Appreciating the 4 "Ts" of Loneliness When Providing Psychiatric Care for the Lonely Patient.

Loneliness can be evaluated from a 4-concept viewpoint of territory, threat, trauma and trust (4 Ts). Territory refers to an area of ownership that is controlled on a daily basis and is fundamental to one's daily life. Lonely individuals often manage boundaries by gaining greater control over their physical environment by territorial behavior. They guard personal territory well as the only area where they can exert dominance and feel safe. Perceptions of social isolation or loneliness increase vigilance for threats, decrease trust, and heighten feelings of vulnerability. Clinical teams caring for the lonely must be especially attentive to a history of prior trauma. Clinicians who ask permission, who pay attention to nonverbal cues, distance, and speed as they enter the lonely person's space, and who respect boundaries may be more successful in gaining trust. Achieving trust diminishes the risk of physical harm, while allowing lonely persons the perceived control they need to permit health care interventions. Veterans are at higher risk for loneliness. Given their military training, they may be particularly attentive to boundaries, protecting the perimeter, watching for threats, and defending their space. In this article, we discuss the successful mental health treatment of a lonely male veteran in a Veterans Affairs Medical Center, by paying attention to the 4 Ts of loneliness. We used a 4-step approach of validation, mentalization, reality testing, and socialization to decrease the sense of threat as we sought acceptance to the patient's territory, followed by building trust and working on past trauma.

Castaways: addressing hostility and helplessness in severely lonely adults.

Hostility and helplessness are recurrent themes in severely lonely adults, and they can be both causes and effects of subjective feelings of loneliness. Since many lonely patients report a history of abuse, hostile and helpless states of mind may reflect identification with hostile (aggressor) or helpless (passive) attachment figures. Hostile intrusiveness and helpless withdrawal by the parent are 2 distinct patterns of parent-child misattunement that can lead to infant disorganization via disrupted emotional communication and to loneliness later in life. Anxious-ambivalent lonely older adults tend to exhibit hyperactivating hostile behaviors (to deal with a core sense of powerlessness), whereas those with fearful-avoidant attachment styles exhibit deactivating helpless behaviors (to deflect intense underlying feelings of rage). Based on this model, we outline different treatment approaches for lonely persons with different attachment styles by describing the successful treatment of two severely lonely, suicidal veterans. We describe an approach to treating hostile and helpless behaviors in lonely patients, using validation, mentalization, reality orientation, and socialization. Validation provides a sense of safety and rapport. Mentalization allows the lonely individual to better appreciate his or her own mental processes and those of others. Reality orientation provides feedback to lonely individuals on whether their perceptions are accurate and reality-based and helps them appreciate the consequences their behavior may have for self and others. Finally, socialization reduces disenfranchisement by teaching/re-teaching individuals social skills that may have become impaired by prolonged isolation.

Severe loneliness in community-dwelling aging adults with mental illness.

Successful aging involves adapting to changing needs. The 2009 U.S. Census noted that 43% of adult Americans are single and that the oldest-old population is the most rapidly growing aging segment. Geriatric, lonely, hopeless individuals are at high risk for depression and suicide. Lonely individuals fail to adapt to their circumstances; and physical and mental illness place them at risk for neglect, morbidity, and mortality. The authors discuss the role of attachment in the individual's subjective experience of loneliness and suggest how attachment theory can be used to guide interventions to improve the individual's self-esteem, coping, and problem-solving abilities. This article also discusses the use of multimodal therapy, including psychodynamic, interpersonal, and cognitive-behavior therapy and coping skills training, to improve the individual's ability to adapt to the surrounding environment and to reintegrate into the community.

The aging physician with cognitive impairment: approaches to oversight, prevention, and remediation.

There are many important unanswered issues regarding the occurrence of cognitive impairment in physicians, such as detection of deficits, remediation efforts, policy implications for safe medical practice, and the need to safeguard quality patient care. The authors review existing literature on these complex issues and derive heuristic formulations regarding how to help manage the professional needs of the aging physician with dementia. To ensure safe standards of medical care while also protecting the needs of physicians and their families, state regulatory or licensing agencies in collaboration with state medical associations and academic medical centers should generate evaluation guidelines to assure continued high levels of functioning. The authors also raise the question of whether age should be considered as a risk factor that merits special screening for adequate functioning. Either age-related screening for cognitive impairment should be initiated or rigorous evaluation after lapses in standard of care should be the norm regardless of age. Ultimately, competence rather than mandatory retirement due to age per se should be the deciding factor regarding whether physicians should be able to continue their practice. Finally, the authors issue a call for an expert consensus panel to convene to make recommendations concerning aging physicians with cognitive impairment who are at risk for medical errors.

Integration of religion into cognitive-behavioral therapy for geriatric anxiety and depression.

Religion is important to most older adults, and research generally finds a positive relationship between religion and mental health. Among psychotherapies used in the treatment of anxiety and depression in older adults, cognitive-behavioral therapy (CBT) has the strongest evidence base. Incorporation of religion into CBT may increase its acceptability and effectiveness in this population. This article reviews studies that have examined the effects of integrating religion into CBT for depression and anxiety. These studies indicate that improvement in depressive and anxiety symptoms occurs earlier in treatment when CBT incorporates religion, although effects are equivalent at follow-up. The authors present recommendations for integrating religious beliefs and behaviors into CBT based on empirical literature concerning which aspects of religion affect mental health. A case example is also included that describes the integration of religion into CBT for an older man with cognitive impairment experiencing comorbid generalized anxiety disorder and major depressive disorder. It is recommended that clinicians consider the integration of religion into psychotherapy for older adults with depression or anxiety and that studies be conducted to examine the added benefit of incorporating religion into CBT for the treatment of depression and anxiety in older adults.

The after-death call to family members: academic perspectives.

OBJECTIVE: The authors discuss clinical and teaching aspects of a telephone call by the treating clinician to family members after a patient dies. METHODS: A MEDLINE search was conducted for references to an after-death call made by the treating clinician to family members. A review of this literature is summarized. RESULTS: A clinical application of the after-death call is proposed, with emphasis on a "no regrets" approach. The authors also discuss the management of "at risk" situations, and end with teaching points. CONCLUSION: The after-death call is an example of "best practices" in the care of every patient, and can be used to teach residents and students of all disciplines. Primary care providers and consultation psychiatrists may find this valuable as they communicate with families in the sensitive and often traumatic context after a patient dies.