Helping People who Suffer from Dementia

This post reviews an article by Amano & Toichi (2014) about on-the-spot EMDR sessions for people suffering from dementia.

Dementia, as a group of symptoms caused by organic changes in the brain, is a disorder that may be diagnosed consequent to diseases such as Alzheimer's or stroke. The symptomology, when behavioral, manifests as irritability, aggressiveness, wandering, screaming, inappropriate interactions, hoarding, cursing and sexual acting out; psychological symptoms include anxious and depressed mood, delusions and hallucinations.

Dementia features may appear in early, moderate or late stages of the disease. The early stage finds the identified client presenting with confusion and forgetfulness but retaining some insight, while the moderate stage causes ever increasing memory problems and confusion, and inability to properly complete activities of daily living without help. In the later stage, the individual will not be able to recognize people or objects, will lose the ability to speak, will become incontinent, and will suffer from severe memory loss.

In addition, those in the later stage of the disease will lose touch with reality, believing they are living in a different time, and will present with restlessness and increased aggressiveness at night; eventually loss of speech will occur, with individuals only able to cry out.

The American Psychiatric Association's guidelines for therapeutic interventions for dementia include cognitive, behavioral, emotion and stimulation-oriented therapies, while The Group for the Advancement of Psychiatry Committee on Aging recommends reminiscence and validation therapeutic work as a way to help individuals in the early stage of dementia address and process emotions that arise from confusion, memory loss and disorientation.

Individuals in the later stage of the disease will need the care of a psychiatrist or geriatrician who will prescribe medications; a nurse liaison; a psychologist creating the treatment plan; and a social worker/case manager to integrate the family into the treatment plan.

Literature Review

Dementia-care nursing home residents may wander, scream, become agitated and restless, and exhibit violent behavior and speech; these behavioral and psychological manifestations may arise from previous traumatic events. These manifestations become ritualistic and can be compared to symptoms of PTSD. EMDR is an evidence-based therapy for PTSD and has been used with younger survivors of trauma; the current undertaking seeks to modify standard EMDR protocol to fit the needs of an older dementia population in later stages of the disease.

Methods

Three nursing home residents in moderate to late stages of dementia participated in the 4-6 session study after their relatives or legal guardians gave consent. Behavioral and psychological symptoms were frequent in these patients, and had progressed to severe physical aggressiveness and irritability, with incidents of screaming, restlessness, confusion, wandering and agitation perhaps enhanced by previous traumatic experiences.

On-the-spot EMDR was modified from standard EMDR protocols to fit the needs of the patients. Phases of the EMDR protocol were addressed in the following ways:

• Phase One, or history taking, was adapted to gather history from family members instead of the patients themselves;

• Phase Two, or the preparation phase, enables the formation of trust within the therapeutic relationship; in the case of patients with severe symptoms of memory loss and confusion, each encounter began with introductions and rapport-building;

• Phase Three assesses for target-memory reprocessing in standard EMDR treatment; on-the-spot EMDR assumes that memories are being acted out through uncontrolled emotions and behaviors;

• Phases Four through Seven focus on reprocessing material in standard EMDR practice using bilateral stimulation, either with eye movements, listening to tones, or holding buzzers which alternate output; on-the-spot EMDR utilizes the tapping method only;

• Phase Eight, or reassessment, utilizes chart review and staff observations to help determine success rates for the modified treatment.

When patients were in much later stages of dementia and expressing traumatic memories, EMDR followed a simple blueprint:

• the physical position of the therapist vis-a-vis the patient remained straightforward;

• eye contact was maintained by the therapist;

• the therapist used calm demeanor and speech to deescalate agitation and high emotion;

• the therapist repeated patient keywords and observed physical expression of emotion;

• the therapist used EMDR tapping to install feelings and cognitions of safety;

• when appropriate, and the patient was relaxed and no longer outside a window of tolerance, the therapist helped the participant develop inner, positive resources while identifying memories, sensations and images which were then be installed using tapping.

Results

All three participants benefited from the on-the-spot EMDR treatment and saw significant reduction and elimination of symptoms like screaming, cursing and physical aggression. The participants no longer endorsed or acted out distressing memories even after 6 months of treatment termination. These results surprised the researchers since study participants experienced severe cognitive deficits due to organic brain damage, including atrophy in the prefrontal cortex.

Discussion

Treatment-as-usual for dementia is effective only during the intervention itself. On-the-spot EMDR provided relief for up to 6 months post treatment . The resource development protocol matches reminiscence therapy since it facilitates the recall of positive memories; additionally, positive sensations can arise during tapping, and these, along with images, can account for return to and maintenance of a calm state.

Possible mechanisms of on-the-spot EMDR can be related to the reprocessing of traumatic material, the latter which may be enacted during aggressive, screaming and other episodes. Bilateral stimulation, and for these participants, bilateral tapping, can be seen as facilitating physical calming, desensitization of memories experienced as distressing, and enhancement of recall.

The authors of the study conclude that dementia may require a PTSD-like syndrome modifier which can be treated in a non-pharmacological manner using 4-6 sessions of on-the-spot EMDR with a therapist, and continued tapping moments from a caregiver.

- Amy Discepolo, LMHC, EMDRIA Certified Therapist

As a certified EMDRIA therapist, I am available to consult with you about this type of short programming that you can implement in your facility/agency. Please contact me with any questions at info@gentletherapyplace.com or call 904-344-8320.

References

Amano, T., & Toichi, M. (2014). Effectiveness of the on-the-spot-EMDR method for the treatment of behavioral symptoms in patients with severe dementia. Journal of EMDR Practice and Research, 8(2), 50-65.

Post-Crisis Communities

How can the field of mental health care best address the problem of systemic trauma at the international and community levels?

Post-crisis communities suffer from disruption in aid services, blocked access to relief, and traumatized populations without recourse. These communities are located within systems that may face chronic instability and therefore need organizations dedicated to growing beyond crisis using less regimented and paternalistic structures in favor of more focus on collaboration and fluidity (Brady, 2019; Lauder & Marynissen, 2018; Mihelicova et al, 2018).

Within the international world, the World Health Organization (WHO) outlined its mental health action guide in 2004 as a set of principles for mental health providers to follow. The recommended actions call for supporting various post-crisis crisis communities in the promotion of mental health well-being while attention to factors that result in long-term disability are addressed at the community and group level, with sensitive easy-to-implement interventions (Brady, 2019).

Without sensitivity towards those who have encountered trauma, practitioners may view and treat populations through a specific lens, furthering stigma and oppression (Mihelicova et al, 2018). The mental health practitioner who is consulting in such a situation will play multiple roles, including directing how connections are set up between stakeholders, designing collaborative models for organizations to utilize for the long-term, implementing evidence-based interventions, and bolstering already existing services. In addition, the consulting or community psychologist will ensure trauma-informed care serves everyone affected by crisis, homelessness, war, poverty, violence, and other systemic violations (Brady, 2019; Mihelicova et al, 2018). Even with their best practice and evidence-based approaches, psychologists are still challenged to translate their knowledge into practical applications in all kinds of settings, including non-crisis environments. When help is required at an international level due to war or other catastrophic events, consulting psychologists will be called on to create change at the organizational level while staying open to and mindful of cultural factors, infrastructure and technical operations, and sustainability of new models and developments (Brady, 2019).

Trauma-informed service delivery (TISD) targets the gaps between those whose needs are complex and usually not addressed due to barriers within and outside of the traumatized person or populations, and the services that will be delivered at the psychic, interpersonal and social levels. TISD works with several important principles which include fostering awareness of the impact of trauma, engaging trust and collaboration, and empowering survivors to seek choices in how they go forward, with an attention to client safety (Brady, 2019).

TISD principles support a framework for implementing organization-wide change only when trauma-informed care is not restricted to applications of specific interventions. These may not take into account broader structural dynamics like a community's history of deficits and possibly violence, poverty, homelessness and street living, organizational policies which have to choose between safety and re-victimization, and ingrained staff attitudes and cultural characteristics, all of which may lead to consequent re-traumatization (Brady, 2019; Mihelicova et al, 2018).

Trauma-informed services should also note that psychosis may arise not from organic, brain-centered or the usual, expected mechanisms functioning within a medical model, but instead emerge as a consequence of traumatization due to circumstances and events present in daily living (Mihelicova et al, 2018).

Additionally, first responders, families and clients all require psychoeducation on recognizing symptoms and seeking help, readily available at all times, in trauma-informed and appropriate ways (Mukherjee & Saxon, 2019). Clients should also be informed as to how long the helping intervention will be expected to last, thereby conferring upon the client agency and a sense of stability (Hatchett, 2020).

Trauma-informed and sensitively-administered therapeutic interventions can be successfully implemented to address post-crisis situations on an international level while also remaining relevant to local community needs (Brady, 2019; Mihelicova et al, 2018; Mukherjee & Saxon, 2019).

Understanding that events can't neatly be translated into specific therapeutic responses, and that people react to chaos by exhibiting behaviors and symptoms similar to those diagnosed in mental illness, can help shape an appropriate atmosphere in which trauma survivors find support (Brady, 2019; Mihelicova et al, 2018; Mukherjee & Saxon, 2019; Lauder & Marynissen, 2018).

Discussion

Chaos and crisis can be viewed as large-scale events impacting whole populations. Humanitarian, organization-wide projects which bring together various stakeholders in an effort to treat traumatized victims can have successful outcomes when certain trauma-informed principles are in effect. These principles include establishing trust within and between organizations and stakeholders, project transparency in order to instill a sense of safety, many opportunities for stakeholder participation, improving on communications through active collaboration, encouragement of stakeholders to discover their own empowerment, implementation of learning exchanges, and modeling of principles (Brady, 2019).

Retaining flexibility when assisting others in managing crisis, whether small or large, entails understanding not only how trauma-informed principles can be translated into practice, but also that rules made to conform to certain variables may have an opposite effect when rigidly retained in fluid situations. Organizations need to realize how their interdependence, stakeholder micro and macro-dynamics, and constantly changing reactions need continuing realignment and adaptation (Lauder & Marynissen, 2018).

Health care providers should keep in mind that that oppression can take on various forms – both overt as in catastrophes, and covert as in embedded racism – and should design their spaces and modulate their presence and interactions so that survivors and victims can feel safe enough to receive and benefit from services (Mihelicova et al, 2018).

Second-order change across organizations can be facilitated by consulting or community psychologists who will use strategies to increase collaboration, empowerment, and coalition-building. Both welfare of clients and provision of necessary services should act as common goal and intended mission (Brady, 2019; Mihelicova et al, 2018). When in-person therapeutic interactions are not possible due to outside circumstances or intrapsychic challenges, tele-health should be widely available (Mukherjee & Saxon, 2019).

Recognition that trauma-informed care – with its sensitivity to culture, history, ecology, family dynamics, stressors, oppression of all kinds, and the effects of widespread crisis – when implemented across organizations, can foster a newfound understanding within practitioners themselves who may then go on to reshape their work environment, policies, and outlook on life ((Brady, 2019; Lauder & Marynissen, 2018; Mihelicova et al, 2018).

True engagement in the process of constructing and implementing trauma-informed care comes about through active stakeholder participation as these members of various disciplines and entities are encouraged to reveal their situations, needs, and questions, and collaborate on shaping the training they will give and receive (Brady, 2019).

The consulting psychologist facilitates growth by offering evidence-based trauma-informed psychoeducation and training. Facility or organization members can then take useful paradigms and work together to translate their knowledge to their own special circumstances (Brady, 2019; Hatchett, 2020; Lauder & Marynissen, 2018; Mihelicova et al, 2018).

Community and consulting psychology can use transformative approaches to address power imbalances, facilitate empowerment, and help both practitioners and clients recognize the influence of the environment, including the systems and operations to which agencies must conform, as one which has important repercussions for individual and collective mental health (Mihelicova et al, 2018).

- Amy Discepolo, LMHC, EMDRIA Certified Therapist

(This article is reprinted from Bloom Behavioral Health)

References

Brady, L. L. (2019). Connected world, connected profession: Increased recognition of opportunities for local and global engagement by psychologists in postcrisis communities. Consulting Psychology Journal: Practice and Research, 71(1), 47-62.

Hatchett, G. T. (2020). Anticipating and planning for the duration of counseling. Journal of Mental Health Counseling, 42(1), 1-14. http://dx.doi.org/10.17744/mehc.42.1.01

Lauder, M. A., & Marynissen, H. (2018). Normal chaos: A new research paradigm for understanding practice. Journal of Contingencies and Crisis Management, 26(2), 319-323. http://dx.doi.org/10.1111/1468-5973.12189

Mihelicova, M., Brown, M., & Shuman, V. (2018). Trauma-informed care for individuals with serious mental illness: An avenue for community psychology's involvement in community mental health. American Journal of Community Psychology, 61(1), 141-152. http://dx.doi.org/10.1002/ajcp.12217

Mukherjee, D., & Saxon, V. (2019). “Psychological boarding” and community-based behavioral health crisis stabilization. Community Mental Health Journal, 55(3), 375-384.

Chronic Illness in the Family - Part 2

How Therapy Can Help Families Navigate Chronic Illness

Our previous blog post looked at the impact of chronic illness on a family system, along with important features to be addressed by a medical family therapist. A family therapist, or an EMDR therapist may also explore how family dynamics change when a chronic illness disrupts daily routines, family member identities, family relationships, and future goals.

Understanding the Biology

A therapist who is helping a family through the changes that accompany a chronic illness diagnosis will seek to understand its biological aspects. The therapist will consult with those medical providers who are involved in treatment and care through conference talks that include both family and patient.

A humble focus on the patient's experience gives the medical therapist, family therapist, and EMDR therapist the correct stance and curiosity necessary to help those in distress.

History, Meaning and Healing Medical family therapists, family therapists, and EMDR therapists will begin to elicit from family members their individual and personal narratives. This gives every family member the chance to express who she or he is apart from the illness; this also gives family members a forum in which they can speak about hopes and fears.

Hopes and fears contribute to making meaning about the illness. When family members can speak freely about their inner worlds, they find a safe place in which to explore their own belief systems. In addition, through encouraged expression of hidden hopes and fears, more history can come to light. When elicited without judgment, this type of expression can prove to be healing in its own right. Meaning equates with healing.

To Respect is to Accept

A good therapist will always take note of feelings of blame, shame or guilt, and will use pertinent psychoeducation to help families understand the dynamics between illness and these emotions. Education, along with the processing of difficult feelings, give families and patients relief, and present a path towards a fuller acceptance of self and the conditions in which the family finds itself.

In addition, providing information on strategies for coping should help families find appropriate supports within the family system, online, and in various support groups, some of which already exist within primary care settings. Communicate! The medical family therapist, family therapist, and EMDR therapist are all concerned with facilitating the acknowledgment of feelings in whatever time frame feels most comfortable for each family member. Opening up communications between patient and family members gives everyone a chance to unburden himself or herself, while continuing to accept unacceptable and difficult feelings.

Also, when families and patients understand how the medical community conceptualizes specific treatments, expectations on both ends can be tempered and managed.

Developmental Stages Matter A chronic illness can affect a family at any stage in its development, whether, for example, at inception when a couple first gets together, or during the phase when children leave the home, The therapist will help families understand these natural stages as they impact both individual and family life.

The therapist can provide examples of how others fare and cope, and can provide information about where each family member may be finding himself or herself in the moment. A Different Way of Seeing Things Asking families to imagine the illness as something external is a technique which can help families remember how they used to function before the illness manifested. This kind of therapeutic intervention helps families envision how they could manage their lives after they have put the illness in a rightful place. This externalization can be done through story-telling, art-making, role-plays, visualization, and various EMDR techniques.

When Families Feel in Charge

Family sense of agency means that families feel in charge of their lives. The therapist can help families increase a positive take-charge feeling by:

• helping families understand and work with their medical providers to collaborate on treatment;

• helping families incorporate enjoyable activities into daily living;

• providing positive reinforcement for effective family responses to illness;

• and rehearsing with families how they would like to respond to friends and neighbors, or anyone else who may be curious about the illness. Connection after Isolation Families may have spent time isolating themselves due to the exigencies of a chronic illness. They may have been struggling with identity issues, treatment logistics, breakdown in communication, disruption to schedules, misunderstandings, and confusion. Helping families recognize and process these challenges is the first step.

After some time, the therapist can help family members learn how to invite others into their lives; this can lead to a sense of connection. When we forge bonds with others, we exchange with them deeper thoughts and feelings. This gives our lives meaning.

Summing It Up

These posts have examined how therapists can help family members and patients deal with chronic illness. We've looked at some ingredients that make for beneficial therapeutic encounters. Discovering meaning through the process of becoming intimately acquainted with one's own and others' strengths and vulnerabilities can lead to satisfaction, a sense of accomplishment, a measure of control, and a way to accept life's varied circumstances.

- Amy Discepolo, LMHC, EMDRIA Certified Therapist

(This article first appeared in Bloom Behavioral Health)