Personality Disorders in Older Adults: Insights from a Subject Matter Expert

Welcome to the Living to 100 Club Podcast. Here's our host, Dr. Joseph Casciani.

Well, hello to everyone joining us today on our podcast. You're listening to the Living to 100 Club, and I'm your host, Joe Casciani. Before I introduce our guests, I'd like to remind everyone that I'm available for public speaking events, particularly to community organizations and senior groups. I love to talk to others about aging well, keeping a positive frame of mind, and making it over those hurdles. There's an option on my website to set up a call to arrange a presentation for your group. I also offer a free 30-minute lifestyle audit for individuals to look at lifestyle practices attitudes, and outlook. This audit gives us an idea if one-on-one counseling with me may help to bounce back from those challenges and setbacks. Set up a call with the same button on my website to get started. And one last item of self-promotion: if you're looking for a consultant or trainer on clinical topics like dementia or depression, this is an area of specialty for me, so feel free to contact me if there's a need in your organization. Contact options are on my website, again, livingto100.club. Now, onto our podcast. Our guest today is Dr. Arlene Rosowski. She will share with our audience descriptions of psychological disorders in the elderly with a special focus on what are called personality disorders. First, a little background. Arlene Rosowski, PsyD, which is a Doctor of Psychology, is professor in the clinical psychology department at William James College, also abbreviated as WJC. Prior to her retirement, she served as director of the concentration in geropsychology and the founding director of the WJC Alliance for Aging. She's a teaching associate in the Department of Psychiatry at Harvard Medical School. Dr. Rosowski has achieved international recognition as an expert on late-life personality disorders. She's well-published in the professional literature and has also authored 3 books, numerous chapters, articles, and columns. In 2011, 2012, and 2017, Dr. Rosowski was a Fulbright Specialist Scholar in Global and Public Health visiting the Netherlands, Belgium, and China. In 2012, Dr. Rosowski received the American Society on Aging Award for outstanding contributions to the field of aging. And in 2020, Dr. Rosowski was the recipient of the first annual Michael Duffy, PhD Award for outstanding contributions to training and mentorship of psychology in long-term care. An old friend and colleague, welcome to our program, Arlene.

Thank you, Joe, for inviting me. I'm honored and delighted to visit with you.

Great, great, thanks. Glad you're with us, and I'm looking forward to our conversation. I always like to open by asking our guests to tell us briefly about the journey that brought you to where you are today. You've had a long journey, a lot of accomplishments over the years, but tell us what brought you to where you are today.

I shall briefly and hope that it might be encouraging for people to make some shifts at various times in their life and come out better for it. I'll start with— I was in a PhD program at Boston University in neurocognitive rehabilitation grad program, finished my coursework and clinical work and had been working in the area of aphasia. And that was my study. And just at the beginning of starting to do my dissertation, I developed a very serious, serious medical issue and it required surgery and about 6 times in the course of a year and a half rehospitalization, long-term recovery, long-term rehabilitation, which as many existential things do, gave me lots of time to think about what I want to do and what really meant something for me in my work trajectory. So when I thought about that, aphasia was an interest I was going to write on it. And most of my clinical work was done with aphasic patients who tended to be post-stroke and tended to be older. And when I had this enforced year and a half of thinking, I knew that I had fallen in love with old people and wanted to focus on them. I liked their stories, their narratives, their experience, the family's experience, the couples. I adored the older couples. Couples and how they got through this incredible trauma and being very brave. And I noticed that some were braver than others and some made more use out of an adverse event. So I did what any normal, reasonable, middle, almost middle-aged person would do was I decided to start all over and become a clinical psychologist. And so I had to start with year one in graduate school. And then 4 or 5 years later, a few things happened. One is that in taking graduate studies and going through, as I'm sure you did as well, Joe, developmental psychology. My school kind of ended it at age 40. And as if there was no development after that. And when I protested, as was my want, I was told if I wanted to talk about that, that I was free to do that class. So fast forward, I did it for a number of years. I would come in at the end of the year and do, you know, the 1-hour, 2-hour lecture on everything you need to know about development and older age. But after I graduated, got my doctorate in psychology, I was very fortunate to get a National Institute of Mental Health postdoc at— through Harvard at Mass Mental Health Center, which got me into community mental health. And I was attached to the positive aging services. Isn't that wonderful? Positive aging. And at that point in my life, Joe, I got a wonderful mentor. Dr. Gurian at the medical school. And at the end of the 2-year postdoc, he said, "What do you want to do for your capstone research project?" And I said, "I don't know. I'm interested in pretty much everything. I've been sitting there with really, really smart people who are very experienced and kind of just taking it all in." And he said, "Well, Arlene, what are you most curious about?" And you know, Joe, that has been a very helpful question because I thought, "Well, I'm curious about just about everything." What I'm most curious about was how come some of the patients got these very experienced, very erudite professors and clinicians— how got them rattled when they were actually behaving differently than their usual presentation? Who were these people that made them rattled? It didn't seem to be patients who were diagnosed with schizophrenia or bipolar disorder, called manic depressive disorder then, But there was something else, some, some kind of group of people. We didn't have a name for it then, really. Personality disorders was, was maybe 2 sentences, if that, in the DSM at the time. But it was more in the analytic school of people who were— had primitive personalities, or people who, who are characterologically impaired, you know, this kind of thing. So I did my first little baby research projects on these people. And that really got me a research associate at Harvard in a hospital in the Department of Elder Services after I finished my postdoc. In the meantime, I was working for a big mental health clinic in the more— in the western part of my state that covered 16 cities and towns. But it was at the time, about a year later or 2 years later, when By the state got rid of all of us psychologists because we were less helpful. The community mental health centers had— were now starting to close up and lose their center. So that's it. So I can tell you about practice and my research going forward, but that's how I became a geropsychologist.

Yeah, yeah, with the focus, the combined focus, the parallel focus on older adults and personality disorders. And I understand that you are one of the noted authorities in the country with this specialty, maybe outside of the US. And, you know, let me jump right into it, Arlene. Let me ask you then, as we talk about personality disorders, what are the major common features that we see in these conditions?

Okay, start with, you know, start with a very brief definition because that will answer the question. You know, these are the tough, tough people to work with. But it requires— the definition requires that it is an enduring pattern as opposed to a one-off situation when something extreme happens, you know. And so it's an enduring pattern of one's inner experience. What does that mean? That means one's thoughts and feelings. Yeah. And behavior. So it's a pattern of thinking, of feeling, and behaving that's enduring. It's not a one-off. And that also deviates from what is expected in one's culture, in one's phase of life, in one's historical moment, you know. So something that is markedly distinctive in thoughts and feelings and behavior that is a pattern that transcends time and space for the individual. Now, getting a little finer than that— sure, the pattern has to affect how the person thinks, how the person feels with their affectivity, and impulse control, if they're able to manage some of these cognitions or feelings, and bingo, interpersonal functions. And it's the bingo of interpersonal functions that generally is what makes these folks fairly difficult. Okay, so that's my definition.

That's good, that's good.

And you should recognize by late adolescence or early early adulthood. I have pediatric colleagues in looking at children who say you can sometimes recognize it through the rearview mirror in childhood. And one of my latest publications, which was a research study which was published just at the beginning of the COVID situation, really puts forth some reasonably good thinking and good data that it is possible for it to be de novo, brand new. In old age. Now, that— if that gets confirmed further, that really blows out of the water the mandate that it be somehow by late adolescence or early adulthood. So we're making a case actually that it can appear later in life.

Sure, yeah. And there's always those concerns about late-life onset of schizophrenia, which is very rare but not out of the question. So we now see that possibility with late-life onset of personality disorders. So let me— this is a little bit more technical, but let me ask you, we understand other types of mental disorders, psychological disorders of neuroses or psychoses, as the person struggles to deal with anxiety and managing how they, how they defend against anxiety, and that's what manifests in different conditions. Now, the person with a personality disorder does not struggle with that type of distressing anxiety. Would you agree with that?

Yeah, kind of. I do. Let me take that and then take a little riff off it and maybe it'll be a little clearer. I think what you're getting at is that it's syntonic to them. If you or I are not— a depressive episode, a depressive episode, we are able to say, this doesn't feel like me. You know, I'm having a depression. I have to see a doctor. I have to speak to a therapist. Maybe there's a medication I need. This is something that's foreign to me, you know, or you, whoever.

Yeah.

So that it becomes dystonic, right? Our feelings become dystonic. That's the fancy word of it doesn't— it doesn't resonate as self, huh? So with people with personality disorders, their disorderedness— and we can talk a little more about it— is syntonous. It resonates with them. As we move forward, I can lead toward a whole theory of the fact that it needs to be— feel like oneself, you know. The pain and misery is awful. But let me say, to actually nail it a little more specifically, rather than personality disorders— there's many personality disorders, and, and the DSM has cured some overnight and brought some out, you know, etc. But they do come into clusters, and some of the, the later DSMs had them in Cluster A, B, and C. And then your, your listenership will, will recognize that more than just a personality disorder. And we can talk about any of those, but cluster— that comes in 3 clusters, or I tell my students 3 flavors. They can, you know, one is the Cluster A, which is the odd and eccentric one, and incorporated in that are the paranoid personality disorders, schizoid, schizotypal, um, just Picking paranoid as an evidence, but I'm happy to talk about any of them. These are people who go through life and feel syntonik, feels like them, with a core of being suspicious. They're distrustful, you know, they bear grudges. They don't confide in others because they don't quite trust others. They're preoccupied about— with loyalty and fidelity and trustworthiness. Constantly scanning confirmation of suspicious activity from just regular interactions. You know? So this is how that Cluster A paranoid personality disorder— this is how he or she goes through the world. Goes through the world. And it feels— it's not an add-on. It's not because they're in a strange country and they don't know the language and they have to be vigilant. No, no. This is under regular interactions. This is their core of their being.

Sure. Yeah.

Now I can— yeah, yeah, that's—

um, before we go into Cluster B— no, I would like to ask about the other two clusters, but, um, the point you make about syntonic versus dystonic, that's very helpful because that really does explain a lot where there is that kind of, uh, certain satisfaction, or this is me, this is my pattern of getting through the world. And that's— I— that partly explains why some of these conditions are resistant to treatment, because for the person with a personality disorder, there's really nothing wrong with him or her. They're content. It's like, this is who I am, this is my natural pattern, and why should I change it? It was fair to say.

Yeah, I think— yeah, without even annotating it that way, it just is the way it is. And when things crop up repeatedly, they don't see a pattern because that's blaming the outside. It's blaming something else, another person, a situation, etc. Or bingo, for example, with paranoid, every so often, you know, guess what? They're right. It's kind of selective reinforcement, right? And you can't do that. So this really— which brings, you know, besides smiling about it, it really brings to mind that there's nothing deviant about these traits. It's just that they're either too much or applied too liberally or totally misapplied altogether. That gets these people into trouble. There's nothing wrong with being a little suspicious, you know, in some places you really need to be.

Yes.

You know, and Cluster B is the— that's the one that we have most information about because probably because it's the most exciting, but it's the erratic and dramatic. Constellation of personality disorders that includes antisocial, borderline, which has a lot of press usually, histrionic, and narcissistic, which of late has even more press perhaps. So just jumping into narcissistic, as I just mentioned, there is a lifelong, presumably, uh, pattern of grandiosity, need for admiration, a sense of heightened self-importance, They, they believe they are special. There's a little funny inside humor about it's difficult to get a therapy group of narcissistic people because they all believe they are unique and therefore shouldn't form a group, right? Because their, their situation is most—

no group would fit, right?

No group is— they're impersonally, interpersonally exploitative, and that becomes hurtful. They tend to lack empathy. Don't not have the capacity for empathy like with the antisocial person, but— and they tend to go through life with a fairly arrogant attitude, you know, very dismissive, because they're one up, which means they have to put people one down, you know.

Yeah, that's great.

And they're difficult to, to manage. And I'll hit on Cluster C and then go and talk a little bit about how each of these would present in a nursing home setting or a— or something like that.

Uh, Cluster C, any—

yes, is anxious and fearful, and that incorporates the avoidant person, the dependent person, and obsessive-compulsive personality disorder that people talk about as well. Um, difference between the avoidant person and the person who is schizoid from Cluster A is that with schizoid, the lack of connection and interrelationship feels syntonic. It feels fine. They don't want it. The avoidant desperately wants it but is socially inhibited, feels totally inadequate, very sensitive to negative evaluation, criticism, rejection. So they don't want to socialize because they're frightened, you know, and they don't— they hang back. Yeah, yeah, that's sadness.

Yeah, that's very helpful. That's very helpful. So the Cluster C is the anxious, fearful. Yeah, very—

yeah, needing a lot of reassurance, you know.

Yeah. Okay, so you, you started to mention nursing homes, and I'm curious about, are these conditions manifested differently in old age? And we used to talk about them more so philosophy. If a person was a certain way in his 30s or 40s, they're only more so in their 70s and 80s. Is it just a more so trend, or is it— are there—

yeah, no, that would be easy. More so, um, that's actually not true. There are 4 basic things that happen as far as— and then I can get into specifics, but some of it is, is pretty constant. So there, there's your once PD with a paranoid, you always kind of— so it's kind of a flat trajectory. Another one is a, uh, which is the most prominent one is like a reverse J-shaped curve where it actually is nasty and then gets in middle age— I wish you could see me drawing a U, like a J-shaped U— and then it goes up again in older age. And that one we'll go back to because that your people will want to know about. And the other one is a more flat and then it appears, and that's the one we're talking about now, which isn't— flat means not at all, and it appears de novo in old age. And the other one is that it just goes down and disappears. So it's— that it's no longer diagnosable. So the one that is the most J-shaped curve kind of thing is important because there are— the key to this is you can't have a personality disorder by yourself. It has to have a referent, which is unlike having a, God forbid, cancer or something like that, you know? It requires that interrelational piece to say they don't have it, or it's excessive, or they're criticism, rejection, need, all those things require somebody out there to be part of it, which makes it so hard. But you understand?

Sure, sure.

So what happens in midlife, the going down part of the curve, the U-J-shaped curve, is that in midlife there are roles and relationships that can contain the expression of the pathology. Give you a quick example. A man who is— I'm not trying to be sexist here, but let's say a man is, is not sociable, is a kind of a suspicious, paranoid type, and his wife or partner is able to smooth the social interaction course, right? And he's doing— it doesn't come to attention. It kind of— I call it binding the pathology, you know, tampering it down. Now the wife dies or leaves or whatever else, and then you see a re-emergence, right? It becomes more functional— functional impairment, um, because somebody is not there. Jobs, you see a lot of re-emergence of, uh, some personality pathology.

And retirement, we need context for these conditions. They don't appear if the person goes away.

Yeah, old age. And so if the trajectory can change. With the erratic and dramatic, that's high energy, you know, to fly around and sleep around and drink around and do all sorts of around stuff and live high takes energy, which dissipates in old age. So it— and opportunity dissipates in old age. So there's a change in some but, but not the intent. You know, they— the risk-taking of the borderline, we'll see in hospitals, nursing homes, where they pull out their, uh, their oxygen tubes, or they decide to pull it out and go to the recreation room and smoke a cigarette with it. You know, so there, there's some behavior that, that can be, be substituted behavior for that kind of acting out.

So as you, you talk about the different pathways or trajectories, the, the J-shape is an example where somebody helps to contain or bind the expression of a lot of these, or the job, or the role, the role or relationship.

Yeah.

Okay. And then another trajectory is where it just dies off because the person doesn't have the energy to maintain that. Maybe the dramatic or erratic behaviors, and it just dissipates over time.

Or the older woman or man who is very, very dependent is now in a, in a facility where dependence is quite fine.

Welcome.

So it's not deviant.

Yeah, okay. So it is the context, it's very context-dependent. Sure. Yeah, it's kind of like, I remember being in a graduate course, um, existential psychology, and my teacher would always talk about embarrassment. —and how you can't have embarrassment if you're just by yourself. You need another person, you need a context for that to occur. You can never be embarrassed if you're walking in the forest by yourself, I think.

And embarrassment is— and I even have a case that I can share with you— embarrassment is a shame, and that is particularly connected to narcissism.

The absence.

Yeah, yeah, yeah. And the avoidance of shame.

All right, so that's helpful. I mean, understanding the different ways that these play out over, over the years, over succeeding years, and sometimes they will trail off and other times they might go hidden for a while and then come back.

And yeah, so it really does, right? They're still there. There's a huge There's a huge distinction, Joe, between personality style and personality disorder. You know, the style is, is just, well, you know Mary, or you know Joe, or you know Earlene. This is a style, right? But a personality disorder means that it, it hurts. You know, it feels distressing to the person. And as we shall see, it feels distressing to the people with whom they're in relationships, right? And it also affects functionality in work and in school and in careers and and everything. So it's more than a style, which is a style, you know, it's— but it's the same traits. There's nothing— that's what I'm saying. It's, it's nothing. It's how the traits play out and where they play out that it becomes—

yeah. So the same trait, is it like the volume is turned up a little higher? Not appropriately played out.

I mean, there can be, for example, if there are people are into doing burlesque or, um, costumes or anything for social kind of stuff, and this is a part of their culture and being, it becomes an appropriate thing. If you dress that way and walk into, you know, your financial advisor— so there's an inappropriateness or too much, you know, or, or downright dangerous, you know, cutting and that kind of thing.

So it might be the same volume, it's just different locations where it's okay and other— others where it's not okay. Yeah. Oh, that's good, that's helpful. So you mentioned, um, it can be difficult for other people interacting with someone with any of these conditions, and family and friends and neighbors. And I was particularly aware of this in nursing homes and how caregivers were left to, you know, cope with it or manage their, their patients with these personality disorders. So they, they affect the— they affect others, right? I mean, they affect family and friends and caregivers, doctors, healthcare professionals.

They really do. I think there's probably more people who retire from work in nursing facilities or skilled, you know, other facilities with older adults because of people. It's not the sick people, physically sick, it's the people who are manipulative and rude and angry and hostile and And well, you know that from— those are the ones who burn out staff, etc. Sure. And the, the key with that is that it's hard to get our head wrapped around it, but part our reaction to these difficult people as a clinic is part of their pathology. Yes. Okay. It's not the reaction, it is actually diagnostic. Yes. Okay. So it's— that makes it different from any other condition. To understand that your response is part of their pathology. Okay, you recall the features and the traits that we were talking about. You notice that all of them are referent-related— suspiciousness, exploitative, etc. And these— their reaction is that they feel like me, feel like myself, even if it doesn't get their needs met. You know, it's maladaptive. I would, if I rewrote it— I would say, not personality, I would call it maladaptive personality because the person needs to get their needs met. We all do, right? And their personality is what's getting in the way of that. So it's— Right.

And what I, what I would always talk about when I was training nursing staff on these issues, dealing with the different behavior problems of the residents, is that these patients were looking for the same kind of response from their nurses and aides that they had from their neighbors and family members. It's like they kept searching and they would press those same buttons in the nurse, in the caregiver, whoever, so they could, you know, kind of, that's their comfort zone. That's where they were, so they—

Even if it doesn't work. You're exactly right, because the big question I'm sure you, is they would say to me, Dr. Ozofsky, if he knows that he's gonna get punished and sent into his room, if he knows that he's gonna do it, why the you know what does he continue to do it? I said, because that feels like me to him. It's exactly what you, what you have.

I call it the search for sameness.

The search for sameness is perfect. Yeah, absolutely. And then not only are these people bruised and inept and not getting their needs met, they're being rejected all over the place or shamed, etc. And they start shedding or losing a lot of the things that keep us to feel like ourselves. In other words, they lose relationships. They can't hold on to relationships. They burn them out, whether they be a hired person or somebody, a love relationship. And we have a lot of losses with advancing age, period, the end. And this just means that they're not able to recruit others to be helpful.

Yeah. Yeah. So, it can be very difficult for any relationships, as you talk about. For family members.

I want to say that these people with personality disorders, you can see that, you know, my heart aches even talking about it, but they're not— they're the antithesis, Joe, of resilient. These are anti-resilient because with all the challenges of aging, they respond maladaptively. And you know that we have so many when we get older, and they have a very tiny little repertoire of coping strategies. Yes. You know, the old saw, if all, all one has is a hammer, everything looks like a nail. That's right. So they either respond with anger or suspicion or fear, depends, you know, what, but with everything. Yeah. And so it sometimes they're lucky and it kind of matches, but most of the time it doesn't. And they, and the We need to be in older age, we need to be able to be interdependent. Nobody can do it alone. Nobody can do it alone. You know, rugged individualism, Roosevelt was— this was not good for old age. These are people who can't be interdependent because they hurt other people or they burn them out.

Yeah, it doesn't work for them to be interdependent. Sure. Yeah, yeah. So this brings me to the, the heart of this, uh, conversation is, all right, so we have individuals with these conditions and we're around them and for their family, neighbors, acquaintances, co-workers, peers, patients. How do we— what's the best way to interact with the individual, narcissistic personality, paranoid personality? Avoiding. What's the— what do you— I know I'm sure it's more specialized, but are there some general recommendations on how to interact in an optimal way with individuals like this?

I think so. And you're right there, I mean, it's, it's this— there's nobody's the same. I think the hardest part is wrapping your head around the fact that you cannot change their personality. And when I consult with— I don't do therapy anymore, but I consult consult with families who have elders who have to make a move or have to and are being difficult. Accepting the fact that you can't change it. In fact, I'm going to go even stronger on that. I think it would be unethical as a clinician to change or go after a person's personality when they got older. I mean, if you could give them purple pill or an injection and an older person would wake up at the age of 60, 70, 80, whatever. And say, "Oh my gosh, I have done my whole life wrong because of my meanness, my me-ness." I think that would be cruel and abusive and unethical and probably amoral. So, to recognize it, and a lot of times with family members, you know, from working in this field, that they want to have some kind of rapprochement, some kind of evening out at the end with a very difficult elder in their family.. And that becomes a real challenge and a really a goal that it might not be a good goal to have. The question is always, whether you're a staff member or a family member, is how can I reduce his or her distress and help his or her to meet his or her needs better, or at least more often. And it can be very, very direct, but not the head-on confrontation with you are silly to be so— you're being suspicious is getting in the way of everything. It's not going— if it didn't work for the first 75, 80 years, guess what, folks? Not going to work in any other sentient years. Sure. Another thing is they blame us, or they would blame, because they need you as part of their mirror. They need you to admire them.— or to criticize them, or to violate their trust, or to show— you understand, they need your reaction to feed that. So one thing is to be aware of that, you know, have a boundary in that kind of interaction, but try not to play into it. Yeah. Right. And the third part is that these are people who, they might be very smart, or intelligent or whatever, but they cannot self-evaluate. There isn't a prayer that they're going to be able to take themselves as object. Um, that's what's so difficult to treat in psychotherapy, certainly with the more depth therapies. It's not, not possible, really. It's not possible. So, but people in families have to make sure they keep their boundaries so that it's not a question of, of being beaten up emotionally by the individual, but also not abandoning them. By understanding them, you know, and believe me, I'm not— when anybody's threatened or their life or well-being is at stake, you, you know, just get out of harm's way. I'm talking about getting along. And these are the kind of things that I do when I work in nursing facilities with the aides who actually are working with these people. And, you know, try to— there's a narrow little line to thread the needle between abandoning them and being consumed by their neediness to be part of their mirror.

Sure. Yeah, yeah, that's great information, Arlene. That's great information. I mean, the overriding point is that it's not changeable. Let's not try to change it. Let's, let's understand the person.

The behavior a little bit. I can give you a little example of how concrete it can be. Would you like a little? Sure, sure, sure, please. This is a woman that, that I was seeing. Her daughter, a middle-aged daughter, not so middle-aged actually, young enough. She had a 11 or 12-year-old boy. And it was her— my patient, the older lady, her only grandchild. So you can imagine that this was an important person in this woman's life. And she was a heavy chain smoker. And also, I don't know how to say this nicely, very rough around the edges. You know, every other word out of her mouth was— she was histrionic. So definitely histrionic personality. And it was a swear word. And very— she was a colorful Patient, I can tell you, but memorable. And her daughter— and she was very abusive and dismissive of her daughter because she was narcissistic enough to have to have anybody in her presence one step down. She gave me a pass on that, but sometimes I was— had to be a step down too. And she was furious with the daughter because the daughter said, you cannot come over and stay in my house and see whatever the little boy's— young boy's name was. I'm not having it anymore. First of all, the house smells of your smoke. It's hard to get done. And my patient was furious. And I asked if we could work with the two of them together and make a contract. And my patient said, swear, swear, swear, why not? And we, you know, she came in, she, and by the way, she was not smoking. I did not allow smoking in my office. And so I knew she could do it. And so I asked the daughter if, you know, if so-and-so didn't swear, you know, could she come and not smoke, could she come back? Could her privileges come— visiting privilege be— this was very important. And the daughter said that yes, that she was, on behalf of her son who liked his grandmother, was willing to do that. So I went to— it's like you're doing couples therapy— went to patient and asked her how long she could refrain from— I knew she could refrain from smoking for an hour because we have a track record of that, 50 minutes in my office. And could she— how long could she refrain from swearing? And so she, she thought she could for an hour. She thought it would be difficult, but she thought she could. And the fast forward is we actually had a written contract and a revisit, and also what would happen if the contract was violated. How long would it be before she was allowed to have another thing? Because I said the next step would be to shut the— lower the amount of time. If she can't make it, if she lost it after, we have to go back. And the daughter is saying, I don't want her in the house. And I'm saying, okay, but you know, how long will wait before you would allow another contract? Very, very cognitive behavioral contract. Okay. And I was right there with, you know, Skinner would have been proud of me. And, um, She did it, and the fast forward is there was no problem. She didn't smoke, she didn't swear, she played whatever game she liked with the little boy, and, you know, and continued to go on a Tuesday or whatever her grand-da-sunday was, and never heard about that particular problem again. Of course, we had other particular problems, but, um, not that one. So there was a way of actually not saying it's rude, it's bad, etc., not conceding that it's a bad thing to do. It's just, can you hold it bad enough to have your needs met? And is it— what's it— what's it worth?

Yeah, so this is a case of the, the J-shape where the lower part was you helping to bind, uh, some of those impulsive behaviors. You stepped out of the picture and they probably returned, but for a while they were able to, uh, get to you.

And you can do that. I know you, you've been in the nursing home, skilled nursing business for many years. You— this kind of cooperative contracting works pretty well with people in the nursing home to give them— look, we all have dominant personality traits, and if the traits all need a job to stay out of trouble, okay, they absolutely need a job to stay out of trouble. We had one man who was looking for so much attention in his nursing facility. He had been— I don't know, something in merchandising sales representative of something, very outgoing, bubbly, lovely man who wanted to be the leader of the band. Nice, nice, nice, nice. Annoying everybody because he would be following around, "What can I do? Let me do this." So we gave him a job. He was at, I think, St. Patrick's— no, it was another one. Anyhow, he was at a Catholic nursing facility. And so there was chapel. So I suggested to the, uh, the social worker there, give him a job to dress up a chapel and seat everybody. He, he was ambulatory, no problem. And he, and he did it. He loved it. He put a boutonnière in his lapel, you know, like put a sports jacket on, and he had a job. And he had a job. His major thing to do this kind of game, and it was wonderful. And he actually— people liked him, and he got all the recognition that he needed.

So yeah, yeah, finding ways to meet their needs that are a little bit more tolerable or a little bit more acceptable within our world too.

Yeah, but it's a hard sell, Joe, when the last thing the staff want to do is indulge them. Sure.

Yeah, but that's a fine line. You're right, that is a fine line. Yeah, well, this has been great information, Arlene. Um, Let me ask you, what would you hope our listeners take away from our conversation today? Oh boy, summaries, huh?

You've covered so much good info. Yeah, it's, it's, it's complicated, but I would say there's, there's a couple of things that we just kind of ended. One is that to recognize that it's when the feelings that he elicits in you over and over and over again is part of his pathology. It's nothing you can do about it. This is it. That's why he persists in doing it, because he feels it. So that's an important thing. And the other thing is, I just said about the dominant traits that feel like me— give them a job. This is for all of us. I mean, for those of us who are teachers by nature and whatever, you know, when my time comes, please give me someone to teach, because otherwise I'll be finding totally inappropriate ways of doing it and teaching wrong things I shouldn't be. So we— and look at our own dominant traits that will need a job throughout sentient life that we can, and all our listeners can. What roles and relationships in our lives now support these? And what's going to happen when those change or disappear? Who's going to do— and how are we going to do that?

Yeah, yeah. To respect one another, to respect our strengths, what our needs are.

Yeah. And who helps them? Ability to present them in a reasonable way. Super, that's been great.

I really appreciate this, but Earlene, it looks like we're out of time for today. But before we wrap up, I want to remind our listeners about a co-sponsor for this program, A Mighty Good Time. Are you looking for ways to engage and stay active? Check out amightygoodtime.com. It's a one-stop shop for events and activities for those 50 and over. It's free to search and it's free to post amightygoodtime.com. And be sure to visit the Living to 100 Club website to sign up for weekly podcast announcements and monthly newsletters. And while you're there, be sure to download a free copy of my 9 Tips for Living Longer. Lastly, pick up a copy of my book, Living Longer Is the New Normal, all about maintaining a positive mindset in all we do. It's available on Amazon as an ebook or a hard copy. And we're talking today with Dr. Earlene Rosowski. Earlene, for those who might want to contact you, what's the best way to do that?

I think contact my website, which is earleensyd.com.

EarleneSyd.com. Very easy. Yeah, great. Thank you for inviting me. Yes, you're very welcome. I'm so glad we could have this conversation. I, I know our audience will enjoy it. Thank you. And thanks to all of our listeners for tuning in. Hope to see you next time. Bye-bye.

Hi, this is Suzanne Newman, host of the Answers for Elders podcast and radio show. We are the North Star that guides you through the complicated journey of senior care with trusted experts in money, law, living solutions, and more. So join us on this station, your favorite podcast channel, or just go to answersforelders.com. Meet the wayshowers who will help your journey go a lot easier.