[This blog is part of a series of blogs commissioned by ELDAC to support aged care health professionals and care providers in providing end of life care. You can find more information on the ELDAC website.]
Older adults can experience a vast array of mental health issues: complicated grief (see Part One of this blog series), change related stress (not to mention the impact of COVID-19), depression, anxiety or panic, unresolved trauma, and frustration living with a multitude of disabilities and/or experiences of physical discomfort.
In my therapeutic work, I have a smorgasbord of evidence-based options for treatment, and the modalities that I find most useful for work with older adults include Acceptance and Commitment Therapy (ACT), Mindfulness-Based Interventions (MBI), Cognitive Behavioural Therapy (CBT), Interpersonal Therapy, Narrative Therapy, Dignity Therapy and Reminiscence Therapy. If that were a psychological buffet your eyes would be bulging with the choice! However, so you don’t get indigestion I will only share here about Acceptance and Commitment Therapy (ACT) and how it can be adapted to a senior clientele.
If you read the first blog in this series about grief, it might be worth mentioning here that even leaders in ACT are cautious when using the word “acceptance” lest it lead to a crippling sense of failure or frustration that one has not “accepted” their lot. My two favourite synonyms or phrases here are “allowing for” or “making room for”. You encourage the person to make room for the emotional pain – care for it – even if they don’t like it or want it. You suggest that they allow for the reality that they find themselves in – as well as grieving it – but minus the struggle or fight which can often just add to their distress and magnify experiences of physical discomfort.
One example from my experience of using ACT for an older client is shared below:
Example Story: As I turn the corner into Mr Bright’s room, I am surprised to see him sitting in his wheelchair. I have suggested this to him before, but he had complained about the effort it took for staff to get him organised. He answers my raised eyebrow with, “Well, I can’t just wither away in there,” and looks at the bed. I agree and feel chuffed. There are other signs that Mr Bright is engaging more in life and being responsive to his world. The curtains that once were drawn, strangling out the light, have been flung open these last few sessions at my urging. Today there is also a gentle breeze blowing which brings with it the smell of blossom. Perhaps, I think, it is time to go deeper.
If I was with a younger client I might already be “dancing around the hexaflex” - a model consisting of six interchangeable concepts and practices: present moment awareness, acceptance, cognitive defusion, the observer self, connecting to values, and committed action.  With Mr Bright, however, explanations or exercises common to ACT might be too abstract or effortful for his situation. Instead, I reach into my bag and get my values cards. I give him only seven at a time. “Just pick one in each group that you relate to the most. Our values can represent who we are – those things that have always been important to us and can still be even if we are in really different circumstances. Values are who we are inside – no matter what.” He chooses ten overall, “belonging” being the one that speaks to him the most.
At another time I help him “notice five things” of what he can see, hear and feel. This has helped other residents in giving them a wide appreciation of their experience – not just what’s going on in their head – but for Mr Bright it only amplifies the reality of where he is and how ravaged his body is with discomfort. I try another tact. At my suggestion he identifies a painful emotion related to his situation and where he feels it most in his body. “Is it okay if we try something a bit different today? You can stop at any time if something doesn’t feel right. This exercise is called BOLD. It stands for Breathe, Observe and Open up to, Listen and Decide.” With eyes closed Mr Bright places his hand on where he feels distress the most. He learns that he can be bigger than painful emotions; that he does not have to get rid of them, but he can learn to breathe with them and around them while bringing a sense of compassion to his experience. Later I am able to generalise this technique out to his physical pain.
The mindfulness component of ACT, demonstrated above by the BOLD exercise, encourages an openness to unpleasant experiences related to depressed mood. The breath remained the key object of awareness even while distress was contemplated. Understanding relational frame theory and the way that language can lock people into unworkable situations (an underpinning concept in ACT) may not be realised fully with your senior clientele. But what you may be able to impart to them is a different way of relating to their experiences – one that is more compassionate, kind, and allows for an open embrace of emotions in the pursuit of valued living.
Adapted excerpts by Felicity Chapman from her book Counselling and Psychotherapy with Older People in Care: A Support Guide.
Further resources to help you support psychosocial wellbeing for residents and clients can be found in the Residential Aged Care toolkit and the Home Care toolkit on the ELDAC website. ELDAC also has a Diverse Population Groups resource to help you provide end of life care for older people from groups including CALD, LGBTI, and Aboriginal and Torres Strait Islander people.
- Harris R. ACT Made Simple. California: New Harbinger Publications Incorporated; 2009.
The Hexaflex and Psychological Flexibility
Felicity Chapman works as a mental health social worker at Sonder primarily with residents of care homes and is a sessional lecturer for the University of Adelaide and the University of South Australia