Chapter 17 PSYCHOSOCIAL AND SPIRITUAL ASSESSMENT

INTRODUCTION

Psychosocial and spiritual assessments are addressed separately, but they can be interrelated in situations where active engagement and participation in spiritual experiences with other people enhances the psychosocial wellbeing of an older person. The underlying social integration that occurs when spiritual experiences are shared with others can be a protective factor against mental health problems. In this chapter, the term spirituality is used in a very broad sense to recognise that some people have spiritual experiences and practices, but do not subscribe to a recognised religion or system of faith and worship (e.g. Christian or Muslim).

PSYCHOSOCIAL FACTORS

Almost every aspect of an older person’s mental health status is shaped by psychosocial factors. These factors influence the occurrence and course of a mental health problem, how a person behaves and adapts to being unwell, and how well they recover and remain healthy. Psychosocial factors are broad and include self-identity, self-esteem, sexuality, family life, household structure, education, working life, social and recreational activities, hobbies and interests, retirement, losses, socioeconomic status, transportation and access to services.

A framework that has stood the test of time for conceptualising people’s needs, including psychosocial needs, is the work by Maslow (1970). According to Maslow, for normal human development to occur, the physical needs of nutrition and hydration have to be satisfied first and then the emotional needs of love, belonging and self-esteem can be met. After these basic needs are satisfied, then the person can continue to grow psychosocially by seeking meaning and fulfilment in their lives so they eventually reach the stages of self-actualisation and self-transcendence.

As people get older, how they perceive and address their psychosocial needs may influence their ability to remain independent, and how they deal with loneliness, social isolation and the development of mental health problems. Psychosocial support can vary enormously from a brief, weekly visit by one person for a housebound older person through to a person who has three or more social engagements outside the home almost every day. It is not the quantity of interactions but the quality that is the most important aspect. When an older person is struggling with mental health problems, it is high-quality psychosocial support that will act as a buffer in moderating the impact of the stress and will also have a strong influence on recovery. However, addressing an older person’s psychosocial needs is not just a simple matter of introducing and encouraging the support of other people or networks. Unwanted and stressful social engagements can also be detrimental to an older person’s mental health.

The reason assessment of this area is so important is that psychosocial support can mean a lot of different things to each and every person. Individual contacts and networks are used in different ways to satisfy the older person’s needs. These needs can be human contact, emotional connectedness, personal growth, information, advice, the sharing of confidences and ideas through to general conversation. Satisfying one’s needs leads to achieving purpose in life and, no matter what age, most people still want to have a purpose, to learn, contribute and be creative.

In undertaking a psychosocial assessment, the foremost question usually is what the older person perceives as their health concerns. Conversely, the mental health worker may want to focus on optimising physical functioning first because they can see the long-term benefits in such an approach, but this may not be what the older person wants. There may be a cognitive or emotional aspect to their health that the older person considers to be more important to them and their quality of life.

Identification and expression of such matters may not come easily to some older people. Through sensitive questioning, the mental health worker can create the opportunity to explore the older person’s thoughts and feelings in relation to the psychosocial aspects of their life to determine which areas need strengthening and how this may be done. Many older people are very resourceful and recognition needs to be given for this. Some questions to explore psychosocial issues could be:

• What strategies have you used in the past to help overcome adverse events?

• Who do you turn to in crisis?

• Who do you call for everyday help, practically and emotionally?

• What do you see your strengths as?

• What do you see your weaknesses as?

• What are your goals and desires?

• How do you go about achieving your goals and desires?

• What do you fear?

• What do you not want to do?

• Do you feel as though you have reached your potential in family, work and public life?

Ecomaps

To determine the size, structure and strength of psychosocial networks, a good starting point is the use of an ecomap (Wright & Leahey 2000). The ecomap is an extension of the genogram, which outlines family relationships. The ecomap is a graphic depiction of contact, with not only family members, but also friends, social contacts, health services and any other significant contact. A lot of information can be contained in these diagrams. Information is recorded in squares or circles, which can be strategically placed or organised to show how all the relationships fit together. The strength of the relationships is signified by lines. Straight lines indicate strong relationships (the wider the line the stronger the relationship), while dotted lines indicate weak relationships and slashed lines indicate conflictual relationships. The frequency of contacts can also be noted on the diagram. See Figure 17.1 for an example of an ecomap.