Behavioral Therapy for Psychogeriatric Patients: The Role of Positive Reinforcement
It is a common prejudice that older people are very innocent and behave like children; perhaps, both are more or less the same with respect to their behavior and dependency. Moreover, it is considered as an easy task to hit the desired outcome in both the ages with the help of presenting gifts or positive reinforcement. The concept of positive reinforcement plays very powerful and effective role in shaping and modifying behavior in all human beings. It works by presenting a motivating item to the person after the desired behavior is exhibited, making the behavior more likely to happen in the future.
In mental health nursing, the concept of positive reinforcement was introduced under the umbrella of behavioral theory, proposed by Ivan Pavlov. Later, Thorndike observed that desirable behaviors are strengthenedby rewards and weakened by punishment, he named the phenomenon as “law of effect”, which later led to the development of operant conditioningby Skinner. Thus, positive reinforcement is a key concept within the field of behavior analysis in the discipline of psychology and a method of training using a reward-based system, the technicalities of defining behavior and its result, (Angela.F, Hanna.A.S.N & Patricia.D.S, 2012).
It is really interesting to unfold the psychiatric concerns while dealing with geriatric patients because the nurse-patient dealing is not as simple as it seems. There is a variety of mental health needs to be addressed if identified thoroughly and timely with an excellent skill of assessment through communication. It is a clear truth that geriatric mental health is the most neglected area of the general health care system globally. Even if we consider the millennium developmental goals followed by Millennium Summit of the United Nations in 2000, we can easily see psychogeriatric health as the least important area because it covers all the fundamentals of health and even talks about gender inequity but not geriatric mental health.
This highlights the need to focus upon the elderly patients. According to the consultant geriatrician at Shifa International Hospital, Dr. Shahzad Khan states,“with around 10 million of the Pakistani population comprising of elderly persons, the average life span among elderly persons in Pakistan is growing and there would be more demand of health care facilities for them in the years ahead” (2012). In addition, there are many nursing homes for senior citizens in our country but unfortunately they are lacking in trained psychogeriatric healthcare providers which accelerate the burden of diseases nationally as well as globally. However, the therapeutics dealing with human behavior are considered to be a vehicle that promotes mental health because they provide the strong bases for most of the treatment modalities related to psychiatric disorders.
During my mental health community clinical, I found a 60 year old male patient who had returned from USA a month ago and was temporarily staying in one of the famous nursing home for the purpose of medical treatment although his wife was staying at her parents’ home. It was really interesting and new experience for me as it has been my prejudice that older people are very innocent and reflect more childish behavior as they progress with their age. My patient always asked for a candy whenever I met him and inquired about my own family. Moreover it has been observed that the staff also used this weakness by committing to present a candy in return of the desired task.
Initially, I found it appropriate due to his age so I began bringing a candy daily for him but upon further visits, my patient increased his demand by asking for 2 or more candies. I got alarmed on the 4th day when I brought 2 candies and then he passed an inappropriate comment regarding me and my personal life. He broke the nurse client therapeutic relationship and started inquiring about my own family, his attitude reflected as being more interested in my family discussion rather then securing his own health. My patient pretend as being very innocent but use to discuss my personal life and decisions on various scenarios on daily basis and start giving inappropriate advice which are not relevant to the clinical area.
In contrast, it has been observed that he is delivering false information regarding his care like he has the problem of urine incontinence for which he has to wear the diaper continously, but he usually forgot to tie the diaper upon using the washroom, wet the bed daily, never admit his problem and mostly stay in denial phase which ultimately compromised his personal hygiene, leading to many infections.
Here came the climax where I got stuck with my prejudice but then I made up my mind to set some professional limitations in this clinical relationship. I was shocked to observe that as soon as I refused to bring candy and stopped discussing my own family, my patient’s attitude changed drastically. He started behaving rudely and did not cooperate with me during his actual clinical care like taking bath, medications, monitoring vital signs and taking meals but I remained consistent by maintaining a therapeutic relationship with the help of therapeutic communication skills and by drawing a fine line of professional boundaries of nurse patient relationship. After 3-4 days, my patient got settled gradually. This reason persuaded me to select this unique topic to reflect and learn more about this concept.
In the shared scenario, positive reinforcement and the signs of disinhibition are clearly visible which needs to be managed properly. The possible reasons for disinhibition includes an exaggeration of a life-long pattern, thinking a nurse or other member of staff is your partner, misinterpreting the purpose of personal care and longing for intimacy (Krishnamoorthy. A & Anderson. D, 2011). I think that sometimes we leave behind all the knowledge and deal with the patients naturally by forgetting the professional boundaries and it mostly happens when we are dealing with elderly patients due to the eastern values and norms of paying respect to the elders but we need to understand that professional boundaries are the spaces between the nurse’s power and the patient’s vulnerability. In relationships with any level of comfort and closeness, boundaries are needed to separate individuals appropriately,(Adibelli. D & Kilic.D, 2012). It is now clear that maintaining a therapeutic relationship in psychogeriatric patients is really challenging and requires certain settings and having control over self-disclosure while being empathetic.
Nurses provide the front line in health care for older adults in a wide variety of settings, including preventive care in primary settings, in the community, acute care in hospitals, and long-term care in nursing homes. A nurse may choose to use self-disclosure when it is determined that the information will therapeutically benefit the patient otherwise it should be strictly prohibited, as according to the scenario, I was also sharing my personal details initially but later on I stopped. The following strategies are helpful to improve the quality of care and could be implemented while caring for elderly patients with mental disorders and managing behavioral disturbances:
- Staff patient relationship should be professional and therapeutic.
- Limitations should be set initially and strictly followed by the health care providers.
- Active listening and understanding the person’s emotions is very important.
- Staying calm and being in control is essential.
- Avoid physical contact, confrontations, blaming and maintain personal space.
- Always acknowledge the inappropriate behavior of the patient.
- Frequent demands by the patient should not be entertained.
- Positive reinforcement could be implemented to achieve the required output instead of misusing it for undesirable and routine tasks.
- Provide reassurance and redirect attention using distraction techniques.
- Counselling should based upon the cognitive-behavioral interventions.
According to Grady.P.A, the overall challenge for team members is maintaining internal balance in relation to the patient and in feeling, thinking, compassion, objectivity, closeness and distance within the context of the patient’s precarious internal stability (2011). In order to deal effectively, the mental health team should comprise of highly skilled staff to identify the hidden areas that alleviate mental suffering and its tactful handling. The current health care system serves mentally ill older adults poorly and is unprepared to meet the upcoming crisis in geriatric mental health (Cassum.L.A, 2014). To work on this learning area, all the health care providers should strictly abide by maintaining therapeutic communication skills and avoid misusing the helping tool of positive reinforcement. As Jones.S.H discussed that it is crucial for clinical social workers to help the team develop a good understanding of patients’ life experiences and histories in order to respond with a balance of empathy and limits (2008).
In a nut shell, this clinical experience has completely changed my preset mind of being sympathetic with elderly patients by integrating the learnt knowledge of basic mental health concepts. In addition, I must say that mental health should be considered equally along with other health components like maternal and child health, and could be included as the 9th millennium goal for the future to bring ultimate change in the burden of future diseases. In reference with the reviewed literature by George1.J, Adamson. J & Woodfard. H (2011), there is a need to strongly raise the term psychogeriatric health to establish joint clinical settings and this paper also addresses the need for health sector to prepare for the upcoming “agewave” by training the necessary number of mental health professionals to enhance the effective health education focusing upon highly skilled and specialized care to all the elderly patients to preserve their better mental and physical health.
There is no doubt in saying that, stereotypical and traditional views of aging reflects negative perspective dominated by disability, poor health, mental illness and functional limitations but, recent research reveals that older persons typically age well (Myers, 2003); are resilient in responding to stress, transitions, and change (Myers & Schwiebert, 1996); and experience a lower incidence of mental illness than do persons of younger ages (Smyer & Qualls, 1999).
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About the Author: Rozina Rahim Hirani graduated as post RN BScN last year from Aga Khan University, Pakistan and now is working as a coordinator in the same hospital. She can be reached at [email protected]
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