Fall. Back to school. New beginnings. New projects. For many of us, fall's clear air and triumphal colors serve as a last gasp of outdoor activity before winter drives us inside.
But what about those with limited mobility or other physical challenges? Or those isolated by depression and anxiety? Even long before the frosts of fall, those who suffer from depression or anxiety might well be drawing blinds tighter and walling themselves off from the world around them.
My colleagues at the Visiting Nurse Service of New York -- Carl Jin, a behavioral health field manager, and Gerard Mounic, clinical specialist in occupational therapy -- spend their days (autumn and otherwise) working with patients who are limited by illness, injury, depression and anxiety -- helping them take those first steps back into the world.
Carl and Gerard offer insight into how we can help ourselves or a loved one -- an aging parent, a spouse who's had a stroke, a depressed friend alone in the apartment -- enjoy a crisp fall day, welcome a visit, and maybe even travel, whether to Paris or to the front stoop.
1. Establish connections.
From homebound seniors isolated by depression and anxiety, Carl often hears, "I have no one." His first step is to perform a reality check, asking questions to separate truth from perception. "Tell me about the people you used to talk to on the phone or socialize with," he might ask. "Tell me about your family."
"You start to peel layers," he says. "You might find they have children who they think are too busy. Or friends who've lost touch and, they assume, lost interest. Then we explore the truth behind that. 'Are your children really too busy for a phone call? How do you know your friend isn't interested?'"
The next step is to have the isolated person initiate contact. There may be resistance, and Carl and our other nurses ask, "What's the worst that can happen? The other person doesn't call back, or perhaps doesn't have time to talk. How would you deal with that? Would you be any worse off?" Recently, Carl helped a patient rekindle her relationship with a sister several states away, after the two hadn't spoken in years.
Once the phone call is made, keep the questions going: Do you want a telephone relationship? How often will you talk? Will you make plans to get together? Does the isolated person have access to or interest in technology? Skype and Facebook are not yet commonplace among seniors, but they are the fastest growing group to embrace social networking. The Pew Research Center found that social networking among internet users ages 65 and older doubled -- from 13 percent to 26 percent -- between April 2009 and May 2010.
Even if there's no immediate support network, there are more layers to peel: How about a religious or spiritual community? That question was enough to connect Linda, who had recently moved to a new neighborhood and was feeling isolated, to her nearby synagogue and its robust community. If someone can't get to church or temple, inquire whether the organization has a transportation assistance program, or a friendly visitors program that sends a church or synagogue member into the home.
2. Identify pleasures. Set goals.
Identifying pleasures and setting goals are both vital, whether someone is limited by depression , physical illness or injury. Begin by setting a simple goal: To introduce one pleasurable thing into -- or back into -- one's life. This might be playing cards, reading (or listening to) books, getting outside, knitting, listening to show tunes, talking on the phone.
With patients suffering from depression, Carl tries to break the cycle of negative thought. "Everything begins with 'I can't,'" he says. "I ask, 'If you had no barriers at all, what would you love to do?' From there, we can peel away layers of 'I can't.'"
Identifying pleasures often entails reaching back in time: "What did you enjoying doing before ... ?" Before depression set in, before the stroke, before the Parkinson's got so bad, before the leg strength deteriorated. As an occupational therapist helping people return to the tasks or "occupations" of their daily life, Gerard probes deeper once his patients identifying something that brought them pleasure. "How did you do it?" he asks. "Where? When?" That helps him and the patient set goals for the future.
For Jenny, a Long Island resident who suffered a bilateral stroke, it was passing long summer days at the beach down the street. For Lily, whose Parkinson's has gotten quite advanced, it was traveling. For Ken, who has mild dementia and other physical complications, it was walking his dog in the morning. (Note: We have changed patients names to protect their privacy.)
From these pleasures come goals -- goals that are small enough to be attained, but challenging enough to create real change. Gerard helped Ken take small steps -- literally -- towards his goal. First, they walked down the hallway, then to the downstairs mailbox, down the street, and finally, down the street holding the leash. "We needed to see if he could maintain balance, endurance and attention for the necessary amount of time," Gerard explains. "It's a graded intervention to get to the goal."
3. Identify barriers.
Goals always come with barriers. For people limited by depression or physical disability, identifying those barriers is critical. Are you reluctant to go outside because you're afraid you'll get dizzy, or because you don't like your appearance?
"What's standing in the way?" Gerard asks. "Is it your balance, strength, level of cognitive ability, visual impairment? Or is it fear or anxiety?" Answering those questions is crucial, because the answers lead to the solution: "How can we compensate?"
Rosa, who suffered two debilitating strokes and a heart attack, was excited about using a new power wheelchair to return to her active life -- but she kept crashing into things on her left side. After identifying a visual impairment on that side, Gerard taught her to compensate and operate the wheelchair more safely by frequently turning her head to the left to check her field. From there, Rosa felt confident enough to go food shopping regularly with her attendant, go to the movies and travel to her country house in Upstate New York, where she hadn't been in six years.
4. Break down barriers. Create solutions.
Once passions and goals are articulated and barriers are identified, then the real connections to the community can begin.
Lily wanted desperately to travel, but could cite a host of obstacles that her advanced Parkinson's presented. One by one, Gerard broke down those barriers. Surely she could get to and from the airport, and once there, she could use her wheelchair right up to the door of the plane. Every aircraft has an onboard wheelchair, so she could get around in the air, and once in Paris, she could stay in an accessible hotel. So in July, Lily traveled to Paris. "It required a lot of careful planning," he notes, "but she left the country for the first time in 10 years."
For Jenny, the stroke survivor who wanted to get to the beach, Gerard helped her discover that her town of Long Beach, New York, provides "beach wheels," wheelchairs specially adapted to the sand. This summer, her husband brought her to the beach each morning, where she set up and enjoyed the day.
Increasingly, Gerard is using an iPad in treatment for a variety of patients, including the visually impaired, who can read by increasing font size or using an application that magnifies. Cynthia, a patient with Amyotrophic lateral sclerosis (ALS) who had grown isolated by her limited mobility and speech, began using an iPad to communicate, typing or tapping on common words and sentences, which the device then spoke. As an added benefit, an iPad is portable enough to easily attach to a wheelchair.
There are many resources for enrichment and companionship, even for those who are unwilling or unable to leave the house. David, a musician, experience with depression had isolated him not only from friends and loved ones, but from his lifelong passion. A VNSNY behavioral health nurse connected him to Concerts in Motion, which brings live performances to those who are homebound or hospitalized. We have also connected patients with Dorot, which offers telephone classes through its University Without Walls program and home visits and reading assistance through its Friendly Visiting program.
5. Establish routine.
Nothing leads to lasting change better than routine. Linda made lasting connections in her new synagogue because she established a routine, attending services regularly and extending her relationship by signing up to receive weekly home visits.
It's great to call your mother, who lives alone, suffers from anxiety and doesn't get out much. It's even better to call her every Tuesday night, or every Sunday morning. "It may be something simple in a child or grandchild's life," notes Carl, "but think about how much it matters to the patient."
Have you broken down barriers of your own, or helped a loved one? How did you do it? What were you -- or they -- able to achieve? Share your story!
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