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The Internet Journal of Geriatrics and Gerontology
Volume 4 Number 2
What do you say when a resident loses control?
S Marson
Citation
S Marson. What do you say when a resident loses control?. The Internet Journal of Geriatrics and Gerontology. 2008 Volume
4 Number 2.
Abstract
The most humiliating experience an alert nursing home resident faces is unpredictable incontinence. Generally, nursing home
staff perceive the event as inconsequential and follow procedures for cleaning up. Professional staff do not define this event as
a psychological catastrophe and respond in a nonchalant manner. The premise for following this nonchalant path appears to be
ageism. That is, staffs think incontinence does not breed humiliation among elders. It does. A review of literature supports this
position. The critical question becomes, How does a nursing home professional verbally and nonverbally respond to a resident
upon experiencing incontinence for the first time? Based on a role playing experiment, effective responses to incontinence are
discussed and analyzed.
Presented at the 28 Annual Meeting of the Southern
Gerontological Society (Greensboro, NC), April 13, 2007.
Ashley Nicole Bunnell proof read the draft for publication.
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INTRODUCTION
From working in nursing homes over the decades, I have
witnessed bowel and bladder incontinence. Two critical
biopsychosocial aspects of this event exist. First, this event
is a normal part of terminal drop 1 . Bowel or bladder
incontinence is a part of giving up on life. Here, terminal
drop is the independent variable and incontinence is the
dependent variable as illustrated in Figure 1.
Figure 1
Figure 1
The phenomenon is best illustrated by a person s conscious
or subconscious desire to surrender life. The willingness to
surrender one s life leads to a series of biopsychosocial
characteristics such as a drop in IQ scores, disengagement
from social interaction, bowel and bladder incontinence, etc.
Within this scenario, little human service intervention is
available or perhaps even appropriate.
Second, and much less obvious, bowel or bladder
incontinence is the precursor to terminal drop. Here,
incontinence is the independent variable and terminal drop is
the dependent variable as illustrated in Figure 2.
Figure 2
Figure 2
The phenomenon is best illustrated by a person s physical
inability to control one s bowel or bladder. The emotional
devastation of bowel and bladder incontinence is so
humiliating; a nursing home resident (or a person living
independently in the community) no longer has the desire to
live. This profound emotional devastation leads to terminal
drop or passive suicide. Within this scenario, human service
intervention has the potential of being successful. In
institutional settings, where little privacy exists, the first
response to the accident is critical. Role playing lays the
foundation for a successful first response.
REVIEW OF LITERATURE WITH COMMENTARY
To pursue this investigation, a review of literature is
necessary to address several questions. These questions
include:
--What are the emotional consequences of
incontinence?
--What is the relationship between terminal
drop/passive suicide and incontinence?
--What biopsychosocial variables predict incontinence?
--What damage is the result of incontinence?
--Is psychosocial intervention fruitful?
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What do you say when a resident loses control?
The review of literature is organized around addressing these
types of questions.
THE EMOTIONAL CONSEQUENCES OF
INCONTINENCE
The literature on the consequence of bowel and bladder
incontinence is unambiguous and supports common sense.
Depression (Bogner, et. al, 2002; Corna & Cairney, 2005;
Fultz, & Herzog, 2001; Heidrich, & Wells, 2004; Holroyd et
al. 2004, Meade-D'Alisera, P., et al. 2001; Melville, et. al,
2005; Nygaard, et. al, 2003; Perry, McGrother, & Turner,
2006) and anxiety (Bogner, et. al, 2002; Corna & Cairney,
2005; Fultz, & Herzog, 2001) are a direct results of bladder
and bowel incontinence. Regardless of living independently
in a community (Bogner, et. al, 2002; Corna & Cairney,
2005; Fultz, & Herzog, 2001; Heidrich, & Wells, 2004;
Meade-D'Alisera, P., et al. 2001; Melville, 2005; Nygaard,
et. al, 2003; Perry, McGrother, & Turner, 2006) or in an
institutional setting (Holroyd et al. 2004), the results remain
the same. Psychological distress, usually in the form of
anxiety and depression, will emerge as a consequence of
bowel and bladder incontinence.
In addition to the emergency of anxiety and depression,
Shaw (2001) offers a review of literature in which he notes
that stigmatization, reduced life satisfaction, and impaired
quality of life exist. Willingness for community elders to
leave their homes decreases. Disengagement is expedited.
For nursing home residents, the emotional consequences
appear to be more severe. Community elders can hide their
accident whereas nursing home elders cannot. Feelings of
helplessness and hopelessness are more profound among
nursing home residents.
TERMINAL DROP, PASSIVE SUICIDE AND
INCONTINENCE
One of the most comprehensive studies is the work of
Holroyd-Leduc et al. (2004) where the authors content that
two valid causal relationships exist as seen in Figure 3.
Figure 3
Figure 3
Within model 1, conditions associated with terminal drop
induce a person from wanting or needing to control his/her
bowel and/or bladder. Within model 2, the person
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experiences involutional depression and/or anxiety inducing
him/her to ask the question, Is life worth living? Their
findings suggest that both models have emerged from their
research as well as research cited in their review of
literature. Essentially, they contend that both models are
valid explanations. Since social gerontologists focus on
linear mathematical models, the useful relationships between
terminal drop/passive suicide and incontinence are
cumbersome to express with state-of-the-art social science
methodologies. However, there is an alternative explanation
to their empirical findings.
An alternative explanation is that the relationship is less
linear and more ecological. Figure 4 best illustrates this
causal linkage.
Figure 4
Figure 4
First, an interaction variable exits. Incontinence and the self
destructive feelings spin and perform as a single variable.
Past research identifies incontinence as an independent
variable and the psychological reaction as an intervening
variable and vice versa.
A psychological reaction emerges with the realization that
one was not able to act like an adult. Within our culture, a
person will interpret incontinence as a regression to infancy.
If a person is residing within independent community living,
one can conceal the accident. If a person is residing within
an institutional setting, one cannot conceal the accident. The
remorse is a precipitating event that leads to passive
suicide and/or terminal drop. Within the model depicted in
figure 4, the first cause is irrelevant. The need for
intervention is apparent without having a clear articulation of
first cause. Incontinence clearly leads to feelings of
involutional depression and/or anxiety which emerge as a
consequence of progressing toward a new phase of life that
is dominated with loss of control and dependency for
assistance in Activities of Daily Living. The circular or
ecological model appears to be a more accurate
representation of nursing home and independent living
What do you say when a resident loses control?
realities.
Conversely, terminal drop lays the foundation as an
interactive relationship between apathy and incontinence as
illustrated in Figure 5:
Figure 5
Figure 5
demonstrate higher levels than women (but not statistically
significant). Lee (2004), using a Hong Kong sample, found
men suffered significantly greater psychological distress
than women. However, both males and females had greater
distress than samples that did not experience incontinence.
THE DAMAGE OF INCONTINENCE
The damage associated with bladder and bowel incontinence
has developed such a significant level of concern and
interest, that at least four psychometric instruments have
been developed to address the issue [see: Robinson & Shea,
2002]. These include:
--Urogenital Distress Inventory (UDI) for women
Apathy for living perpetuates a variety of behavioral
manifestations, including incontinence. Sadly, by the time a
practitioner (usually a nurse or a social worker) identities
terminal drop, no psychosocial intervention can alter the
course. In addition, an ethical dilemma emerges: Does an
elderly person have the right to self-determination when
facing death s door? Does he/she have the right to open that
door? The question remains unanswered. The best option
for the practitioner is to focus on the dynamics found in
Figure 4 rather than Figure 5.
BIOPSYCHOSOCIAL VARIABLES PREDICT
INCONTINENCE
In order to provide effective intervention, it is helpful to
know the predictor variables. In most social science
research, demographic variables are often used as a
foundation for establishing cause or explanation. In
examining bowel and bladder incontinence, such variables
offer little to our understanding. For example, cultural
background does not help explain the existence or the degree
of psychological distress. There is no difference between
African Americans and whites (Bobner, 2004). MexicanAmerican women are similar to whites in the USA (Espino
et al. 2003). Lee (2004) suggests that elders from Hong
Kong suffer significant psychological distress. Culture does
not seem to predict the level of distress.
Socioeconomic status (SES) and sex are generally good
predictors of psychosocial dependent variables. In the case
of emotional distress associated with bowel and bladder
incontinence, SES does not predict (Goode, et al. 2005). For
the sex variable, both women and men suffer psychological
distress, and Goode (et al. 2005) shows that men
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--Incontinence Impact Questionnaire (IIQ) for women
--Male Urogenital Distress Inventory (MUDI) for men
--Male Urinary Symptom Impact Questionnaire
(MUSIQ) for men
These instruments are helpful to practitioners who need to
intervene with clients who have incontinence.
The primary rationale for any type of preventative
intervention is an ability to comprehend the consequences of
a failure to intervene. Some consequences (or dependent
variables) are obvious and discussed earlier. The hallmark of
the obvious factors includes depression and anxiety. A less
obvious factor includes social disengagement. Fultz and
Herzog (2001) point out that when incontinence is noted
among elders living in the community, they demonstrate a
pattern of isolating themselves from the community. The
inverse also appears. Incontinence leads to loss of social
support systems such as family and friends (Corna &
Cairney, 2005). Thus, we see social isolation initiated by the
individual aging person or others within the shared social
system. Such a phenomenon is reminiscent of the discredited
Disengagement Theory originally proposed by Cumming
and Henry (1961).
Social disengagement is likely to perpetuate a wide variety
of problematic social and non social issues. For example,
Juzba, White and Chang (2001) demonstrate that incontinent
elders are significantly more likely to experience falls and
fracture than elders who do not experience incontinence.
Since they are socially isolated, they are more likely to not
gain assistance. In addition and more tragically, Shaw (2000)
cites that elders who experience incontinence are not likely
to report the problem to their physician. Incontinence is too
What do you say when a resident loses control?
embarrassing to tell the doctor.
INTERVENTIONS
For the treatment of depression for an elderly client,
Cognitive Behavioral Therapy (CBT) is held in high esteem
(McInnis-Dittrich, 2005; Dobson, et al., 2006). Success rates
are quite impressive (Fisher, et al., 2006). Tovian et al.
(1994) first noted that CBT might be an effective strategy for
addressing issues of emotional reactions to bowel and
bladder incontinence. Later, experiments demonstrate that
CBT is a statistically significant intervention for improving
the quality of life among elders who are incontinent and also
improves bladder functions (Garley & Unwin, 2006). CBT
and other therapies are effective in reducing the negative
reactions associated with incontinence. The major question
becomes, is it possible to intervene earlier in order for the
reaction to incontinence (depression and anxiety) to never
take place? Role playing may have the answer.
Within the context of medical intervention, a variety of
preventative strategies are available to the medical staff. The
research, however, suggests that nursing homes are doing a
dismal job in implementing preventative strategies (see:
Palmer & Johnson, 2003; Palmer & Newman, 2004). These
research findings note it is less troublesome for staff to clean
up after an accident, then implementing one of the
strategies to prevent bowl and bladder incontinence. Nursing
home social workers are assigned the duty of resident
advocate. Within this role, social workers should be offering
in-service training which focuses on the importance of
preventing accidents before they happen. Special emphasis
should be placed on the emotional devastation associated
with incontinence. The review of literature demonstrates that
neither social workers nor nurses are systematically involved
in preventive strategies.
ROLE PLAYING AND INCONTINENCE
During a discussion of incontinence in my Gerontological
Social Work course, I began by asking the questions, What
do you say to a nursing home resident who lost control of
his/her bowels? All the students had completed their
interviewing course and all consistently responded to my
query by replying with empathically reassuring statements.
The answers were too stiff and I decided to employ a
different tactic. I said, Imagine that as you are sitting in this
class, you have lost control of your bowel. The smell is
permeating the classroom and all the students are acutely
aware that the smell is coming from you. At that point, I
repeated the empathically reassuring statements the students
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made a few minutes earlier and asked if those statements
would help. Consistently, all students acknowledged that
none of the statements would emotionally benefit them. In
fact, all of them assured me that they would drop the class
and avoid seeing anyone who was enrolled. A few students
stated that they would drop out of college.
We began to dissect our words and derived common themes
that would be more helpful in addressing the issue of
incontinence. Unlike students attending a college, nursing
home residents do not have the option of leaving and not
returning. Four major themes emerged from the role playing
experiment. 2 These include:
--make an empowerment statement
--seek medical intervention so that it won t happen
again
--finding alternatives to being confronted by others who
witnessed the problem
--do role reversal
Each will be discussed.
MAKE AN EMPOWERMENT STATEMENT
According to the Strengths Perspective, empowerment and
self-determination are the keys to retaining contentment with
one s self. The prerequisite for articulating an empowering
statement is to have a thorough knowledge of the resident s
social history. Since state regulations no longer mandate
comprehensive social assessments and social histories, this
in-depth level of understanding is often unknown and/or
incomplete in the resident s chart. In essence, the change
agent utilizes a resident s difficult experiences from the past,
and draws an analogy of employing past strengths to the
current issue of incontinence. Acknowledging and reassuring
that past problems in the resident s life were overcome leads
to viewing incontinence can be viewed in the same fashion.
The key to successful intervention at this point is having indepth knowledge of the resident s past. If the change agent
does not possess such knowledge and use it effectively, the
resident s self esteem can worsen.
SEEK MEDICAL INTERVENTION
The simplest and most widely cited intervention in the
literature is to employ the diagnosis for medication or other
intervention (physical therapy) to avoid and limit the
possibility of incontinence in the future. In the role playing
exercise, this strategy failed miserably. We concluded that in
What do you say when a resident loses control?
order to be successful, the encouragement or
recommendation for medical intervention must be included
with an empowerment statement. Otherwise the resident is
likely to regress into a childlike state. The review of
literature indicates that most community elders do not and,
in fact, avoid reporting incontinence to a physician. Failure
to report incontinence to one s physician conceals one s
frailty, but also perpetuates the disorder. When a change
agent links medical intervention as part of empowering, an
elder becomes the master of his/her destiny. Empowerment
is the hallmark for encouraging the elder to report the
incident to a physician. We hope that a physician will not
make the elder feel worse.
FINDING ALTERNATIVES TO BEING
CONFRONTED BY OTHERS WHO WITNESSED
THE PROBLEM
The review of literature indicates that the fewer people who
know about the incontinence, the better for the emotional
state of the resident. Thus, a critical strategy is to limit the
number of people who enter the room. The aides and/or
orderlies who are involved need to comprehend the level of
sensitivity that is required. Unlike the other strategies
uncovered within the role playing exercise, this finding
requires advanced planning. In-service training needs to be
provided to front line workers on how to approach residents
who experience incontinence. Aides and orderlies are likely
to perceive incontinence as inconsequential and follow
procedures for cleaning up. They need to understand that the
resident does not perceive the accident as inconsequential,
but rather as catastrophic.
ROLE REVERSAL
The best strategy uncovered in the experiment is role
reversal. As with the other strategies, this requires in-depth
understanding of the resident s social history. We begin with
the acknowledgment that incontinence is embarrassing for
everyone: It is difficult to accept and stating to a resident,
don t worry about it will only make things worse. An
example of how to engage a resident in role-reversal is, if
our situations were reversed, what would you say to me to
assure me that my incontinence is not a problem? In role
playing, we learned that when a person reflects on the
experience of dealing with incontinence of others, their own
incontinence is viewed in a more accepting manner.
Residents are likely to experience a reduction of anxiety and
avoid the depression that normally follows. In addition, I
hypothesize that if role reversal is employed, residents will
be more receptive to pursuing medical intervention to limit
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the possibility of incontinence in the future.
SUMMARY AND CONCLUSION
The most humiliating experience an alert independent-living
elder and nursing home resident faces is unpredictable bowel
and bladder incontinence. For elders living independently,
the event is concealed in order to avoid embarrassment and
often no medical intervention is sought. The review of
literature suggests that family members generally respond in
an inappropriate manner. Disengagement from family
members is a common outcome. In addition, elders seek
disengagement from their family and others within their
primary group.
For elders residing in an institutional setting, staff perceive
incontinence as inconsequential and follow procedures for
cleaning up. Staff, aides and orderlies do not define this even
as a psychological catastrophe and respond in a nonchalant
manner. The premise for following this nonchalant path
appears to be ageism. Institutional staff operates under the
assumption that incontinence is not emotionally problematic.
That is, staffs think incontinence does not breed humiliation
among elders. It does.
During the role playing experiment, we learned that even
trained professional staff believe that elders (because of their
age) will accept incontinence in a gracious manner because
it are perceived to be a normal part of aging. Clearly, this is
false. The role playing experiment reinforced this
conclusion. Elders, particularly those who experience
incontinence for the first time, identify the experience as
regressive and humiliating. Although a wide variety of
counseling theories and strategies have proved to be
effective in addressing the negative emotional reaction to
incontinence, our role playing experiment suggests that if a
professional intervenes appropriately and immediately after
the accident, therapeutic intervention may not be needed.
If it is needed, the intensity duration of intervention will be
less dramatic.
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What do you say when a resident loses control?
Author Information
Stephen M. Marson, PhD, ACSW
Professor, Social Work Department University of North Carolina at Pembroke
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