PTSD in Long Term Care

Symptoms of PTSD may persist (Rosen, Fields, Hand, Falsettie, & Van Karnmen, 1989) or be exacerbated (Pary, Turns & Tobias, 1986) during the challenges of illness and institutionalization in late life. Having survived life threatening events may provide a basis for enhanced resilience or vulnerability in the face of these challenges (Elder & Clipp, 1989). This case study is described to illustrate the potential for therapeutic reconciliation in late life PTSD and the role of therapeutic aids in facilitating that process.

Presenting Complaint

Mrs. F. is a 79 year-old widowed nursing home resident. Her mobility is limited by both left and right hip fractures and replacements, a right rotator cuff tear from a motor vehicle accident, and a C-5 hemilaminectomy from a WWII shell injury. She also has cardiac, pulmonary, and gastrointestinal conditions. A head CT found lacunar infarcts in the basal ganglia and left parietal lobe. Neuropsychological testing found severe difficulties on unstructured tasks of executive function and moderate difficulties for recent memory. Nursing staff have described her as perfectionistic and periodically rageful and tearful. Following these complaints, the psychiatrist diagnosed her with bipolar disorder and prescribed Depakote to reduce lability. The social worker provided counseling but found “very little improvement.” Eventually Mrs. F. was referred to a PTSD specialty clinic by the nurse practitioner where she was diagnosed with PTSD based on symptoms of hyper arousal (exaggerated startle, insomnia, irritability, angry outbursts, spontaneous tearfulness), emotional numbing (difficulty engaging in close relationships), and intrusive thoughts (nightmares and intrusive memories of WWII). For example, she reported that the current construction in the nursing home was reminding her of the building destruction during WWII and that when she sees other residents with skin ulcers she fights an urge to throw herself over the wounds as she did in WWII.

History

Mrs. F. is the oldest of four children. She excelled in school and pursued a career as a nurse. In 1943 the War Manpower Commission’s Procurement and Assignment Committee rated her a “Class I”–not essential and eligible for war time duty. Although not technically drafted, these nurses were asked to report for service and reminded of their “moral duty to serve.” Mrs. F. became a member of a mobile surgical unit specializing in chest and belly debridement operating while under fire and behind enemy lines, including on the beach of Normandy soon after D-day. She saw innumerable injured, dying, and dead young soldiers. She made decisions about who would receive life saving operations while others died. She was injured by an exploding shell and after a year of recuperation became a director of nursing education and training, as her injuries prevented her from being able to return to surgery.

She developed a reputation as a fair but extremely demanding educator. She was one of the first to admit men into nursing training, based on her experience with male medics in WWII. Throughout her life she had distant relationships with friends and boyfriends. She was briefly married to a distant cousin, although she describes this as a “marriage of convenience.” However, since being admitted to the nursing home she has developed a more close and trusting relationship with another male resident. She reports that the only time she sleeps restfully is during her afternoon nap when he rests in a chair at her bedside, holding her hand.

Psychotherapy

In the first phase of psychotherapy (six weeks) she complained exhaustively about the nursing staff. When asked questions about her military history she tended to repeat a few well-rehearsed stories. When asked specific questions about these experiences she tended to return to her complaints of the nursing staff.

Because a traditional approach to therapy was not productive, in the second phase of psychotherapy (eight weeks) she was seen twice per week and a therapy notebook was introduced to structure both the goals and process of therapy. A loose leaf binder was divided into four sections: childhood, war, career, and late-life. Therapy sessions focused on recording the important experiences and essential lessons from each period and placing these recordings, pictures, and newspaper clippings in the appropriate sections. Discussions of childhood focused on the development of high expectations and moral ideals. Discussions of her war experiences reminded her of her pride for having served, her sorrow for what she saw, and finally, her need to forgive herself for not being able to save everyone.

The third phase of psychotherapy (twelve weeks) returned to weekly sessions and focused on her career as a nurse educator and her life in the nursing home. Eventually Mrs. F. transcribed a two page list of her nursing ideals. The process of committing these to paper allowed her to make these tangible although they were not always tangible in her environment. Therapy was used to emphasize that she retains control over her own values, including her nursing ideals, while recognizing that she is not currently in a position of authority for implementing these.

Mrs. F. came to believe that her childhood and war experiences resulted in her being “perfectionistic.” In war, cleanliness, speediness, and the overall quality of responsiveness meant life or death for others. She brought these same rigorous and inflexible standards to her nursing students and her present life as a nursing home resident, framing many situations with the same life and death urgency. As therapy progressed she decided her goals were “to accept” and “to develop inner peace.” She learned to differentiate between her experiences as a surgical nurse, a director of nurses, and a nursing home resident, realizing that her exacting standards did not always apply and were alienating her caregivers and robbing herself of “inner peace.” She chose focus on the autonomy left to her in physical rehabilitation, arts and crafts, and writing old friends and colleagues. She requested help in lettering and framing her therapeutic goals and a new life philosophy, “adjust to what is available, and make what’s available adjustable.” Repeating these goals in psychotherapy sessions and having these goals visibly present in her room kept her personal goals and values in mind when deciding how to resolve institutional upsets. Of note, during this time period she also applied for a service connected disability award and was rated to be service connected for PTSD, which further validated her sense of herself.

During the fourth phase of therapy, weekly sessions continued to focus on application of the life review and integration captured in the therapeutic notebook. In addition, Mrs. F. joined a time limited relaxation training class. She was an enthusiastic member and liked that she could use the strategies (e.g., diaphragmatic breathing) even in public settings (e.g., the dining room). Nursing staff had fewer complaints about her behavior, although there remained contention between Mrs. F. and some of the nurses because of their differences of opinion as to what was expected of a nurse.

CONCLUSION

This case illustrates how traumatic events may shape responses which are carried into situations later in life. Mrs. F.’s extremely high standards and emotional distancing were important to her ability to save lives during her military service and also served her in her nursing career. Late in life, Mrs. F. lost her health, home, and independence. These losses, her lack of autonomy to execute her high standards in her new environment, and perhaps the re- introduction to a military-like environment resulted in an exacerbation of PTSD symptoms and the development of overwhelming anger and grief. Defense against traumatic re-experience, a high level of affect, and cognitive disorganization made therapeutic inroads difficult. However, the use of a therapy notebook to structure the therapeutic process and the display of therapeutic goals and outcome both in the notebook and on the walls facilitated this veteran in understanding herself, forgiving herself, and shaping a new life in the nursing home which brought forward her values and maximized her sense of dignity and autonomy. The therapy taught the undersigned therapist about the possibility of reconciliation and healing late in life even in the face of limited options and documented cognitive dysfunction, and taught a history lesson on the often overlooked role of nurses in WWII. It is difficult to systematically study the role of traumatic events in life-span development because of the heterogeneity of these events and the way in which they are integrated to influence outcome late in life. However, a more thorough understanding of the societal contributions and personal consequences of such military service seems worthwhile.