The approach illustrated in Assisted Living Decisions in Psychotherapy has origins in a contextual framework. It assumes that a person's cognitions, emotions, and behaviors can be understood in the context in which they occur. Assisted living decisions generally occur in the context of loss: Adults — just like you and me — are losing their ability to independently manage challenges of daily life due to cognitive or physical decline, or both. Routines and divisions of labor that have been established over decades are breaking down.
When individuals experience cognitive and physical decline, they are not only trying to cope with a significant loss of skills but also with changes in their relationships and day-to-day interactions. Their own attempts to compensate for losses may be ineffective and may strain relationships even more. Not surprisingly, in addition to the psychosocial difficulties brought about by cognitive and physical decline, the mere mention of assisted living may lead to conflict within families.
In a time of profound loss and uncertainty, the approach illustrated here works by identifying preferences and values that have guided the person's life so far. Given chronic illness, what activities are still working for the person and match the person's overall life direction? For example, if he or she tended to a garden, how can engagement in planting, growing, nurturing, and harvesting be preserved? What activities are not working anymore? Can a modified prosthetic environment support these longstanding activities, or is there a need for replacement activities that carry similar meaning?
The process of identifying and addressing facilitators and barriers to living a values-oriented life — situational, emotional, physical, cognitive, and behavioral — is called a "functional analysis" and is a key part of the contextual behavioral science approach. The goal of this analysis is a person-environment match. Transitioning successfully from independent to assisted living requires discovering viable ways to maintain important relationships, to live one's values, and to honor one's preferences in the presence of chronic disease.
Frequently, the substantial loss of skills is matched by family members', spouses' or friends' growing concerns for the person's safety. A sense of urgency can lead to an abrupt role shift when significant others assume caregiving responsibilities and preclude participation in choices "for the person's own good." Sometimes significant others are eager to force a decision, any decision, in an understandable yet impulsive attempt to escape from a very stressful experience. Lopsided interactions can become an unworkable battleground, a lose/lose situation in terms of successful transitioning to assisted living as well as cultivating the personal relationship.
An alternative is also illustrated with this DVD: It shows how to slow down caregivers' decision-making process and how to refocus caregivers on promoting mutual respect and trust, by considering the person's history as an active, competent agent in his or her life. This approach helps caregivers notice futile care strategies and build the psychological flexibility to genuinely interact with the person whose skills are failing, in the service of a long-term, amenable solution.
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