

practitioner and licensed therapist

Insurance Coverage

Insurance Services are covered by

Medicare and many commercial

insurance providers.

Valley Health’s financial assistance

department works with each client

individually to facilitate financial

viability when necessary.

References

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2006) Web-based Injury Statistics Query and Reporting System (WISQARS) Retrieved from: http://www.cdc.gov/ncipc/wisqars.

Eisenberger, N. I., & Cole, S. W. (2012). Social neuroscience and health: neurophysiological mechanisms linking social ties with physical health. Nature Neuroscience, 15(5), 669–674. https://doi.org/10.1038/nn.3086

Eitzen, S. (2004). THE ATROPHY OF SOCIAL LIFE. Society, (September/October), 12–16.

Holt-Lundstad, J., Smith, T., & Layton, B. (n.d.). Social Relationships and Mortality Risk: A Meta-analytic Review. Retrieved October 9, 2017, from http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000316

MacNair-Semands, R. R. (2015). Interpersonal Group Therapy. In The SAGE Encyclopedia of Theory in Counseling and Psychotherapy (Vols. 1–2, pp. 570–572). Thousand Oaks,: SAGE Publications, Inc. https://doi.org/10.4135/9781483346502

Mental and Behavioral Health and Older Americans. (n.d.). Retrieved October 10, 2017, from http://www.apa.org/about/gr/issues/aging/mental-health.aspx

Townsend, M. C., & Morgan, K. I. (2017). Essentials of psychiatric mental health nursing: concepts of care in evidence-based practice (Seventh edition). Philadelphia, PA: F.A. Davis Company.

Umberson, D., & Montez, J. K. (2010). Social Relationships and Health: A Flashpoint for Health Policy. Journal of Health and Social Behavior, 51(Suppl), S54–S66. https://doi.org/10.1177/0022146510383501

Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed). New York: Basic Books.