“Intersectionality” in Geriatric Mental Health

My favorite multisyllabic term from college refers to how socioculturally defined categories such as class, gender, race and other dimensions of identity interact to promote inequity. For most of us who are passionate about a cause, the challenge isn’t to understand the implication of falling along different sides of each category or dimension, but to figure out how these forces multiply and play out in different contexts.

Being an older person in a psychiatric hospital can be quite different from being someone with chronic mental illness in an assisted living facility. Geriatric nurses and social workers with training in mental health are a great asset, but it isn’t a given that they can always appreciate the importance of integrating their knowledge from different specialty areas, rather than compartmentalizing it.

As one grows older, the clinical presentation and subjective experience of mental illness may change. Part of it has to do with biological aging, part of it socially driven, part of it one’s history of mental illness. When older patients repeatedly complain about side effects of their psychotropic medications, it may have to do with slower metabolism rate, more complicated drug interaction, or maladaptive personality traits, rather than “because they can’t remember anything anymore!” Of course, it is also possible that as their social network shrinks, they may become more dependent on health care professionals, the only people they interact with.

It is not enough for mental health professionals to know what constitutes normal aging and how to accomodate aging-related changes. Adaptation means MUCH more than slowing down (In fact, you run the risk of being patronizing if you overdo it.) We need to consider how mental illness may have made the experience of aging more challenging, and how aging has made living with mental illness more difficult. When an older person refuses to eat, it is not always because he is paranoid or depressed. It may have nothing to do with his dentures. Perhaps he simply doesn’t like mashed potatos and green beans!

To add another level of complexity, consider the role of culture. At one facility, coworkers often wondered out loud about a patient from a different culture, “Why is she always gesturing and talking loudly? Is she psychotic or is this a cultural thing?” The patient did come from a culture where people were very “expressive,” but she also happened to be hard of hearing, feeling misunderstood because of her language barrier, and a little paranoid. Having someone piece these together was important, because whether her behavior was acceptable at our setting and how we chose to intervene often depended on our conceptualization.

This is a summary of research put together by APA in 2003 regarding ageism.

This is a literature review by the Centre for Policy on Ageing in the UK in 2009 on ageism in mental health care.

For those working in eldercare settings, have you ever felt stuck when dealing with residents with a mental illness other than dementia and depression? For those working in psychiatric settings (civil or forensic), what is your experience with clients presenting with aging-related changes and challenges?


About C

If you consider volunteering at a luncheon for older adults as my first exposure to the field, I have been in geropsychology for at least twenty years. As family, friend, volunteer, trainee, and professional, I have found myself in adult day care centers, senior centers, senior living facilities, nursing homes, medical and psychiatric wards, hospice, and personal homes of older adults. Wherever I go, be it an orphanage, a museum, a prison, an airport, or a random corner in the neighborhood, issues related to aging and mental health often come to mind. I used to think that I could make a difference only if I became a top-notch researcher, educator, or clinician. As I continue to follow this meandering path, it dawns on me that as a nobody in the field, I can still add my light to the sum of light by sharing what I know. Over the years, I have "converted" a few very dedicated individuals to focus on aging-related work within their respective disciplines and encouraged a handful more to stay in this field despite its winding course. I believe by bringing aging and mental health issues to the foreground, we will amass a stronger force to promote advocacy, research, and quality care.
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