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Behavior Therapy 42 (2011) 59–65 www.elsevier.com/locate/bt COMMENTARY Commentary on the Current Status and the Future of Behavior Therapy in Long-Term Care Settings

Victor Molinari University of South Florida

Barry A. Edelstein West Virginia University

THE ARTICLES IN THIS special series focus on several settings (e.g., by teaching family and specific subareas of , one of which is ALF psychoeducational and communi- long-term care. Long-term care can be defined as cation skills that have been refined with nursing the comprehensive, coordinated care for multi-need home staff). older adults unable to manage independently The mental health statistics for long-term care because of chronic medical problems and their facilities are sobering. Nursing homes have been associated . As the literature reviews described as psychiatric institutions, but without the make clear, the aging demographics continue to trained mental health personnel to provide appro- unfold. Older adults comprise an increasingly priate psychiatric treatment (Rovner et al., 1990). greater percentage of the population, with those Diagnoses of and are quite in the oldest age range (over the age of 85) common, and behavior problems associated with increasing most rapidly. This latter group of older are rife. Depending upon its definition, adults is most in need of long-term care, with between 3% and 27% of residents multiple medical problems and cognitive difficulties meet criteria for serious mental illness (SMI; Becker dramatically rising as individuals enter their seventh, & Mehra, 2005; Grabowski, Aschbrenner, Feng, & eighth, and ninth decades. Although this special Mor, 2009), with those with SMI exhibiting poorer series focuses on long-term care in nursing home outcomes when residing in nursing homes than in settings, it should be noted that most long-term care less restrictive environments (Harvey, 2005). One is provided by family members in the community. prevalence study suggests that ALFs have equal or Indeed, the actual number of nursing homes has greater numbers of residents with mental health plateaued. facilities (ALFs) are the problems as nursing homes, although the mix of fastest growing segment of the elder housing market psychiatric disorders may well differ between long- (Becker, Schonfeld, & Stiles, 2002). Luckily, with term care settings (Rosenblatt et al., 2004). the appropriate modifications, research findings Behaviorally oriented psychologists have translate fairly easily from nursing homes into addressed many of the mental health–related pro- ALFs, continuing care retirement communities, and blems of long-term care residents over at least the past four decades, although the first published application of the principles of operant conditioning Address correspondence to Victor Molinari, Ph.D., College of in an institutional setting appeared even earlier, in Behavioral and Community Sciences, University of South Florida, 1949 (Fuller, 1949). Fuller reinforced the arm 13301 Bruce B. Downs Blvd., Tampa, FL 33612; e-mail: movements of an 18-year-old boy who was bedrid- [email protected]. den and unable to roll over independently. Operant 0005-7894/10/059–065/$1.00/0 © 2010 Association for Behavioral and Cognitive Therapies. Published by approaches have subsequently been applied to the Elsevier Ltd. All rights reserved. behavior of nursing home residents (e.g., Hussian, 60 molinari & edelstein

1981; Hussian & Lawrence, 1981; Rinke et al., psychological treatment must always be based 1978) and to the nursing home as a system in order on a thorough assessment of the identified to bring about changes in resident behavior (e.g., patient whose long history and complicated MacDonald, 1978). Margret Baltes and her collea- intersecting emotional and physical complaints gues were strong advocates for the application of an embedded in a unique social context invariably operant model to the nursing home environment in make evaluations lengthy and complex. Individu- the 1970s as well (Baltes & Barton, 1977). alized assessment is a core skill competency for The strategies and behavioral techniques uti- geropsychologists to master, especially for those lized in working with frail older adults in long- working in long-term care settings (Edelstein & term care settings have become more sophisticat- Koven, 2011; Edelstein, Northrop, & MacDo- ed over the years, as evidenced by the articles in nald, 2009). Recommendations for the adminis- this series. The research in this issue on accept- tration, scoring, and interpretation of specific brief ability of interventions (see Baker & LeBlanc, screening instruments for mental disorders in long- 2011) and improving staff communication (see term care settings have been proposed (Pachana et al., Christenson, Buchanan, Houlihan, & Wanzek, 2010), with requisite follow-up by more detailed 2011; and Williams & Herman, 2011) owe a assessment when appropriate. major debt to Burgio and associates (Burgio et Many of the problems of long-term care residents al., 2001; Burgio et al., 2002), Cohen-Mansfield can be satisfactorily addressed through changes in and her associates (Cohen-Mansfield, Marx, staff behavior and alterations of the settings in Thein, & Dakheel-Ali, 2010; Cohen-Mansfield, which problem behaviors occur based on the Marx, Dakheel-Ali, Regier, & Thein, 2010), and thorough assessment mentioned above. Neverthe- Camp, Cohen-Mansfield, & Capezuti (2002). less, psychopharmacology is the primary mode of The latter authors have published on the use of treatment for mental health–related problems in basic learning principles and staff training to long-term care settings. A recent study suggests that shape the disruptive behavior of residents with 70% of nursing home residents take at least one dementia, and these contributions are considered psychoactive medication within 3 months of foundational in the field of behavioral gerontol- admission, and 16% take four or more such ogy. The promotion of positive activities (see medications (Molinari et al., 2010). The rationale Meeks & Looney, 2011) is a nice complement to for psychoactive medication usage is often poorly the work of Hyer, Yeager, Hilton, and Sacks documented and of longstanding national and (2009). Hyer et al. successfully implemented their international concern (Avorn, Dreyer, Connelly, Group, Individual, and Staff Training (GIST) & Soumerai, 1989; Holmquist, Svensson, & program by making use of behavioral activation Hoglund, 2003; Sorensen, Foldspang, Gulmann, principles and goal-setting to increase pleasant & Munk-Jorgensen, 2001). The deleterious side- activities and to improve the affect of depressed effects of these medications are well known and nursing home residents. include falls, cognitive impairment, delirium, mor- Unfortunately, there remain far too few trained bidity, and hospitalization (Cooper, Freeman, psychologists who have the requisite knowledge Cook, & Burfield, 2007; Draganich, Zacny, Klafta, and skills for working with older adults, especially & Karrison, 2001; Gurwitz et al., 2000; Svarstad & in long-term care settings. There are approximate- Mount, 2001). ly 10 graduate programs in clinical/counseling Although psychiatric medications certainly psychology that emphasize training with older have their place in the array of options for adults (Hinrichsen, 2003), far fewer than the mental health care of long-term care residents, numbers needed to manage the demographic they may be overused by staff who are not well boom. To make matters worse, there are even trained in managing behavior problems and who fewer programs that have specific faculty expertise do not identify psychosocial alternatives. Indeed, to address the complex mental health needs of a primary purpose of the Omnibus Budget frail elders in institutional settings. Indeed, half of Reconciliation Act (Omnibus Budget Reconcilia- all nursing homes do not have access to a tion Act, 1987) was to establish regulations psychiatrist and three-quarters of nursing homes because of the overuse of psychotropic medica- don't have access to behavioral consultants tions in nursing homes. According to these (Reichman et al., 1998). interpretive guidelines, these medications are The need for psychological approaches to inappropriate for many of the behaviors for treat the mental health problems of older which they are administered (e.g., restlessness, adults in long-term care settings is overwhelm- uncooperativeness, agitation if not a danger to ing. However, it should be noted that self or others). One should first document that commentary on long-term care 61 psychosocial/environmental/preventive approaches disruptive behaviors and stress management that have failed before using psychotropic medications leads to positive outcomes for caregivers, such as to modify resident behavior that is not due to reduced burden and depression, improved social one of the “specific conditions” listed in the support and health, and decreased behavior guidelines (e.g., schizophrenia) (Stoudemire & problems (Burgio et al., 2009). Smith, 1996). In recently published surveys of It should be noted that there is also a nursing home administrators and front-line staff substantial literature on the stresses of providing (Molinari, Hedgecock, Branch, Brown, & Hyer, paid care in institutional settings. Turnover of 2009; Molinari et al., 2008) researchers have nursing assistants has been reported to be as high found that nursing home staff at all levels are as 50% in a 6-month period (Donoghue & Castle, generally sensitive to the mental health needs of 2006). Although turnover rates have been found their residents, but feel that system constraints to be related to the characteristics of the and pressures hinder their abilities to address institution—for example, ratio of nurses to beds, these needs. Staff members recognize their need quality care deficiencies, number of Medicaid beds for more training and welcome continuing (Donoghue & Castle, 2006)—they also have been education. Training in nonpsychopharmacologi- associated with behaviorally modifiable elements cal mental health is obviously a niche for in work conditions such as participation in team geropsychologists well-versed in applied behavior meetings (Banaszak-Holl & Hines, 1996), tokens analysis. of appreciation, autonomy, and resident attach- Behavioral principles also can also be utilized to ment (Kramer & Smith, 2000). Recent research reduce the distress and improve the coping of suggests that empowerment of formal caregivers , who as a group are over- improves their job satisfaction and may even burdened and underserved. Contrary to popular enhance quality of care in the process (Kostiwa myth, family members do not abandon their older & Meeks, 2009), perhaps reducing such high loved ones (Brody, 1990), but in general do turnover rates. everything they can to provide proper care, often Although there are well-established protocols for stretching their own resources to the breaking reducing disruptive behavior in those with demen- point. Burden on caregivers has been well tia and for family programs utilizing documented and includes emotional, physical, behavioral principles, there are also emerging social, financial, and vocational strains. Care- frontier areas for the application of behavioral givers of those with dementia are more likely to approaches. ALFs (Becker et al., 2002), continuing be depressed, perceive themselves as less healthy, care retirement communities, in-home community become socially isolated, and have reduced care (Yang, Garis, Jackson, & McClure 2009), and incomes due to paying for expensive medical (Haley, Larson, Kasl-Godley, Neimeyer, care/medications and losing time off from work & Kwilosz, 2003) are geriatric settings in need of (Molinari, 2006). Perhaps even more troubling, evidence-based mental health interventions. The caregiverdistressisassociatedwithnegative modification of CBT protocols that have proven outcomes for care recipients, leading to poorer effective with older adults in community settings for treatment of their symptoms, neglect, and prema- use with more cognitively impaired residents is well ture institutionalization (Messinger-Rapport, under way (Clifford, Cipher, Roper, Snow, & McCallum, & Hujer, 2006). Even when their Molinari, 2008); such adjustments present obvious loved one is institutionalized, caregiver emotional creative practice and research opportunities for burden continues (Zarit & Whitlatch, 1992). This those with behavioral orientations in these novel burden may be reflected in dissatisfaction with settings. nursing home care and arguments with staff, As scientist-practitioners who are interested in perhaps fueled by lack of meaningful involvement evaluating the evidence for the effectiveness of in their loved one's care (Tornatore & Grant, behavioral techniques, the complexities of conduct- 2004) and/or guilt and feelings of failure. Inter- ing well-controlled research in long-term care ventions targeting caregivers have therefore re- settings must be noted. The great majority of ceived a lot of attention, both for the sake of older adults in long-term care are on complex caregivers and care recipients. Although members medication regimens due to multiple medical attending peer support meetings are very satisfied comorbidities, and perhaps also due to the need with the camaraderie engendered by a group to take medications to offset the adverse effects of networking format (Molinari, Nelson, Shekelle, & other medications (e.g., constipation, extrapyrami- Crothers, 1994), it is the addition of skills training dal symptoms). Conducting trials of behavioral components such as behavior management of interventions with a “pure” group of residents not 62 molinari & edelstein taking psychiatric medications can be daunting, cient to ensure properly implemented programs, and even if successful would raise questions and rewards and other contingencies for satisfac- regarding the generalizability of findings. However, tory performance are necessary. research can be done if the resident is stabilized on These are exciting times for psychologists medications, with such situations representing interested in older adults. Clinical geropsychol- creative opportunities for the application of single- ogy was awarded specialty status at the recent subject designs (Barlow, Nock, & Hersen, 2008). American Psychological Association (APA) con- There are other challenges to the implementation vention. Geropsychology has finally garnered and formal evaluation of behavioral interventions. recognition that it is its own field with distinct Gaining informed consent from residents who are professional attitudes, knowledge, and skill sets cognitively impaired with or without guardians is drawing from basic research on learning derived difficult. Staff resources are scarce because few from experimental psychology, aging via life- mental health professionals are employed full-time span psychology, foundational principles of or even part-time in nursing homes. Therefore, assessment and treatment from clinical psychol- training in reinforcement principles most often will ogy, interventions for the psychological conco- need to be conducted with nursing aides who mitants of medical conditions validated by health provide most of the hands-on care in nursing psychology, assessment of cognitive difficulties homes, but who have less than a college education which is the mainstay of neuropsychology, and and are charged with the difficult day-to-day tasks the basic tenets of psychological rehabilitation of care for and cleaning up after the residents and their application with older adults (see (Kramer & Smith, 2000). One strategy is to teach Buchanan, Christenson, Houlihan, & Ostrom, the staff how to alter the environment to preclude 2011). Most geropsychologists are guided by the behavior problems (i.e., antecedent control). There biopsychosocial model and understand the need are many behaviors of caregivers that serve as for culturally competent, interdisciplinary team- discriminative stimuli for maladaptive resident work employing input from varied disciplines behaviors. Staff can learn that just by changing and branches within psychology for the optimal their own behavior they can often avoid problem- care of older adults (APA, 2008, 2009). atic resident behaviors and support more adaptive Representing the aging field within APA, there is ones. Oftentimes, even relatively simple reinforce- now a standing Committee on Aging, along with ment schedules using basic inattention to disruptive Division 20 (Human Development and Aging) behavior and rewarding of appropriate prosocial encompassing researchers exploring the basic sci- activity can be tough to implement without training ence of aging; Division 12, Section 2, embodying of all staff when one must rely on three shifts of the more applied side of the field; and Psychologists nursing aides who, even if motivated, are not in Long-Term Care, comprising those geropsychol- psychologically sophisticated. ogists who focus on working with frail older adults. The turnover rates in many nursing homes are This latter group publishes a newsletter, has a very quite high, often reaching 150% in one year, informative website (http://www.pltcweb.org/ meaning that training must be continuous and index.php), and an active listserv where members ongoing. As has been noted by Burgio and Burgio discuss important considerations of public policy, (1990), systemic “buy-in” must be accomplished reimbursement (Norris, 2008) and ethical quanda- before an overall behavior program can be imple- ries (Karel, 2008) frequently encountered in these mented in a particular nursing home site. Such settings. Of particular note, there is a newly formed “buy-in” includes preliminary meetings with, at the Council of Professional Geropsychology Training very least, nursing home administrators and per- Programs (CoPGTP) whose main mission is to serve haps even the owner of the nursing home in order to as a resource for upgrading the training of assure the appropriate outlay of resources and psychologists to work with older adults (http:// commitment to this endeavor. For successful www.usc.edu/programs/cpgtp/background.html). consultation, adequate payment for the psycholo- Indeed, CoPGTP recently commissioned a task gists' time to train nursing home staff, and force to develop an assessment tool for supervisors especially endorsement and active encouragement and supervisees to evaluate their competencies in a by administrators for staff to engage in the variety of domains in geropsychology. The Pikes necessary education to implement behavioral pro- Peak Competency Assessment Tool (Karel, Emery, grams, must be agreed upon. Support also is & Molinari, 2010) measures the geropsychology essential from the Director of Nursing (DON), as knowledge base and skills across five domains: most programs are implemented by staff supervised general knowledge about adult development, aging, by the DON. 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