Beyond “DEATH and Dying” – Part 3

Anger

Meet Harry.  Every building has one – the resident who is NEVER HAPPY.  “The oatmeal is lumpy.”  The building’s too cold; you keep the thermostat too low. You people don’t understand or care about the needs of old people!  I never had this problem at home.”

Sound familiar?  It might be Harry, or Mabel, or Mrs. Smith but the common characteristics are that you can’t seem to make them happy and they often lash out at employees and even other residents for no apparent reason.  They may be very vocal in complaining about other resident’s “disabilities” – e.g. he states loudly in the dining room “There are too many #*&^! walkers in this place; they’ve put me in a nursing home with a bunch of old, sick people!”

In “On Death and Dying”,  Dr. Elisabeth Kubler-Ross taught us that ANGER is a normal human reaction as a part of the process of grieving for a loss.  She says: “When the first stage of denial[1] cannot be maintained any longer, it is replaced by feelings of anger, rage, envy, and resentment.”  Many older Americans don’t understand WHY they have suffered this loss – i.e. the death of a spouse, inability to easily accomplish physical tasks that used to be second-nature to them, a reduction in mental capacity and clarity, or even the loss of certain bodily functions such as continence.  These cause a great deal of frustration for the individual who questions what he/she did wrong to now be faced with this loss.  They ask “Why me and not so-and-so?”  As a result, they often express their resentment towards others who are not similarly affected.

Dr. Kubler-Ross points out that anger is often “displaced in all directions … almost at random” and that family and staff members often find it very difficult to cope with.  Even worse, the anger often feeds on itself and leads to an increasingly problematic cycle.  Especially when the resident believes they have been forced to move into the facility, “the visiting family is received with little cheerfulness and anticipation, which makes the encounter a painful event.”  The family members “either respond with grief and tears, guilt or shame, or avoid future visits, which only increases the resident’s[2] discomfort and anger.”  And, of course, that just drops the problem in the lap of the on-site management.

Compounding this situation is the senior’s perceived loss of independence and control, coupled with their fear of the unknown.  They faced many challenges throughout their adult life and generally found a way to overcome or at least handle those concerns.  Now, they are being forced to deal with the effects of aging and their own mortality, while society and even their own family tell them that they need “help”.   So, if they can’t control their own situation today, what chance do they have to control it in the future?

We know that Harry uses a cane but we don’t know why at this point.  It could be arthritis, a joint replacement, effects of a stroke, or general weakness.  However, when he sees the walkers in the dining room, he knows that might be the next step for him.  He doesn’t want to be reminded of that potential or that he doesn’t know how to stop it from happening so he “acts out” his anger.

How Does this Concept Impact Marketing?

Consider the following points:

  • Unhappy residents are not long-term residents. They will move themselves out, their family will get tired of the complaints and move them out, or their angst may lead to an earlier death.  Regardless, the community will have to find a new resident to fill the vacancy.
  • STUFF HAPPENS in any building.  Most of the time, residents are relatively understanding and management can fix the problems and move on.  However, the “angry resident” stirs the pot with their irrational complaints.  Sooner or later, the rest of the residents begin questioning whether the complainer is “all wrong” and become less tolerant of the management and staff.
  • Likewise, family members forget how difficult Harry used to be for them to handle and have a tendency to start blaming the staff for Harry’s attitude.  {They’re wrong of course, but who’s talking rationally?}  This can lead to negative publicity in the general community.
  • You obviously don’t want Harry to interact with prospective residents during a tour or marketing event.

We once found a “disgruntled” resident who liked to sit outside the front door of a building that had a very low closing rate.  We then found out that the resident was expressing her anger to everyone that came into the building.

What Can We Do?

First, resist the temptation to take the quick move-in that is driven by the children instead of the potential resident.  You are risking a time-bomb if the prospective resident doesn’t take an active part in the tour, discussions, etc. and at least buys into the decision.   Don’t “gang-up” with the family members to force the prospect to move in before they have completed the psychological grieving process. [3]

As discussed in earlier parts of this series, communication is key.  The more you understand about the types of losses the individual has recently endured (See Part 1 for examples), the better you will be able to help de-fuse the anger.  However, this requires that you take the time and spend the energy to establish a personal relationship with the prospect / resident.

Understand that anger is a normal AND NECESSARY step in the healthy grief process.   Educate your staff to the importance of remaining calm and not allowing the resident to “bait” them into losing their temper.  Kubler-Ross advises: “don’t get into unnecessary arguments” over issues that are “often totally irrelevant.”  Remind the staff that the anger being displayed generally has nothing to do with them!

Avoid the tendency to ignore and further isolate the troublesome resident.  This gives them a legitimate reason for complaining and often leads to further “acting out” with escalating demands and louder and more public complaints.

Give them some attention.  Similar to a misbehaving child, their behavior is a cry for help.  They want to be “unique”, but still loved and accepted.  They need to know that someone knows they are there and cares for them.  At the same time, let them know that they don’t have to raise their voice to get your attention.

One of the secrets to managing grief is to generate HOPE for the future.  Recognizing the natural fears of the senior residents, focus on their CAPABILITIES instead of disabilities.  Encourage them to try new things, make new friends, etc.  The key is to get them to look favorably to the future which will cause the past losses to fade in importance.

PLEASE SHARE YOUR EXPERIENCE(s) WITH ANGRY RESIDENTS BY COMMENTING BELOW. A short background synopsis of the individual would be appreciated.  Indicate how you learned of the underlying losses that were driving their behavior and how you dealt with the situation.


[1] See “BEYOND DEATH” and Dying – Part 2 for a more detailed discussion of the denial stage.

[2] Changed from the original “patient’s”.

[3] NOTE:  I recognize that different rules apply for admissions to Alzheimer’s / memory care units.

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16 CommentsLeave a comment

  1. Fortunately there is research going on (like stem cells) that may one day serve the cure this disease.

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  2. You have identified one of the very common problems that exists and are now soliciting our ideas of how to deal with the problem.

    Please tell us about how you would or have dealt with Harry. You are the expert. We are eager to hear YOUR solutions, oh wise one.

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    • Kim,

      First, let me point out that “Harry” isn’t one individual. He’s a composite of a number of residents I’ve dealt with over the years.

      I’ve offered several suggestions in the article: communication, learning why they may have unresolved grief, paying attention to the individual, etc. I’ve found success finding out what the resident likes (or used to like to do – maybe with their spouse) and then getting them involved in a similar activity in the building. My really, really GREAT activity directors (or whatever today’s politically correct term is) devise a custom program if necessary to get Harry involved. A “grand slam” is when the senior living community can help the resident achieve some lifelong ambition.

      One of the interesting things I’ve learned is that you can generally find at least a handful of residents in any building who will participate in the new activity. Thus, it may appear to Harry that you’ve done something just for him, while in reality you’ve improved the resident experience for many.

      Tell us about “your Harry” and maybe I and/or others can offer some suggestions.

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  3. My father was “Harry” for years while my mother was alive. She died a year ago and all of a sudden we are fiding the joking, loveable dad we never had. When asked about the transformation he said ” When your mother was alive I felt like I had to protect her and take care of her but I knew there was no way I could physically do it. I struck out at anyone and everyone who could help her under the belief that I was protecting her from those medlers. Now that she is gone, the stress is not pulling at me all the time. I know she has gone to a better place. I wish I had seen that long ago. Life is just a process of moving on.” Maybe the elderly will solve thier own “Anger Issues” or we can help them understand bettr. I agree with Art. Communications is one of the least expensive, most productive and most rewarding things we can give to seniors. One less hour of TV, one less hour of Internet surfing, one more personal visit instead of e-mail or heaven forbid “texting”. Many seniors fear the social value of computers will override the personal visits of thier loved ones. Could they be resisting for that reason?

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    • Great story Paul.

      Thanks for sharing it.

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  4. I once heard a very good sermon about “The Walking Wounded” which basically reminded all of us that we can’t know what events may have shaped the people we run across in our daily lives. This holds especially true for Seniors and your advice to research their background is correct.

    Involvement in their community is another tool for dealing with what I call the “Negative Nellies.” But this can backfire on you too, so caution is sometimes needed. One grieving widow at one of our properties desperately needed to become involved in a community project to help take her mind off of what she was missing in her life. She had excellent organizing skills and was asked to chair a committee that was putting on a community yard sale. Unfortunately those excellent skills lacked a willingness to listen to anyone else’s ideas and she felt that they should all just do what she told them to do. My mistake was in asking her to chair the committee. She should have merely been responsible for one of the tasks of the committee. This would have avoided me being put in the position of refereeing and risking alienating both sides.

    This resident has now become less participatory in community events and still suffers from bouts of grief over the loss of her spouse. Another tool will need to be found to help her become engaged in the community again. While this method of asking residents to participate in planning various activities has worked to dispel many of our Negative Nellies it doesn’t work with everyone.

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    • Debbie,

      Your instincts of getting the resident involved in activities are superb. One thing I didn’t mention in this article but your example illuminates is another approach when the resident shows no interest (or actively resists – remember they are in the ANGER stage) in participation in the building’s activity programs. That could be an indication that the activity programs aren’t creative and challenging enough, but I’ve also had success in asking that resident for help. Maybe they are suffering from their perceived loss of independence and identity because they’ve now been “committed” [intentionally inflammatory word because that may be the resident’s perception] to your facility. They may perceive joining group activities as further loss of identity – remember a lot of ANGER is stimulated by the desire to be recognized as a unique individual with “value”.

      In this situation, you may find success – as Debbie did — by asking the individual to VOLUNTEER. You may find someone that was a tremendous volunteer in their “time”, plus you give them recognition by asking them to do something special that utilizes their unique talents.

      Debbie might have named the resident as a Co-chair with a staff member to have accomplished the same thing without antagonizing the other residents. YET, obviously, this resident believes herself to be a great organizer of events and that certainly played to her higher level (Maslow) EGO need. I wonder if she acted any differently in this situation than she might have done when she was younger. That would be an interesting question to pursue with family members Debbie.

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  5. Another great in depth article that showcases your balanced understanding of the complex human elements and operational issues of a well-run community. The article will serve as a go-to reference piece for anyone dealing the issue.

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  6. Great Article Art:

    I think that a key element in supporting grief is simply to name it…. Too often, staff in residential facilities want to cheer people up and are frightened to talk about grief. One community that I consulted with struggled with a group of men who were your exact profile. Not only were they angry – but they were getting more and more angry as they became a tight knit group. The problem that these men were facing was that they were all grieving – not just the loss of their partner or their own health – but their loss of their identity. The narcissistic losses of aging are enormous in our culture. Giving venues for people to talk about them and have these losses validated is really helpful. We formed what got known as the “grumpy old men’s group” (I promise not a clinical term or my choice!) This gave a safe place for these men to talk about their feelings that were below their anger. As they started to do this, they could see shared connections, develop empathy to each other and shift their focus from their hatred of the new paint job in the lobby to what was really bothering them. I really believe that all communities should have mental health professionals as part of their key staff. It is the norm to have Wellness staff, nurses, activity directors etc – we spend money of expensive exercise equipment etc – but way too often leave the internal lives of people unspoken and lonely. What gets left unspoken remains unconscious and this leads to behaviors that demonstrate the feelings, rather than venues to process and work through them

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    • Thanks for the input Tessa,

      This is a great story and FANTASTIC observation to identify the need to open communication and TALK ABOUT GRIEF and/or OUR LOSSES.

      Strangely, letting the group name their own group was probably the ideal thing to do. First, as you observed, it gave them some renewed control in their lives and a “new” identity. As operators, we often prefer to have everything pretty and rosy, innocuous names that won’t offend anyone, etc. The reality is that our clients are “pretty tough old birds” and not afraid to make fun of themselves (that is a whole different situation than someone else making fun or putting them down which is disrespectful and takes away dignity!).

      I once knew a “Sewing Club” that became informally known as the “Stitch & Bitch” club, because the sewing ended up only being an excuse for getting together and gossiping. It takes courage for a building manager to “allow” this type of group to exist. Maybe by learning some of the tenets of the grieving process, we can help them understand that the clubs can be beneficial and not subversive.

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  7. I strongly agree with Tessa that there is a need in long-term care facilities for residents to have opportunities to express their grief. I agree that generating HOPE is helpful, but it has to be done skillfully as not to make the resident feel his or her feelings are being negated or minimized. In most facilities, staff have little time to sit and talk to residents 1-on-l about their feelings but tend to avoid it by minimizing their feelings or trying to distract them. This only tends to increase the grieving resident’s frustration and sadness. By utilizing a mental health provider who can spend the time to provide individual and/or group grief counseling, you can reduce the angry outbursts and acting out of grieving residents. Contemporary grief experts agree that grief work takes time. The bereaved work through their grief by telling their story over and over again until they can integrate their loss(es) into their new reality. Older adults often have multiple losses to deal with (spouse, home, health, independence, finances, pets, etc.). As mentioned in the article, about the impact of residents’ anger on marketing, is makes good business sense to have mental health services in long-term care facilities to deal with residents’ emotional needs.

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    • Lou-Ann,
      Thank you for your comment. Now a thought-provoking question for you:

      How do we get residents to attend “group grief counseling” sessions?

      One of the things I’ve observed is that – especially in the early stages of denial and anger, the residents tend to hide their losses and as mentioned in the article focus their anger on other items in their environment instead of admitting to themselves and certainly to others that they are hurting from a loss. In fact, I suspect in the anger phase, one of the things that “sets them off” is an unrealistic expectation that others don’t “magically” understand WHY they’re upset.

      In a skilled nursing facility, management may be able to get a doctor’s order – assuming they can get someone to pay for it- for mental health counseling and the patient can be required to receive “treatment”. On the other hand, in assisted and independent living, the resident themselves (sometimes the family) must ASK for that help and even group sessions would have to be SOLD to the resident. Then we have to get over the “embarrassment” issue as to why Harry needs to go to THOSE SESSIONS!

      The potential role of the activity director in this situation is significantly under-rated in many senior living communities. Her/his ability to get Harry involved in group activities and create an environment where, as you say, Harry can work through his grief by telling his story over and over again can be the crucial element to helping him progress through the stages of grief while building new relationships and shifting his focus to daily accomplishments. (See other postings re. Maslow’s Hierarchy of Needs).

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  8. Art – you once again mastered the issue with ‘Angry Harry,’ whom we’ve all met more than once in our careers. I particularly appreciate your incorporating Abraham Maslow’s Hierachy of Needs into the equation. As a Naomi Feil Validation Worker, I turn to that pyramid along with Erickson’s Stages of Life to get a glimpse into resident issues. More often than not we can ‘turn back the pages’ and help our disenchanted residents when we realize that it’s unmet needs of a life time that have caused the situation. Thanks – well done.

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  9. Yes, once needs are met, bonds are made and empathy is shared the resident can relax and enjoy being part of the community. At this point she/he can be inticed to participate in activities. The arts (dance, music, painting)give residents a sense of achievement and allows for self expression. Here are two stories to illustrate the point.
    Helga was a frail elderly lady who rarely spoke. Because she had been well cared for there was still a trace of elegance about her. With her face aglow she held the blue balloon we had used in our class to her cheek. Helga began by saying,”You know when I was a little girl in Germany we always celebrated our birthdays with brightly colored balloons. But then when the war came there was no rubber for balloons and birthdays weren’t the same.” She goes on to tell the whole story of how her family fled to Holland and then to America where once again celebrations were marked with balloons. Eyes shining, Helga continues her story with the time she and her husband floated over Long Island Sound in a Hot Air Balloon! The class had been a success.

    Then there was grumpy Ethel! Ethel was the type who wore a permanent scowl. She felt everyone was
    out to get her. She was sure staff and residents were stealing from her. She refused to hold another
    residents hand…too dirty! Well, by some miracle I managed to earn Ethel’s trust and she always
    participated in my sessions. On my way to class one day I spotted Ethel at the end of the hallway.
    Humming one of our favorite waltzes, I called to her and invited her to class. Picture this. Here comes
    Ethel swinging her walker from side to side dancing down the hall to me! I think she may have been
    smiling!

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    • Sheila,

      Your stories demonstrate that it doesn’t have to be the BIG THINGS, but often just an extra touch that makes all the difference in the world for a resident.

      I developed one of my trademark programs “Creating Precious Memories” on that principle. For those 2 residents on those days you definitely created a precious memory that will encourage them to get up tomorrow and LOOK FORWARD to what the new day has to offer.

      CONGRATULATIONS FOR A JOB WELL DONE!

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  10. Great article. It helped a lot and I now have a lot of insight now.

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