Journal of Rural Community Psychology,
Vol. 2, No. 2, 1981
Rural Mental Health Service
Delivery To The Elderly
John H. Kirchner
Great River Mental Health Center
Muscatine, Iowa
Abstract
Senior citizens tend to underuse men health centers. Described is the
delivery system of a rural community mental health center in which 13.6%
of those receiving direct service were 60 or older. Additional elderly
people were reached through consultation and community education-prevention
programs, which also are discussed. Evaluation measures pertaining to the
delivery system from related studies are considered.
Since the elderly often are beset by financial problems, the most logical
place for them to seek mental health services is the community mental health
center (Wilensky & Weiner, 1977). Federally funded centers are mandated
by Public Law 94-63 to provide programs for senior citizens. Persons over
65 years of age comprise 10% of the U.S. population. Yet, less than 3%
of the elderly are seen in outpatient centers (Dye, 1978; Gilbert, 1977).
In 1970, 12.3% of the population of Muscatine County was over 65 years
of age. Estimates from the 1980 Census place the figure at 11.9% (Note
1). At the Great River Mental Health Center, serving a blue collar rural
county of 37,181 in Muscatine, Iowa, persons over 65 represent 8.46 % of
the case load. Another 5.15 % are between the ages of 60 and 64.
Based on 1970 census figures, data provided by the National Institute
of Mental Health for Muscatine County (Note 2), indicate a 21.9% age dependency
ratio (number of persons 65 and older per 100 person population), a 30.2
% incidence of elderly in poverty, and a 12.1% figure of aged persons living
alone. While the percentage of persons over 65 in the Center's caseload
does not equal the percentage of elderly in Muscatine County, the Center
is reaching a far greater proportion of elderly than the average mental
health center.
It is the purpose of this paper to detail an effective delivery system
for the elderly, which can be divided into direct clinical service, services
to other care providing agents, and community education-prevention services.
These categories are not mutually exclusive.
Delivery System
Direct Clinical Services
Among the assumptions concerning services to the elderly reported by
Smyer & Gatz (1979) are that aging is a life span developmental process
and that it is inappropriate to work with senior citizens in a traditional
manner in a traditional setting. I have no disagreement with the first
assumption. However, a blanket generalization for the second assumption
is not warranted. The elderly, like most other people who refer themselves
to mental health centers, perceive some kind of serious problem in their
lives (Kirchner, in press-a,b). Those who have had a previous developmental
crisis and who formerly have had a favorable experience with mental health
services often are predisposed to want these services again.
The means of entry for this subgroup of senior citizens into other
community services may be through the mental health center. Since mental
health services are what these senior citizens know, they tend to attach
less of a stigma to receiving mental health services than they do to services
which definitely connote poverty (e.g., food stamps). Part of the way in
which the therapist helps these individuals is to work with their attitudes
toward accept, at least temporarily, other existing community support systems.
Senior citizens often have a value system similar to Longfellow's village
blacksmith ("...and he looks the whole world in the face, for he owes not
any man"). Gilbert, (1977) astutely points out the importance of not hurrying
the elderly in therapy, of letting them present things in their own way.
It is equally important in working with senior citizens to let them pay
their fee and to accept their handmade gifts. Such human factors help them
preserve their sense of self-worth.
Three major problems that psychologists anticipate in people 60 years
and over are: (a) developmental crises, (b) reorientation due to proximity
of death, and (c) waning physical and psychological vigor (Dye, 1978).
Within these contexts, therapy still is needed for the retired person who
considers social, recreational, and/or senior citizens' activities frivolous,
for the man with cancer who is receiving estrogen and is concerned about
his body becoming feminine, or for the elderly spouse who knows it is a
matter of time before the ailing mate dies. Elderly persons under stress
often label themselves "crazy" and wonder if they should be hospitalized.
Alternative therapeutic and support systems are new to them. As with younger
patients, part of the therapy is educative.
Flexibility of location is important in mental health service delivery
to the elderly. Rural people tend to accept mental health for others cognitively
before they accept help for themselves behaviorally (Rabkin, 1974). Going
in to their homes often is a prerequisite to their being seen in an outpatient
center. This usually happens when the wife desires marriage counseling
and the husband "will never go to a center because somebody might see him."
As they continue with services, senior citizens are encouraged to visit
the center since limited staff resources make center located services more
cost effective. But, there are times, especially in winter, when the aged
person with a broken leg will require delivery of therapeutic services
in the home. Community health nurses have long recognized such circumstances.
To work with the elderly, mental health professionals also must recognize
these circumstances.
Screening is an integral function of service delivery to the elderly.
The initial center contact may come through sons and daughters, who have
concerns about their mother's or father's different behavior. Sometimes,
these elderly parents reside in another part of the country. Their children
wonder about bringing the parent to live with them, about nursing home
facilities, and/or institutionalization. In other instances, it may be
the landlord or neighbor who makes the initial referral of the elderly
person living alone. Perhaps a community health nurse requests that a mental
health professional accompany her to a couple's home. The wife has Alzheimer's
disease and the husband is trying to care for her. The nurse has questions
about the husband's capacity to cope with the situation. Community supported
mental health centers have a definite obligation to respond to these kinds
of community needs. The screening may involve outpatient therapy and/or
other services.
Direct services for the elderly may involve formal diagnostics.
It generally is reported that incidence of mental illness is lower in rural
than in urban areas (Dohrenwend & Dohrenwend, 1974). Kisker (1964)
has considered migration, less stress in rural areas, and lack of integration
of religious, occupational, and social groups in the cities as causative
factors. Millon (1969), cites as possible explanations the more benign
environment in the country and/or the ability of rural dwellers to care
for the mentally ill at home. These positive factors for rural areas do
exist, but the effects of poverty and isolation for the rural elderly also
exist (Youmans, 1977). For example, another side of the coin is the
person who 50 or more years ago was thought to be mentally retarded and
whose parents allegedly were told by school officials that he or she was
unteachable and should be left home. Sometimes the rural families of these
children, who were somehow different, kept them out of sight. Sometimes
these individuals also were culturally deprived. Now these former children
are senior citizens. Their former natural care givers are deceased or require
care themselves. Traditional psychological evaluations including intelligence,
achievement, personality, and/or vocational components often are necessary
to assist in determining the level of functioning of these lifelong, homebound,
senior citizens. Perhaps they are eligible for some form of assistance.
Perhaps they can function in a sheltered workshop. Those considered for
workshop placement often are required to have a psychological evaluation.
Differential diagnosis can aid in formulating their individual program
plans in a workshop. It also can help the aged person's self-esteem (e.g.,
someone labeled "dumb" or "stupid" for decades often is encouraged to know
that the problem is a learning disability and not retardation).
There are still other elderly people who will need re-evaluations,
in order to retain their current supplemental social security income. Still
others will be required to have them to continue in a workshop placement.
Diagnostic services also are important for elderly persons involved
with the judicial system. Being a danger to oneself or others, or being
competent to handle one's affairs are criteria used by the courts. There
are elderly people who can continue to live independently and who can manage
their finances. There are also those who cannot, and who require a guardian,
or institutionalization, or court-committed outpatient care. Mental health
professionals can aid the legal system in these matters. Eschewing forensic
evaluations by psychologists is not going to be helpful to the elderly,
their families, the physician, the patient advocate or the judge. Avoiding
these evaluations also is not going to result in improved assessment methods.
By saying we can't, we don't.
Services to Other Care Providing Agents
It is estimated that 5% of people over 65 years of age live in institutional
settings (Kalish, 1975). Many of them reside in nursing homes. Since Hyerstay
(1979) has defined nursing homes, there is no need to repeat the definition
here. He also has stated that psychologists are rarely found there and
that there are ill-defined and often conflicting role expectations. Nursing
home patients may either be paid for privately or supported by public funds
such as Medicare or Medicaid.
At first, nursing home referrals to the Great River Mental Health Center
involved crisis intervention. Usually a resident had become assaultive
or engaged in some sexually inappropriate behavior. Depending on the individual,
the elderly person might be worked with directly or a behavior modification
plan might be formed. Later, persons with other problems were referred,
such as residents who would not leave their rooms, or ones who became depressed
because their children were moving away, or ones who were exhibiting paranoid-like
symptoms. Flexibility again was the key. Some nursing home residents were
serviced there; others enjoyed getting out and going to the center.
In time, the crisis intervention, diagnostic, and other direct service
activities diminished, and the mental health professional role included
increased consultation. A federal consultation and education grant facilitated
the change. Only those residents who received direct services were considered
mental health center patients in the 13.6% case load reported earlier.
Contracts with all nursing homes in the country provided (a) case consultation,
which involved programs for residents who were not center patients; or
(b) staff development, which included talks and group discussions on topics
such as depression, death and dying, etc., in which nursing home staff
had expressed an interest.
In Iowa, county care facilities provide residential, medical, therapeutic,
and educational services to people with emotional and/or developmental
disabilities, often of long duration. These institutions help maintain
people in their home community where they can more easily retain contact
with families and friends. Many of these residents are senior citizens.
By providing direct service and consultation to the county care facility,
the center was able to meet another community need in serving the rural
elderly.
A third method of service delivery to institutionalized senior citizens
is inclusion of monthly visits to the geriatric ward of the mental health
institute (state hospital) as part of the aftercare program. Contact is
maintained. Improved continuity of care also results when geriatric patients
return to families, nursing homes, or county care facilities. Serving as
a liaison is part of the role of mental health professionals with other
care providing agents to the elderly. Often a nursing home administrator
will feel easier about accepting a new resident from a mental health institute
when there is a personal report from a community based psychologist who
recently has seen that resident.
Community Education-Prevention Services
Community education is also a prevention service to the elderly. Con
contacting senior citizens organizations, the commission on aging, retired
teachers' organizations, etc., and offering to give talks, lead discussions,
or conduct groups is still another means of reaching the elderly. Senior
citizens contacted in this manner are not included in a community mental
health center's case load, but a record can be maintained of the programs
and the people in attendance.
Programs about retirement, information about mental health services
to the elderly, and information like that included in Lobsenz's (1975)
"Sex after Sixty-five" or in Masters & Johnson's (1970) chapters on
the aging male and female usually are of interest to senior citizens. They
also help to dispel myths on these topics.
Awareness of programs of other service providers to the elderly also
is essential to service delivery. The Iowa elderhostel program through
which senior citizens can attend specially designed courses at universities
during the summer is but one example of the type of program that psychologists
work with senior citizens need to know about. Witnessing the personal growth
and exuberance of a senior citizen with an elementary school education
who had attended one of these enrichment programs is convincing evidence
of the program's worth.
Evaluation of the Service Delivery System
One measure of service delivery is the fact that the program described
above accounted for 13.6% of the case load and reached more elderly people
through consultation and community education activities.
In related research at the Great River Center, questionnaires mailed
to former center patients 13 years of age and over who received direct
mental health services revealed that the vast majority felt that the counseling
or therapy helped them and that the therapists were interested in them
(Kirchner, in press-a). These results occurred in two successive years.
Patients over 55 constituted 10% of the sample in 1975-1976 and 12% of
the respondents in 1976-1977. The overall response rate for 1975-1976 was
40% (N = 80) and 53% for 1976-1977 (N = 173). Results from
both years also indicated that age appeared to have no statistically significant
relationship to the degree that the person felt helped or the perceived
interest of the therapist in them. Relatively comparable data obtained
from the Jasper County Mental Health Center in Central Iowa, which serviced
a county of 35,425 in 1980 and has a 55.9 % rural population, yielded the
same results (Kirchner, in press-b). Those data were obtained for 1978-1979.
The response rate was 60% (N = 73) and 7% were older than 55 years
of age. From the three samples (N = 325) on the age-perceived degree
of therapeutic help interaction, when the older than 55 age group is compared
with those aged 13-54, 85% (28 of 33) believe they have been helped to
some extent by counseling or therapy, versus 89% (259 of 292) of the younger
age group. Forty-two percent of the elderly (14 of 33) felt extremely helped,
compared with 28% of the 13-54 age group (82 of 292).
For the general picture of the age-therapeutic help variable, the follow
up results reported here appear to support Blum and Tallmer (1977) who
cite six studies in which there was no significant relationship between
outcome of therapy and age of the patient. Further research may uncover
other unknown factors which may be operating.
Service delivery through consultation to the agencies providing care
to the elderly was not conducted separately. One evaluative criterion,
however, is that the five nursing homes and the county care facility did
renew their consultation contract with the center. All organizations that
contracted for consultation during 1977-1978 were asked to evaluate it
(Kirchner, Note 2). Agencies servicing elderly people were part of those
contacted. The agencies felt that the mental heath consultants were open
to criticism and to follow through.
As part of a county-wide needs assessment to county residents (Kirchner,
1981), the community education-prevention delivery system also was evaluated.
Overall, 77% of the respondents knew of the mental health center and 57%
were aware of its location before they received the questionnaire. Of the
respondents, 43% were 55 or older. Analyses comparing them to younger respondents
on knowledge and location of the center were not significant. The elderly
were as well informed as other age groups.
Overall, 20% of those who heard center programs found them very in
formative and another 50% rated them informative. No one marked that they
were dissatisfied or extremely dissatisfied with the talks. For those 55
and over, separately, 32% found the talks very informative and 44% thought
them informative.
Conclusions
In summary, a greater proportion of senior citizens can be served by a
rural mental health center if it provides direct mental health services,
services to other care providing agents, and prevention services. Related
evaluative data, gathered from the county served, indicate that there are
no significant differences between the elderly and younger people in terms
of satisfaction with therapy and counseling, knowledge of existence of
the mental health center, and satisfaction with preventive talks. Other
care providing organizations (i.e., nursing homes) also appear to be satisfied
with consultation efforts.
Reference Notes
1. Miller, G. Iowa Commission on Aging, Des Moines. Personal
interview, 198l.
2. National Institute of Mental Health. Mental health demographic
profile system: Muscatine. selected data
from the 1970 census, Rockville, Maryland, 1970.
3. Kirchner, J. Evaluation of consultation services: Muscatine County.
(Available from 2009 First Avenue East,
Newton, Iowa, 50208).
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