Robert E. Reichlin, Ph.D.

Houston Psychologist ∙ Psychotherapist ∙ Geropsychologist ∙Bellaire, Texas

Caregiving & Dementia, Part II- Time

Thursday, January 30th 2014

In my previous post, I discussed some of the elements that make the caregiving of older adults diagnosed with a dementia rather unique. Another aspect to consider is the experience of time. One of the many accomplishments of childhood and adolescence is to develop a complex understanding of time: time as a set of boundaries by which we regulate behavior or allocate effort toward goals; time as an experience of duration or action taken in a timely manner; time as having a sense of history or the experience of reviewing one’s past. These aspects of time reflect some of the complexity and depth of the word. Usually, we move freely across these nuances with little thought (sometimes too little). But, when someone we care for begins to make frequent errors with time, it is rather difficult at first to understand what is happening. For example, many early stage patients can attend to their personal daily activities (shower, toilet, dress, etc.) but do so more and more slowly. In my experience, such individuals rarely experience how long it is taking them other than the self-perception of being slow. Cognitively, what seems to be occurring is that the person is struggling to recall the sequence of actions necessary to complete the task at hand (e.g. which clothes to wear or the order the clothes are put on). When executive functions (such as maintaining focus, managing time, planning and organization, self-control of behavior, and integration of past experience with present experience) and memory begin to unravel, simple tasks that must be completed in a timely manner take longer and longer.

In other words, experientially, the sense of duration is impaired. Without a sense of duration, it is harder to judge when things happened or will happen. In a way duration provides the experiential link between past and future (e.g. this happened way back when; that will happen a little later). As the use and experience of time as an integrated set of skills becomes impaired in conjunction with memory failure, the person becomes increasing forced into a present that has no past or future element. This ‘being in the moment’ isn’t the same thing as mindfulness or being present in the usual sense because there is nothing else but the present (as the disease progresses). Caregivers eventually learn to communicate with the impaired person as if only the present matters–not so easy to do at first because of our expectations of normative adult functioning and the fact that cognitive impairment doesn’t occur in a predictable manner.

Perhaps the most difficult problem related to the impairment of time sense is repetition of questions. For the patient, he or she asks questions multiple times because there was neither a memory formed of the question having been asked nor of the answer given. Hence, he or she experiences the repetition as the first time the question was asked! There is no experience of the interval between each question and answer, no experience of duration. Part of the caregiving task is to develop a view of the patient’s difficult behaviors as unmotivated– they are not asking the same question over and over again to drive you crazy (although it may feel that way). What if that behavior is viewed as an effort of adaptation that has failed, i.e. the person keeps asking because he or she wants to know where they are going, or what’s planned for the day, etc? By seeing the behavior in that light, we might have enough empathy to react in a helpful way by repeating the answer or re-directing the conversation to another topic. Re-direction feels discourteous– one is simply, and without preface, changing the subject abruptly. But, it can work, provided we do not express our frustration, weariness, or irritation that accompany such situations.
Contact Dr. Reichlin at 281-813-7202 Drreichlin@robertreichlinphd.com

Caregiving & Dementia, Part I

Wednesday, October 3rd 2012

Today I want to address the issue of the caregiving of individuals with dementia (e.g. Alzheimer’s disease, Vascular dementia). I have been working with caregivers and their families for many years and I’ve observed that there are a number of common events that should be better understood. This post is Part I of a series of posts that will be forthcoming about caregiving.

It’s been my experience that it takes about 2 years for a person to learn how to be an effective caregiver of someone with a dementia. Why so long? I want to discuss two aspects of the answer to this question: assumptions about what’s normal and comparisons to childhood.

It takes time to understand the nature of this kind of illness so that one can distinguish between behavior that in the past appeared intentional from behavior that is most likely determined by a neurological disease that is progressive. Part of growing up in any culture involves developing a set of expectations for how an adult is supposed to act. We take for granted that our spouse, parent, brother or sister, etc., has the capacity to reason, understand speech, draw logical conclusions, focus their attention, and remember what has been said or observed. Of course, there are variations in all this depending on the situation, the personalities involved, the nature of the relationship, etc. But, these expectations are revealed in sharp relief when the person stops acting in conventional ways. For example, repetitive questions occurring over a short time, not recognizing familiar people or places, being unable to perform simple tasks in a sequence (e.g. getting dressed), saying things in public that are both out of character for the person and inappropriate to the situation.

People diagnosed with a dementia are not children. The similarities are that as the disease progresses, the person becomes more dependent. Also, the ways we have to assist that person, especially with simple tasks- are reminiscent of childrearing. But, a person with dementia is an adult disabled cognitively. What’s the difference? If you’ve reared children or been around them, you know that they learn exponentially, and children strive to be independent. That is a very different context from which to understand someone’s behavior (e.g. when you’re helping a 3 year old to get dressed you’re not thinking of how tragic it is that he/she has lost that ability). It’s the difference between witnessing a slow, grinding destruction of hard won skills and autonomy instead of the often exciting race to grow up and be independent.

As will become evident in future posts, caregiving for a disabled adult requires new skills, a different sensitivity, and a deep compassion- similar to parenting- but ultimately very different. The patient will die – that is for certain. With love and safety and some luck, the child will grow up.

Thank you for reading this post.

If you find that my perspective on caregiving makes sense to you, and you are considering psychotherapy, send me an email or give me a call and we can schedule an appointment.

Contact Houston Psychologist Dr. Robert Reichlin 281-813-7202 Drreichlin@robertreichlinphd.com

Failure, the Blues, & Baseball

Wednesday, August 5th 2009

This being baseball season, it seems an opportune moment to comment on one of the many things about the game that, for me, has been a source of amazement: If you fail to get a hit 7 times out of 10 for twenty years you go the Hall of Fame. Ty Cobb, for example, played 24 years in 3035 games and was at bat 11,434 times. He got 4189 hits (meaning he did not get a hit 7245 times!). Think of that, each time you go to bat you are very likely to fail (for purposes of argument, I’m excluding walks and sacrifices). And, it’s completely transparent- the public can see every mistake! Failure at the plate or in the field (called “errors”) is the norm, not the exception. Ball players know a lot about failure and what it takes to be a success.

Failure is problematic for any number of reasons. There are small failures and serious failures. There are failures that knock us way off track and are difficult to recover from. There are other failures that somehow result in new opportunities. What is striking about failure is that it represents a kind of crossroads. Now, as you blues fans know, Crossroads Blues is a famous song by Robert Johnson (and Cream). Johnson was reputed to have made a pact with the devil: he exchanged his soul for his extraordinary ability to play guitar (Johnson clearly got the better part of that deal). Many cultures have folk tales concerning crossroads which are viewed as a location between the natural and supernatural, representing liminality, i.e. a place neither here nor there, or betwixt and between (http://en.wikipedia.org/wiki/Crossroads_(culture)). If we think about failure as a kind of crossroads, it can be viewed as a point at which an important choice is to be made. We can see it as having the potential for learning and adaptation or retreat and loss of hope. Back to baseball:

When a major league ballplayer comes to the plate he can’t dwell on his last failure to get on base. To do so would compromise the most important thing he can do- see the ball (paying attention to what kind of pitch the pitcher throws). Previous experience with that pitcher and his statistics (what he throws and when) figure in to be sure. But, when it counts, it is the present moment that defines the batter’s reality: no past, no future, no place other than at the plate, a place that is always indeterminate. All the training, all the practice, every review of mistakes, leading up to that moment provide the backdrop to the immediacy of being at the plate; but they don’t define it. That only occurs when the pitcher throws and the batter decides (with remarkable speed) whether to swing or not. A batter wants to get a hit, maybe even needs to get a hit, but he also knows that if he is thinking about getting a hit, he is not fully present to the ball coming at him. Staying focused requires good preparation and the ability to block out distractions. It means to let go and to take a risk. All success is predicated on just these factors: preparation, focus, and risk. Or, as Seneca the Roman philosopher (and the Marine Corps by the way) puts it: Luck is what happens when preparation meets opportunity.

In a highly competitive society that seems to regard failure as a moral weakness, yet exhorts us to learn from our mistakes, it is very hard to experience failure as a necessary part of learning and success. To do so would mean to suspend our expectation of having to get it right every time (whatever ‘it’ is). If you’re concerned with getting it right, you’re not paying full attention.

Failure inevitably involves tolerating our emotional response to failure. If we learned that failure is responded to with disapproval, we are likely to experience failure as deeply wounding. You can’t learn or take a necessary risk when you’re hurt like this because the task is to recover one’s equilibrium and feel better rather than to ask oneself what there is to learn from the failure. If too much pain follows failure, focus is deflected and risk is avoided.

To sum up, failure is integral to success because it shares with success 3 factors: preparation, focus, and risk. That failure occurs should come as no surprise since one can never be certain that one is fully prepared, completely focused, or fully cognizant of all that risk entails. But, we are going to come up to the plate whether we want to or not. Life is full of crossroads. Are you going to watch the ball or think about striking out?

Thanks for reading this post.

If you find that my perspective on success and failure resonates with your experience, and you are considering psychotherapy, send me an email or give me a call and we can schedule an appointment.

Contact Houston Psychologist Dr. Robert Reichlin at 281-813-7202 Drreichlin@robertreichlinphd.com

Health Care for Grown Ups

Sunday, July 12th 2009

In view of the current discussion about health care, I want to make two comments. They are not about a specific plan or political position. Rather, my perspective addresses fundamental issues that, to my way of thinking, are foundational. Of course, these comments refer to those who have accessible medical care.

First, it is my view that each citizen has a social and communal responsibility to care for her or himself. It’s not the physician’s job, it’s not the government’s job. It’s our responsibility to society and ourselves. It’s our job to be informed, to advocate for ourselves, to select the right doctor- no one else’s. It is our job to follow what our physician advises, provided we understand its rationale or, to work with the physician to develop a treatment plan that we are willing- with help- to put into action. It is not our role as patients to be taken care of in the sense of waiting passively for the physician or her or his office to reach out to us.

Second, the way medicine is taught and practiced in the U.S. renders it rather poorly prepared to treat chronic illnesses over the duration of the illness. When there are acute episodes of the illness or changes that are unexpected, medicine can respond quite well. However, for the long haul, it is the patient who must manage her or his disease in conjunction with a physician’s recommendations for self-care. This is particularly true for middle-aged and older adults: the interaction between a chronic illness and age-related changes is inevitable. So must be the assumption that we must be active participants in our own care.

Find the physician who wants to collaborate, who sees her or his responsibility as, in part, insuring that you can learn what your role is in your own care, and will hold you accountable. Sometimes we can’t follow a prescribed regimen: that’s not necessarily a failure on your part or the physician’s, but a real problem for you and your physician to work through (e.g. what are the obstacles to following a specific treatment plan?).

This is an adult approach to health care. The rest is wishful thinking and politics.

Thank you for reading this post.

If you find that my perspective on makes sense to you, and you are considering psychotherapy, send me an email or give me a call and we can schedule an appointment.

Contact Houston Psychologist Dr. Robert Reichlin at 281-813-7202 Drreichlin@robertreichlinphd.com

Psychotherapy and the Stages of Adulthood

Sunday, June 28th 2009

I specialize in working with adults of all ages. Accordingly, I see a wide range of difficulties, given that adulthood can last 60 or more years. In addition to working with younger adults (20-65) over the past 30 years, I have also worked intensively with men and women in their 80’s and 90’s. They have taught me that the challenges of life in one’s twenties or thirties are quite different from those facing someone in middle age or late adulthood. I have found that appreciating these distinctions and utilizing them in psychotherapy requires a sensitivity to the processes of adult development.

Emerging Adulthood
Young men and women in their twenties are faced with two significant tasks: they must launch a career, and emotionally separate sufficiently from their family of origin to establish adult relationships with peers and begin the task of finding a life partner. These are complex activities with many obstacles. Psychotherapy can be helpful in assisting the person in developing plans, focusing on vital issues, strengthening self-esteem, and overcoming the effects of self-defeating behaviors that make successful achievement and effective communication difficult. Creating healthy forms of self-care lays the foundation for healthy adulthood. See Robin Henig’s article: http://www.nytimes.com/2010/08/22/magazine/22Adulthood-t.html?_r=1&src=me&ref=homepage. Also, see the Clark U.poll: https://news.clarku.edu/news/2015/01/29/clark-university-poll-established-adults-enter-2015-feeling-positive-dreaming-big/

Middle Adulthood
Competing demands from many sources make mid-life (~30-60+) particularly difficult. One is often confronted by the consequences of decisions made in the past (e.g. career, spouse) as well as the limits of one’s talents, opportunities for achievement, and enjoyment of work. Responsibilities for family and to one’s life-partner are many. Psychotherapy may involve assisting the person in working through unresolved conflicts from the past, identifying new areas of growth, and tempering a mature and flexible self-esteem. Developing and strengthening self-care is essential to these tasks as well as those involving adapting to how one’s body is aging. Life transitions and mid-life crises test one’s ability to maintain continuity as well as to change and adapt to new circumstances. Learning to provide caregiving to elder parents or other family members becomes a necessity for many in this period of life. See my articles, “Longevity I” and “Cognitive Fitness I

Late Adulthood (Geriatric Psychology)
The challenge of late adulthood (70+) is to maintain a sense of vitality and openness to life while at the same time learning to compensate for physical difficulties and the losses of significant others that come with longevity. The kinds of difficulties people face at this time in life include coping with physical impairment and chronic illness, providing caregiving to a spouse or other loved one, grief over the loss of significant others, especially spouses, and loss of independence (e.g. no longer able to drive). Yet, this also a time of discovery where a person begins to see in clear relief the contours of a long life lived, of appreciating the complexities of that life, and that the lessons learned, were learned for good reason.

If you find that my perspective on the Stages of Adulthood resonates with your experience, and you are considering psychotherapy, please email or call me.

Contact Houston Psychologist Dr. Robert Reichlin at 281-813-7202; Drreichlin@robertreichlinphd.com

Cognitive Fitness

Wednesday, June 24th 2009

If you’re over 50, everyone is talking about Sudoku and crossword puzzles, learning languages or a musical instrument as means to protect the brain and possibly prevent Alzheimer’s disease. However, at present, there is no known way of preventing AD or curing it. Given that fact, is there anything we can do to improve our memory or conserve our cognitive skills? To my way of thinking, one way to answer this question is to broaden our scope and consider how our life style choices impact cognitive and emotional health. In this way we can identify goals that can become part of how we live our lives. In this post, let’s talk about cognitive fitness.

Research in the neurosciences has demonstrated that the cliché, use it or lose it, probably holds true. And, there are some things we do know that are more specific. For example there are two rough categories of learning that are being suggested. One has a maintenance function: practicing what you know helps you maintain that skill. So, if you’re a little rusty on multiplication (in your head rather than on a calculator), practicing will bring back previous skills. Same with crossword puzzles: if you’ve always done them, then you are maintaining your skill and not learning something totally new (e.g. Dean Olser on NPR, All Things Considered, June 23, 2009, http://www.npr.org/templates/story/story.php?storyId=105808456). Maintaining skills is important and creating routines that result in practicing skills is the kind of creative adaptation necessary in middle and late adulthood.

Learning something that’s completely new to you is a different matter: drawing, learning the guitar, developing a new sport, etc. There are many, many things on the menu. Take a look at Anne Underwood’s article, Can Dementia Be Prevented?” http://newoldage.blogs.nytimes.com/2009/06/11/can-dementia-be-prevented/?scp=1&sq=can%20dementia%20be%20prevented&st=cse). She points out that what matters seems to be that the learning be complex, engaging a variety of cognitive skills. For example, learning to play a musical instrument requires that we learn to listen differently, attending to how sounds relate to each other and to the melody, how sounds can be represented in musical notation, learning about tempo and how that is represented visually, etc. Oh yeah, one has to practice like crazy because one’s hands and eyes have to work together in new ways. Challenging!

That practice and new learning are likely to improve cognitive fitness should come as no surprise: the brain is an organ of the body, and we know ‘physical fitness’ improves our health. Why should the brain be any different? The issue is: are you going to take deliberate action designed to improve your cognitive fitness?

Thank you for reading this post.

If you find that my perspective on cognitive fitness makes sense to you, and you are considering psychotherapy, send me an email or give me a call and we can schedule an appointment.

Contact Houston Psychologist Dr. Robert Reichlin at 281-813-7202; Drreichlin@robertreichlinphd.com

Longevity

Wednesday, June 17th 2009

As the population across the world has aged, new concerns have emerged. Longevity now appears to be something to be expected in societies that have enough affluence and stability to provide public health services, disease prevention and control, and health care. To give you a little perspective:

For all races in the U.S., life expectancy at birth in 1900 was 47.3; in 1950 it was 68.2, and in 2005 it was 77.5 (with females 80.4 and males 75.2; my source is: The Centers for Disease Control, http://www.cdc.gov/nchs/data/hus/hus08.pdf#026). These are rather extraordinary numbers. Using these data, in the United States, you can expect to live much longer than your great-grand or grand parents. What does this mean for us?

For our purposes here, let me point out that in addition to the need for greater financial resources, cognitive, social/emotional and physical well-being will also be essential in the years following retirement (which could last 20 or more years!). Preparation for this period of adulthood will need to begin much earlier so that one is able to take advantage of the significant changes that accompany retirement.

Let’s use an example: If you are working, think about your average day: you have a schedule, responsibilities, and individuals with whom you interact. Work, in one sense, is about structure – social, motivational, and goal-directed in real time. This complex structure mobilizes many of our abilities that include cognition, sociability, and physical endurance. If you aren’t working, what will replace this complex structure? How will you stay motivated to learn or perform, develop new relationships, stay physically fit over a decade or 2?

If you find that my perspective on cognitive fitness makes sense to you, and you are considering psychotherapy, send me an email or give me a call and we can schedule an appointment.

Contact Houston Psychologist Dr. Robert Reichlin at 281-813-7202; Drreichlin@robertreichlinphd.com

Changing Behavior

Thursday, June 11th 2009

Why is changing behavior so difficult? One would think that recognizing the logic of changing one’s behavior when necessary would be sufficient. But, it’s not. Not even consequences that are painful make change any easier.

The Spanish philosopher, George Santayana, is famous for his aphorism, “Those who cannot remember the past are condemned to repeat it.” However, he has another that speaks directly to the issue, “Repetition is the only form of permanence that nature can achieve.” I interpret this quotation as follows: life is inherently conservative. We do not make changes quickly because it would be dangerous to do so. Why? We seem to perceive change as destabilizing our sense of permanence, of security. So, we do the same thing over and over again, thinking that through repetition we gain that security. The irony of this choice (one that is rarely conscious) is that this assumption (that repetition provides security) often leads to a marked decrease in our ability to respond to our world in creative and more adaptive ways. We see only what we want to see, remaining within the illusion of safety. Learning about oneself and one’s impact on others becomes less important than maintaining the status quo. More about this later.

Thank you for reading this post.

If you find that my perspective on changing behavior makes sense to you, and you are considering psychotherapy, send me an email or give me a call and we can schedule an appointment.

Contact Houston Psychologist Dr. Robert Reichlin at 281-813-7202; Drreichlin@robertreichlinphd.com

Goal Setting

Tuesday, June 2nd 2009

In my last post, I talked some about realistic goal setting, particularly as it applies to activities that require ongoing effort. I used working out as an example because it captures many of the aspects of self-discipline that are difficult to maintain: showing up and developing modest, flexible goals. The issue today is that goal setting can be approached in terms of setting specific points to be reached on some scale, e.g. increasing the amount of time you exercise by 10 minutes each week, or lifting 10 pounds more every week. To accomplish these goals, one has to control a number of variables: setting the time for exercise, making sure that schedule isn’t interrupted, deciding on how to handle the situation if you are traveling, become ill, stay up too late, have to be at work earlier/later than usual, etc. Compare that to setting a goal of losing a pound a week. Such a goal requires the control of a number of things that are in themselves difficult to control, e.g. sticking to a diet has its own rhythms and complexities (it takes 3500 calories to make/lose a pound). Being exposed to an onslaught of food stimuli is also hard to prevent. You get my point- deciding on goals requires careful evaluation and modesty: in this case, a pragmatic approach means tolerating life’s complexities in a flexible manner. Not so easy to do. More about this later.

Thanks for reading this post.

If you find that my perspective on goal setting makes sense to you, and you are considering psychotherapy, send me an email or give me a call and we can schedule an appointment.

Contact Houston Psychologist Dr. Robert Reichlin at 281-813-7202; Drreichlin@robertreichlinphd.com

Self Care

Friday, May 29th 2009

Today’s post begins a discussion about a general way of thinking about yourself that incorporates wellness, self-discipline, and self-efficacy. Let me define my terms first: wellness refers to being in good physical and emotional health; self-discipline refers to the ability to pursue what you think is right despite temptations to abandon it; and, self-efficacy refers to the sense that you can achieve or accomplish something you want to accomplish. As you can probably see these terms are somewhat circular: to be self-disciplined, it helps to be in good working order; to have the confidence that you can achieve something, it helps to have the ability to stay focused, etc.

But, my guess is that these words are not so easy to bring to life, that we all feel that we fall short on each. I think the reason for this is based on how we are educated as children and how children interpret what they are being taught. From early on we are instructed to be persistent, to practice, practice, practice, to do our homework every day. While it is true that such teaching works (after all, most of us got through school), it may also be true that youngsters hear those instructions as a sort of infinite command followed by a very real finite response; meaning that we come to evaluate ourselves in terms of absolutes. Sort of a ‘do it right or don’t do it’. The problem is that many things can’t be done right every time or even most of the time. Self-discipline seems always out of reach because we expect ourselves always to get it right. So, if you don’t make it to your work out every time then you aren’t very self-disciplined. My experience with this is rather different. The task begins before the activity- we have to plan how we are going to do things that take into account the fact that we are very busy, often fatigued, etc. Setting modest goals, regarding success as defined by showing up rather than always achieving the goal of the activity, and not looking back are pragmatic ways to structure a disciplined activity.

Thanks for reading this post.

If you find that my perspective on self care makes sense to you, and you are considering psychotherapy, send me an email or give me a call and we can schedule an appointment.

Contact Houston Psychologist Dr. Robert Reichlin at 281-813-7202; Drreichlin@robertreichlinphd.com

Robert E. Reichlin, Ph.D.