I’ll never forget the day, March 16, 2020, I was in the middle of a therapy session with a patient in the nursing home & a nurse rushed in & told me I needed to leave the facility immediately. I was both shocked & confused about what was happening. This was the Monday after the CA Governor’s order to shut down non-essential businesses. I knew that my patients had been already very anxious & nervous about the growing COVID concern. I felt so helpless, and I felt like I abandoned my patients without notice in a time when I felt they needed me the most. Pre COVID, I was working in approximately 5 different skilled nursing homes throughout Southern California. I continued to see patients in other facilities in the following weeks, however, one by one I was told to not come back as mental health services were not “Essential.” I went from working in 5 facilities to only providing services in 1 large facility, who thankfully had the foresight to see that patients needed mental health support more than ever at this time, during this global pandemic. By this time skilled nursing facilities had stopped family visits for patients, eventually stopped all social activities, stopped group dining, and limited movement of patients in & out of their rooms and even limiting or prohibiting patients from going outside in general. With all these new restrictions patients began to have a significant increase of depression and anxiety manifested by feelings of loneliness, hopelessness, fear for their own health and the health of their families, disturbed sleep, loss of appetite or increased appetite, gastrointestinal issues, headaches, restlessness, physical pain, and irritability. These symptoms that manifest physically (such as pain and gastrointestinal concerns etc.) but caused by underlying mental stress are called psychosomatic symptoms. There are many studies on the long-term effects of loneliness on the physical body, but since this is not a research post and I don’t want to quote statistics or journal references (plus those are boring), the general findings of these studies are that loneliness can lead to early death, inflammation of the body, increased risk of heart disease, and more susceptibility to flu and cold symptoms. As a mental health provider working with seniors in skilled nursing facilities, I am very often working with individuals who are in the facility after major surgery, stroke, injury, heart attack, renal failure, or some other illness that would require a higher level of care than living independently or with family. In my observation of patient care (since I am not a medical doctor), I have recognized a pattern of patients not recovering medically quite as quickly as they may have before COVID. My hypothesis is that this may be related to feelings of loneliness and isolation, which can then lead to depression and anxiety, and along with depression and anxiety comes a lot of physical symptoms (that I listed previously).
Talking with seniors about depression and anxiety, especially those who have never experienced either can be difficult at times, it requires a certain finesse, honestly, I think it’s my superpower. There is a lot of stigmas associated with the label of being depressed or anxious. My job as a Psychologist is to normalize the feelings, break down the big scary stigmatized labels of depression and anxiety, and to help my patients identify the things in their life that are impacting their functioning. There is not one single patient that I have seen in the skilled nursing home setting or even my private practice who has not been impacted by COVID. With the holiday season approaching there is an additional concern for my patients. Holiday blues commonly experienced in the skilled nursing home setting will converge with the already existing emotional distress related to COVID stressors. I anticipate an even greater prevalence of patients with clinically significant emotional distress in the coming holiday months. Loneliness, in general, is an unpleasant response to perceived isolation, however with seniors living in skilled nursing during a global pandemic there is no perceived isolation, it’s real. Loneliness at times motivates people to want to engage with others, to make friends, to visit family, to go to a social gathering, and prior to COVID, those were things that seniors living in skilled nursing facilities could easily do. However, due to restrictions in senior living facilities to keep patients safe from exposure to COVID, all those things which were coping skills to combat loneliness have been taken away. Many seniors in the facilities I work in have expressed very heartfelt emotions, deep sorrow for not being able to see their families, longing for physical touch, missing precious moments with loved ones including births of grandchildren, funerals for beloved passed family members, Mother’s Day, Father’s Day, Easter, and even Fourth of July family barbecues. My work and practice with seniors in the isolation of skilled nursing facilities during a pandemic have definitely changed. Now I do therapy with a mask, and my patients are usually wearing masks as well – it’s very hard to read someone’s expression with a mask on, and it is often harder for patients to hear me. Imagine someone whom you’ve never met, coming into your room asking you very personal questions from marital status, children, education, work history, trauma, history of mental illness, testing your cognitive ability, asking about your sleep, appetite, pain, and so forth. All that and you do not even really know what they look like, it definitely makes building rapport a bit more difficult. I have found that my patients are craving conversation, they want to know what is happening in the world (beyond what they see on the news), they want to talk about things that are hopeful and they sometimes just want to ask me questions, about my kids and family and want to know how they are doing. I have found they want to talk with me as if I am there visiting them, having a conversation with them as they would their own family or friends who once used to be able to visit. This is not the “normal” psychotherapy model of course, but my job is to also meet my patients where they are, and if there is a benefit to my patient talking with me as a visitor then I find therapeutic value in that. It helps me to also gauge where they are cognitively, if they can hold a conversation or attention, I find out their thoughts on many things from their own stressors to how their families are doing and occasionally some local gossip. I also facilitate face-time or Skype calls with their families and friends. This is now the new normal, at least for now, I feel very rewarded at the end of most of my days, I also feel sad sometimes and helpless and wish I could do more. Patients who receive letters or cards feel so special and they feel like they are not alone and that people do care about them. They often want them hung up in their rooms or kept on their bedside table so they can see it and remember that they are not alone and forgotten.
On a brighter note and an update to the accessibility of mental health services to seniors in skilled nursing facilities, I have resumed my work in all 5 facilities as they have definitely seen the psychological impact that COVID-19 has had on all the patients. Mental health screenings are now the norm in the facilities, I often get patients who see me working and talking with other patients and then ask if I can also come to talk to them, if this is how I can combat loneliness in seniors then I’m glad to be a part of the solution on a daily basis.