UNIT II – THE ELDERLY PATIENT

ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT

INTRODUCTION

Erickson’s psychosocial theory views personality as developing across lifespan and distinguishes 8
distinct stages within the lifecycle. According to Erikson, development functions by the epigenetic
principle. This principle says that all develop as humans through unfolding of personalities through
distinct stages. Each developmental stage is defined as a crisis in which particular stage – specific
issues present themselves as challenges to the individual’s ego. Individuals pass through a series of
transactions in which they are particularly vulnerable to a complex interaction of biological,
psychological and social forces characteristic of their period of life.

The meaning of crisis is not in a true sense but it means that during each stage is a time where the
individual may move closer to either a positive or a negative resolution of a particular psychosocial
issue. The success of resolution is measured by favorable or unfavorable attributes. These attributes
are qualities of the ego that will develop based on how the crisis is resolved.

These crises are of a psychosocial nature because they involve psychological needs of the individual
(psycho) conflicting with the needs of society (social). Erikson also proposed that each of the 8 stages
provide an opportunity to develop our basic strengths. These strengths or virtues develop once the
crisis has been resolved successfully.
TRUST VS. MISTRUST

Stage occurs during 1st year of life during greatest time of helplessness. The infant is totally
dependent on the primary caregiver for survival, security and affection. The baby’s interaction with
the mother determines whether an attitude of Trust or Mistrust for future dealings with environment
will be incorporated into the personality.

If the mother responds appropriately to the infant’s physical needs and provides affection and security,
then infant develop a sense of trust. In a similar way individuals learn to expect consistency,
continuity of sameness from other people such as peers, school etc. On the other hand, if the mother is
rejecting, inattentive or inconsistent in behavior infant develops mistrust and becomes suspicious
fearful and anxious. Though the problem is set is in infancy, the problem may reappear at a later
developmental stage.

The basic virtue of HOPE is associated with the successful resolution of crisis during this stage.

AUTONOMY VS. SHAME AND DOUBT

During this stage children rapidly develop a variety of physical and mental abilities and are able to do
many things for the self. They learn to communicate effectively, walk, climb, push etc.; children take
pride in these skills and usually become independent. The most important of abilities are holding on
and letting go.

For the first time children are able to exercise some choice, to experience the power of their
autonomous will. They begin to see themselves as person in their own right and they want to exercise
their newfound strengths. When parents thus thwart and frustrate their child’s attempt to exercise
his/her independence, the child develops feelings of self-doubt and a sense of shame in dealing with
others.

The basic strength that develops from autonomy is WILL, which involves a determination to exercise
freedom of choice a self-restraint in the face of society’s demands.

INITIATIVE VS. GUILT

Motor and mental abilities are continuing to develop and children can accomplish more on their own.
They express a strong desire to take the initiative in many activities. Initiative must be supported and
encouraged by parents. If they punish the child and otherwise inhibit these displays of initiative, the
child will develop persistent guilt feelings that will affect self-directed activities throughout his or her
life. The child’s initiative can be channeled toward realistic and socially sanctioned goals in
preparation for the development of adult responsibility and morality.

The basic virtue is PURPOSE that arise from initiative. Purpose involves the courage to envision and
pursue goals.

INDUSTRY VS. INFERIORITY

The child begins school and is exposed to new social influences. Ideally, both at home and at school,
the child learns good work and study habits (industriousness) primarily as a means of attaining praise
and obtaining the satisfaction derived from successful completion of a task.

The child’s growing powers of deductive reasoning and the ability to play by rules lead to the
deliberate refinement by the skills displayed things. The attitudes and behaviors of parents and
teachers largely determine how well children perceive themselves to the developing and using their
skill. If children are scolded, ridiculed or rejected they are likely to develop feeling of inferiority and
inadequately. Praise and reinforcement foster feelings of competence and encourage continued
striving.

The basic strength that emerges from industriousness during this stage is COMPETENCE. It involves
the exertion of skill and intelligence is pursuing and completing tasks.

IDENTITY VS. ROLE CONFUSION

At this stage individuals must meet and resolve the crisis of our basic ego identity. This is when
people form their self-image the integration of our ideas about ourselves and about what others think
of them. If this process is resolved, the result is a consistent and congruent picture.

Adolescents experiment with different roles and ideologies, trying to determine the most compatible
fit. Adolescents with a strong sense of self-identity are equipped to face adulthood with certainty and
confidence. Those who fail to achieve a cohesive identity that experiences an identity crisis – will
exhibit a confusion of roles. They do not seem to know who or what they are, where they belong or
where they want to go. They may withdraw from the normal life sequence. There is a strong impact
of peer groups on the development of ego identity in adolescence.

The basic strength that should develop during adolescence is FIDELITY, which emerges from the
cohesive ego identity.

INTIMACY VS. ISOLATION

Individuals establish independence from parents and institutions and begin to function more
autonomously as mature, responsible adults. Individuals engage in attainment of intimacy involving
establishing a mutually satisfying close relationship with whom a lifelong commitment if made. A
perfect intimate relationship is the intersection of two identities but not a total overlap because each
partner preserves a sense of separateness. Individuals can merge their identity with someone without
submerging or losing it in the process.

People who are unable to establish such intimates develop feelings of isolation. They prefer to be
alone because they fear intimacy as a threat to ego identity. The basic virtue that emerges is LOVE.

GENERATIVITY VS. STAGNATION

The motive for caring for the next generation emerges from the resolution of intimacy psychosocial
crisis. This is a stage of maturity in which we need to be actively involved in teaching and guiding
the next generation. This need extends beyond immediate family. One need not be parent to display
generativity.

All institutions provide opportunities to express generativity. When middle aged people cannot seek
an outlet for generativity, they may become overwhelmed by stagnation, boredom and interpersonal
impoverishment. CARE is the basic strength that emerges from generativity in adulthood. Care is a
broad concern for others with also the need to fulfil one’s identity.

EGO INTEGRITY VS. DESPAIR

The conflict to be negotiated in old age is between integrity and despair. To achieve integrity, an
individual reaches an acceptance of the life lived, a sense of “keeping things together and a feeling
that life lived has coherence. The sense of acceptance of past and present self allows the individual to
also view mortality with acceptance that life inevitably must end. If an individual looks back at life
with a sense of fulfilment and satisfaction, believing they have coped with life’s victories and failures,
then we are said to possess ego integrity. On the other hand, if an individual reviews life with a sense
of frustration, angry about missed opportunities and regretful of mistakes that cannot be rectified, then
they feel despair.

Older people must do more than reflect on the past. They must remain active, vital participants in life,
seeking challenge and stimulation from their environment. They must involve themselves in such
activities as grand parenting, returning to school and developing new skills and interests.

According to Erickson, much of despair is in fact a continuing sense of stagnation. Generativity

developed in 7th stage may be most important factor contributing to ego integrity. Despair is the
outcome of the individual’s realization that death is unavoidable and feels discontent with life and is
melancholic, apt of desponding, at the thought of the death.

The basic strength associated with this final developmental stage WISDOM. Deriving from ego
integrity, wisdom is expressed in a detached concern with the whole of life.

PRE-RETIREMENT COUNCELLING AND SOCIAL SUPPORT

INTRODUCTION

Retirement is an important phase of life for elderly people bringing with it many challenges in terms
of adjustments and changes in lifestyle, self-esteem, friendships and vocation. People from different
social and occupational backgrounds not only conceive work and retirement in different ways but also
follow different stages for retirement.

There are many view-points regarding retirement. Many view it as a reward for having displayed a
strong work ethic and a stage in which they would finally be able to exercise autonomy in their time
others were happy to continue working after state pension age, this attitude was reliant on whether it
was an individual choice and not an obligatory state.

Retirement is not just loss of worker role. Thus, pre-retirement period may play the role of career
transition. Better prepared individuals are more likely to postpone retirement, reduce transition
anxiety and feel less uncertain about financial risks of retirement. To minimize loss of prestige after
retirement new activities and interests are needed. Volunteering can fill time voids, part time work can
offer additional income, play critical roles in maintaining strong communities through community
work, etc.,

STAGES OF RETIREMENT

Retirement has many stages according to Annorsemi

• Preparation stage (36-45)

 Period of immediate retirement (45-55)
 Real retirement (56-65)

THE NEED FOR PRE-RETIREMENT COUNCELLING

When confronting important changes in life that necessitates adjustment on part of individuals many
people have found that good counselling and coaching can be a lifeline. This can help shorten the
period where difficulties and worries may overshadow the new beginning and possibilities at the end
of the tunnel. It is easier accessible for good counselling opportunities while one is already in the
labor market than after one leaves the job.
A normal approach to address the above short comings is pre-retirement counselling and also some
pre-retirement courses. These courses or counselling involves providing seniors entering the difficult
process of transition into retirement on how to plan and adjust to the change. The pre-retirement
counselling also helps in identifying alternatives to traditional retirement patterns.

The major objectives of pre-retirement counselling are

• Be more conscious of one’s own strength & competencies and continually develop by using
them as long as possible.
• Be better prepared to find his or her own goals and ways both in east part of professional
career in the years beyond.
• Be able to see through the traditional images and stereotypes on aging and retirement and not
let new life be predicted by prejudices.
• Be able to create his/her own tailor-made way to meaningful by fulfilling life in the 3 rd stage.

The pre-retirement counselling is essential for better QOL (quality of life) in active ageing. The
objectives of pre-retirement counselling are not to persuade seniors following the course to stay
longer on the job or to be involved in cultural or social activities in local communities. The overall
purpose is to assist people to find answers to questions such as:

• Who am I – now?
• What do I want?
• How do I get there?
• How do I sustain and give back?

Pre-retirement courses are usually done in groups because individuals can discuss new possibilities
with other seniors.

AREAS ADDRESSED IN PRE-RETIREMENT COUNCELLING

A new lifestyle in retirement: is one prepared for challenges?

• Meaning of big change

• Retirement aspirations new goals
• Paid Work
• Voluntary Work
• Learning
• Leisure
• Changing relationships: Personal and family
• Connections with other people
• Managing time - New daily routine

Money management and budgeting

• Income – retirement benefits

• Expenditure
• Protecting financial resources

Health Issues

• Physical well-being: risk factors

• Mental well-being
• Social participation
 • Stress management
• Exercise
• Healthy eating

Living arrangements

• Planning housing for next phases of life

FURTHER CONSIDERATIONS

Groups targeted are usually adults who are in their 3 – 5 years before retirement. Counsellors need to
have experienced “Planning” in their own lives before helping people plan. Counsellors must be
familiar with the developmental theories and emphasis on developmental tasks associated
with each stage.

A number of variables may influence people’s psychological responses to retirement. These include
gender, prior levels of psychological well-being, marital quality and financial state, the post retirement
decreases in subjective health or personal control.

Pre-retirement planning is very essential. Riker and Myers proposed a retirement planning model.
The model includes planning for spiritual growth, intellectual stimulation,

social involvement, community involvement, professional involvement and special issues such as
health constraints counsellors can ask open ended questions such as “what will you do with your free
time?”, “How can you use your knowledge skills and interests when you are retired’?

Counsellors must address the couple and ask them to consider following issues: Are they both ready
to retire or is just one person wanting to retire? How will they handle the new relationship if one
person alone is retiring? The kind of compromises they will need to make if both retire? How will
they manage expenses?

Associated Mental Health problems must be addressed by the counsellors such as stress, sedentary
lifestyle, depression, anxiety, empty nest etc. REBT by Albert Ellis is a good solution to address MHP
in order people

INTERVIEWING THE ELDERLY

INTRODUCTION

Interviewing the older patient really should not be all that different from interviewing the younger
patient. Regardless of age, there is a need to evaluate their personal histories as well as their emotional
and cognitive states. Nonetheless, the experience of interviewing an older patient is different. The
obvious difference is that the emphasis of the evaluation tends to be on scrutinizing cognition, since
the chances of finding impaired cognition are statistically higher in older people.

ISSUES IN INTERVIEWING THE ELDERLY

Logistical issues: The psychiatric interview actually begins with your patient’s first phone call
requesting an appointment. Whether you are in solo practice and take these calls yourself or work in a
clinic where support staff does this for you, you can enhance everyone’s experience of your first face-
to-face meeting by taking care of some preliminaries.

Transportation Issues: If parking is a problem, this is likely to be much more of an issue for the
elderly. Likewise, if you have stairs, you had better let your prospective patient know.

Informants: Strongly encourage your new patient to bring an informant (a friend or a family member).
The interview will be covering terrains such as cognitive impairment and ability to manage basic
functions of daily living, and you will want to corroborate your patient’s report with an informant’s.

Medical Documentation: Insist on obtaining copies of primary care medical records, either to be
brought with the patient during the appointment or to be sent or faxed to you before the appointment.

ESTABLISHING RAPPORT

Establishing rapport is a crucial part of the interview with any patient, because this allows the
collection of clinical information needed for a diagnosis and also helps to ensure that the patient will
comply with any treatment that is suggested.

In general, maintaining an attitude of respect and dignity will go far for elderly patients. The therapist
can communicate such an attitude in innumerable nonverbal ways, such as smiling, showing sustained
interest, and making sure that the patient is physically comfortable throughout the interview.

Asking questions in a nonthreatening way:

The techniques that clinicians tend to use in approaching sensitive topics fall into the following three
categories: (a) normalization, (b) symptom expectation, and (c) symptom exaggeration

Normalization: A bread-and-butter technique of accomplished interviewers, normalization begins with

a statement implying that the symptom or behavior under question is normal.

Symptom Expectation: This is similar to normalization, but in this case, you offer a statement or
question showing that you assume that the patient is doing or feeling something. This is best reserved
when your index of suspicion for a behavior is already quite high; otherwise, patients may find it
offensive.

Symptom Exaggeration: In order to encourage your patient to admit to an embarrassing behavior or

symptom, you suggest a much higher frequency of the behavior than is likely. The patient then feels
that if he or she admits to a lower frequency you might be pleasantly surprised.

Asking questions in nonthreatening ways is often critically important for patients with dementia, who
may present with paranoia as a complication of their cognitive impairment.

MOVING THROUGH THE INTERVIEW RAPIDLY

Close Ended Questions: They are questions that can be answered with only a finite number of
responses. Usually, there are only two possible answers: “yes” and “no.” But long meandering stories
and anecdotes are not options when it comes to closed-ended questions.

Gentle Interruptions: Often, when patients are really excessively talkative, the entire interview
becomes a gentle process of educating them about the need to keep answers a little briefer. In order to
interrupt gracefully, consider the following techniques: (a) smile, (b) use a gentle but firm tone of
voice, (c) personalize the interruption by using their name, or asking a question about their concern
and (d) express empathy and interest in them as you interrupt.

Point Redirection: When listening to a rambling patient, try to interrupt by focusing on one point that
you may have heard earlier in the interview, and use that point to logically redirect him or her back to
the relevant topic

INTERVIEWING DIFFICULT PATIENTS

The Hostile Patient: the therapist realizes quickly that the patient is not answering your questions
because of an undertone of anger and hostility. The best approach here varies. Making a direct
comment about the affect sometimes works. But this can always backfire if your patient feels that
your efforts at empathy are too intrusive. If so, simply being quiet while allowing your patient plenty
of time for catharsis allows him to feel that he is back in control; the interview may proceed more
smoothly thereafter.

The Confused Patient: Confusion is a nonspecific symptom that can reflect underlying dementia,
ruminative depression, and overwhelming anxiety, among other states. Frequently, a confused patient
will be accompanied by an informant and you will be tempted to direct your questions to this person,
rather than the patient, in order to more efficiently attain information. However, this can increase your
patient’s sense of anxious confusion as he fights a losing battle to try to understand what is being said.
In these cases, carve out time explicitly for interaction with the patient.

SPECIFIC DATA TO OBTAIN

The second goal in conducting the psychiatric interview, after establishing rapport, is to come up with
a psychiatric diagnosis that is consistent with current nomenclature. This is accomplished via data
collection, partly through unstructured listening and partly through diagnostic questioning.

History of present illness:

The present illness begins with understanding those factors or episodes that precipitated current signs
and symptoms. The therapist has to elicit a chronological description of the present symptoms. The
history of present illness includes details about the nature, frequency, severity, and pattern of
symptoms including exacerbating and alleviating factors. It may be ideal for the therapist to begin
with an open-ended invitation such as “please tell me how all of this began and how it has played out
over time”. The therapist must guide the patient through parts of the story by clarifying, probing and
paraphrasing to get a coherent and sequential history. Treatments the patient utilized during the
current episode are reviewed with attention to response, adherence, and attitudes about the treatment.
Suicide and risk assessment is also done to identify at risk-high priority patients, to maintain a
conducive, risk-free environment and choose an appropriate course of treatment. A final review of the
symptoms, precipitating factors and episodes must be done at the end to ensure that primary problem
or co-morbid disorders relevant to comprehensive diagnosis, treatment planning, and prognosis are
not missed. The events that the patient describes must be perceived by them as stressful even though
they are positive for an average person. The therapist must also note if the onset of symptoms is acute,
sub-acute or chronic.

Medical history:

A review of medications and the medical history should be a part of the initial psychiatric interview of
an elderly person. The therapist must find out if the patient has sought treatment previously for
physical or mental illness and if yes, the duration, type of treatment, surgeries or procedures
undergone and whether the patient is still continuing the treatment.

Mental status examination:

By mental status exam, references are primarily made to the cognitive component of the evaluation.
It should go without saying that the therapist will be closely evaluating appearance, mood, and affect,
speech, thought process and content, and behavior while you are asking questions pertaining to the
PROS. There are therapists who avoid structured memory questions, maintaining that they can
evaluate all the cognitive domains adequately in the course of the normal interview. The history gives
a longitudinal account of the patient’s illness, the development and progress of symptoms kind his
reaction to them. What is further required is a cross-sectional view of his behavior and the clinical
features at the time of examination. It is a systematic collection of the observations (e.g., signs such as
blunt affect or rapid speech) and reported mental experiences (e.g., symptoms such as depressed mood
or hallucinations) that produce a picture of the patient’s current mental state. Its purpose is to suggest
evidence for and against a diagnosis of mental disorder, and if mental disorder is present, to record the
current type and severity of symptoms. MSE has to be repeated several times during the course of the
illness to know the evolution of symptoms, effectiveness of treatment etc. The MSE should be
recorded and presented in a standardized format, although the information contained may derive from
material gained in different ways. It is helpful to record the patient’s description of significant
symptoms word for word.