Box entertaining the elderly: a process of construction as a clinical procedure and its contribution to the quality of the bond

ORIGINAL ARTICLES

Box entertaining the elderly: a process of construction as a clinical procedure and its contribution to the quality of the bond

Caixa lúdica para idosos: processo de construção como procedimento clínico e sua contribuição na qualidade do vínculo

Box divertir les personnes âgées: un processus de construction comme une procédure clinique et sa contribution à la qualité de la liaison

Caja lúdica para ancianos: el proceso de construcción como procedimiento clínico y su contribución en la calidad del vínculo

Liliana Cremaschi Leonardi; Avelino Luiz Rodrigues

University of São Paulo - USP

ABSTRACT

Nobody grows old the same way and the changes caused by aging develop at a different rate for each person. The aim of this study is to preset the use of the Playful Box for the Elderly and the possibilities of influencing the bond quality. The Playful Box for Elderly has facilitated the emotional bond and the socialization of institutionalized elderly in clinical care. It has also given rise to questions related to basic anxieties, unconscious wishes and main defense mechanisms. This technique allows the demonstration of the multiple expressions of the inner world, important in understanding, managing and improving the health and welfare of the elderly as a preventive and easy tool to improve the quality of life for seniors.

Keywords: Aging. Play therapy. Clinical.

RESUMO

Ninguém envelhece da mesma maneira e as alterações causadas pelo envelhecimento desenvolvem-se num ritmo diferente para cada pessoa. O objetivo deste trabalho é apresentar a utilização da Caixa Lúdica para idosos, seu emprego e as possibilidades de influência na qualidade do vínculo. A caixa lúdica para idosos facilitou o vínculo emocional no atendimento clínico, permitiu a melhor socialização de pessoas idosas institucionalizadas, fez emergir questões relacionadas a angústias básicas, desejos inconscientes e principais mecanismos de defesa. Essa técnica permite a manifestação das múltiplas expressões do mundo interno, importante na compreensão e manejo e na melhoria das condições de saúde e bem estar do idoso, tal como um instrumento preventivo e de fácil aplicação para melhorar a qualidade de vida dos idosos.

Palavras-chave: Envelhecimento. Ludoterapia. Clínica.

RÉSUMÉ

Personne ne vieillit de la même manière, et les changements causés par le vieillissement se développent dans un rythme différent d'une personne à une autre. L'objectif de ce travail est de présenter l'utilisation de Boîte de Jeu pour les personnes âgées, son usage et les possibilités d'influence dans la qualité du rapport. La Boîte de Jeu pour les personnes âgées a facilité le rapport émotionnel dans le traitement clinique. Elle a permis une meilleure socialisation de ces personnes institutionnalisées, en faisant ressortir des questions liées à l'anxiété, aux désirs inconscients et aux principaux mécanismes de défense. Cette technique favorise la manifestation d'expressions multiples du monde intérieur, important pour la compréhension, la gestion et l'amélioration des conditions de santé de bien-être de la personne âgée, tout comme un instrument de prénvention et d'application facile pour améliorer la qualité de vie des personnes âgées.

Mots-clés: Vieillissement. Thérapie par le jeu. Clinique.

RESUMEN

Nadie envejece de la misma manera y las alteraciones causadas por el envejecimiento se desarrollan a un ritmo diferente en cada persona. El objetivo de este trabajo es presentar el uso de la Caja Lúdica para gente de la tercera edad, su empleo y las posibles influencias en la calidad del vínculo. La Caja Lúdica para mayores facilitó el vínculo emocional en la atención clínica, permitió una socialización más favorable de las personas mayores institucionalizadas, hizo emerger cuestiones relacionadas con angustias básicas, deseos inconscientes y principales mecanismos de defensa. Esa técnica permite la manifestación de las múltiples expresiones del mundo interno, importante para la comprensión, manejo y mejoría de las condiciones de salud y bienestar de la tercera edad, así como un instrumento preventivo y de fácil aplicación para mejorar la calidad de vida de las personas mayores.

Palabras-clave: Envejecimiento. Ludoterapia. Clínica.

Current Panorama

Being elderly is not just defined by age in years, but implies a set of biological, psychological and social changes. Nobody grows old the same way and the changes caused by aging develop at a different rate for each person and depend on external and internal factors (Augustine, 2004). There is great concern about the growth of the elderly population in Brazil. Data from the 2000 census show that 8.56% of the population is represented by individuals above 60 years of which 55% are women. It is believed that in 2020 there will be over 25 million senior citizens, and the public health services are not properly prepared to meet this growing population (Brazilian Institute of Geography and Statistics [IBGE], 2004). By the law of 8842 January 4, 1994, within the National Aging Policy, the purpose section, second article, «it is considered elderly, for purposes of this law, a person over 60 years of age» (Law no. 8.842, 1994).

In 1996 the population of São Paulo was 9.5 million, and over 880,000 people were 60 or older. Whereas about 30% of the elderly population has some mental disorder this municipality would currently sum approximately 240,000 seniors presenting psychiatric problems. If we consider that we have about 100 outpatient mental health services, there is a shortage of multidisciplinary adequately trained teams for the population demands (Garrido & Menezes, 2002). The elderly experience many difficulties ranging from issues such as inadequate social support to the difficult access to quality health care.

Besides the body changes, according to Zimermann (2000), aging brings to human beings a series of psychological changes which can result in: difficulty to adapt to new roles, lack of motivation and difficulty in planning for the future, the necessity to work the organic, emotional and social losses, difficulties to adapt to the rapid changes which have dramatic consequences in the elderly, psychological disorders which require treatment, depression, hypochondriasis, somatization, paranoia, suicide, low self-esteem and self-image.

Therefore, certain circumstances frequently in old age, such as loss of a loved one, a friend and meaningful activities, may not only precipitate the physical and psychological declining, but also aggravate an illness at any stage of life (Aiken, 1989), since the socially interact ability is fundamental for the elderly. The welfare notion broadens the concept of prevention, which focuses on preventing or delaying the disease (Crepaldi, 1995).

To Gazzalle, Lima e Silva (2004), depression is considered a natural consequence of aging, being neglected as a possible morbidity indicator. The elderly often presents depressions (Almeida, 1999) which are reactions to both physical and psychic losses, often related to the aging process itself. Some of these symptoms (pain, sleep disorders and appetite) (Stoppe Jr., Jacob & Louza, 1994) can often be superimposed to the normal aging process, once again making it difficult to diagnose depression. It should be noted that many cases may be erroneously interpreted as normal aging changes, staying without proper treatment, causing unnecessary suffering to those who do not receive treatment, difficulties to the patient's relatives and high economic cost to society (Adams, 1999; Stoppe et al., 1994).

The personal social network has tendency to decrease as people get older, while the need may become more intense when we treat the institutionalized elderly. Associated to it, the reduction in opportunities to replace these losses may cause emotional problems (Freire & Tavares, 2005). In Porcu et al. (2002) survey, referring to the comparative study of the depressive rates symptoms among older adults who are hospitalized, living in nursing homes or who are in the comfort of their home, it was observed that the hospitalized and institutionalized elderly had a higher prevalence of severe and very severe depressive symptoms compared to elderlies residents. It was observed in residents of nursing homes and the hospitalized, the prevalence of gestures acts and suicidal ideation significantly higher than observed in the elderly living at home.

The good aging

According to Neri (1995), the successful aging depends on a number of factors, identified as determinants or indicators of well-being in old age: longevity, biological health, mental health, satisfaction, cognitive control, social competence, productivity, activity , efficacy, social status, income, continuity of family and occupational roles, continuity of informal relationships with friends, and the main one is the economic, fundamental to the promotion of good physical health and education throughout the life course. Also emphasizes full aging is an individual and group condition of physical and social well-being, referenced to the society ideals, the conditions and values of the environment in which the individual ages and the circumstances of their personal history and their age group.

Such survey involves the facts’ multidimensionality and their interference in accordance with the potentials and peculiarities of health and life of the elderly, interfering in the process of health and illness (Santos, Santos Fernandes, & Henriques, 2002), because several elements are pointed as determinants or indicators of well-being in old age: longevity, biological health, mental health, satisfaction, cognitive control, social competence, productivity, cognitive efficacy, social status, continuity of family and occupational roles and informal relationships with friends.

The subjective character and the relativity of the health concept as well as personal experiences of illness and health are highly influenced by the social space in which they happen (Somchinda & Fernandes, 2003), in different stages of aging from the physical changes to the social devaluation (retirement, becoming an economically inactive population) involving feelings and understandings regarding each step, gain, biological loss, psychological and social functions, frustrations, aspirations, among others (Pereira et al., 2006).

Promote the active and healthy aging, means among other things, foster their autonomy and preserve physical and mental independence of the elderly population, preventing the functional capacity loss and / or reducing the negative effects of events that cause them. Professionals should be sensitized and trained to identify and meet the health needs of this population (Law n. 8842, 1994).

The twentieth century is considered the century of seniors, characterized by social challenge in responding rapidly, qualitatively and quantitatively to the growing demand due to technology and physician progress, reduction of birth rate and increase of the average life expectancy which leads to consequences in the multiple biopsychosocial and cultural dimensions of man and demanding both the redefinition of necessary values and reintrojection of everyday attitudes (De Masi, 2000).

Due to the increasing number of elderly in Brazil and worldwide, researches on this population become increasingly necessary, as well as search for specific vocational training and better public health policies planning (Kaplan & Saddock, 1995; Linhares, Coelho, Guimarães, Campos, & Carvalho, 2003). Therefore, emphasis is put on the scientific and social relevance of investigating the conditions that affect the senescence welfare and the factors associated with the elderly healthy in order to create alternative clinics that attribute effective health intervention, seeking to meet the aging population demands (Fleck, Chachamovich, & Trentini, 2003).

This article aims to present a new possibility for clinical procedure: the use of the clinical procedure the playful box for elderly (Caixa Lúdica para Idosos - CLI), since there were no reports or records found of specific work techniques to the elderly population, at a time when the increasing elderly population makes us more aware of the need for care and attention to this population segment and can be used in the context of assessment and clinical intervention by experienced psychologist. This procedure was developed in a project which was evaluating the quality of life in institutionalized seniors (Leonardi, Damascus, & Roberts, 2007) by Subject and Body Laboratory – Laboratório Sujeito e Corpo (SUCOR) from the Psychology Institute of the University of São Paulo.

History of the Playful box for elderly

This article aims to present a new clinical psychodiagnostic procedure: a playful box for elderly, as well as recount its development.

It arises in a search that sought to evaluate the quality of life in institutionalized elderly (Leonardi et al., 2007) by Subject and Body Laboratory – Laboratório Sujeito e Corpo (SUCOR) Psychology Department at the Psychology Institute of the University of São Paulo.

Towards this objective and the researchers' need to achieve greater understanding of the elderly public, we have developed a research project that encompasses the characteristics and needs of that population, which has peculiarities such as feeling distanced from the productive layer, from social and family life, prisoners of their own memories, or from their habits, loneliness, aggressiveness, impairments and physical losses.

When asked about their daily lives in the institution, routines, activities, among others, we could notice some disturbance about them feeling to be receiving similar treatment given to children. In fact, we are talking about different maturational developments, affective-emotional issues, life history and of various personality structures.

These factors lead us to reflect about what tools or work techniques there were in psychology so far and we noticed the absence of a play therapy clinical procedure of specific research in elderly which would allow us to observe, describe and understand the psychic experience, integrating this information to the seniors' personality. This led us to the existence of the playful box for children and thus, its possible adaptations for the elderly population. Therefore was born the Playful Box for Elderly.

At that time this new procedure was called "Old Playful Box"- “Caixa Lúdica Old” (CLO), or Playful Box for Elderly – Caixa Lúdica para Idosos (CLI). From the reports obtained, we have realized that the presentation of a box with toys and graphic material would not be well received by the elderly, but it could be displayed empty, since the interaction and construction proposed would be implicit and, based on the valuation of the life history of each. Thus was born the playful box for elderly. It is a box with 29 centimeters long by 16 centimeters wide, similar to a shoe box with removable lid presented to each patient for them to fill up with whatever they want and is significant to them (objects, photos, papers writings which represent objects that do not fit in the box, or significant aspects etc.). The patient himself is the one who selects the object or the representative of an object to be deposited in the box. Thereby, the construction (completion) reflects their characteristics, their way of being, feeling and reacting to these objects (internal), their life history, being the box space a continent intended for the patient's internal contents, which can be revised or revisited when they want.

By establishing a parallel with the playful box for children, we remember that it has a lot of toys and materials that are offered to children, according to Klein (1981), reflecting individual preferences and choices. The value of games and toys as an expression of conflicts and desires has been highlighted by several authors who have studied the forms of children's expression, such as Klein (1981), referring to this as a means of access to the unconscious. It is worth mentioning that the theoretical foundation of this work is mainly based on theorists who studied infancy, inasmuch the playful box for elderly is a new procedure, there are no other authors who address it besides the playful box for children. In the case of the playful box for elderly, the objects are elected by the elderly, those endowed with significance in their life and may include concrete objects present or absent at the time, people, facts or circumstances of life. In the absence of concrete objects, these were recorded on piece of paper and enclosed in the senior’s box; the same procedure was done to people and circumstances. Each box got the name of the respective senior through a label sticked on the outside of the lid, in the middle of it, in order to identifying and customizing the material.

The game facilitates

Melanie Klein's studies revealed the possibility of the child, through toys and spontaneous games, imaginary, among others, to represent their basic conflicts, unconscious desires, their fears and their main defenses, beyond the fantasies of sickness and healing. Trinca (1984) used the game as a means of access to the child's unconscious, to the fantasies and desires, informing us about the creative ability, symbolic, allowing on the basis of material that raises, to emerge the formulating of prognostics, diagnostic and therapeutic indications.

The diagnostic potential of the game is enhanced as the child is offered a framework composed of a space, a time and a relationship which the child structures according to the internal dynamics as well as the possibility of projection of anxieties and conflicts that appear represented in objects' shapes, according Trinca (1984).

According to Klein (1981), the toys are not the only requirements for the playful analysis. Here we are faced with a challenging and innovative feature that consists in presenting an empty box and allow the patient to self-organize internally to be able to complete the task to fill it with whatever he or she wants, which may be objects, memories, photos of people , among others, from a reconstruction and reframing perspective, since it is about seniors who already have a life history and reframing moments by affective charges, choices, formed personality, traits, customs, among others (different audience from the child). The differentials of this procedure involve the proposal, the originality, the procedure relevance, the possibility of becoming and the significance of characterizing in this playful space its inner world in the elderly.

The various "playful themes", yet according to the author (Klein, 1981), and the affects associated with it are represented side by side in a small space, and so the proposal was also considered in the playful box for elderly, allowing the same way a good overview of the general connections and dynamics of the mental processes that are being presented. Regarding to the particularity of the raised facts, both practices resemble (playful box for children and the playful box for elderly), because no description could do justice to the colorful particular richness of individuals, who express themselves through these techniques appropriate to their profile and time, respecting the differences and limitations of each one.

Thereby the game appears as a way to allow the latent contents to emerge. In the case of the playful box for elderly, the challenge of filling it freely puts the elderly in the role of someone who has a job that motivates and time to develop this activity, the spatial limits of the box provided, also working as a game, with rules and parameters. According to Aberastury (1974), the child's actions will represent the attitude towards the world, the unconscious fantasies of sickness and healing and how to deal with the figure of the psychologist. Thus, the CLI will evoke different attitudes to each person, the empty box to be filled, the look towards life itself and fill it with memories, photos, objects, papers among others, being able to perform the proposed activity and organize themselves internally according to their possibilities, unlike playful box for children, and the playful form of expression does not suggest a certain infantilization of the elderly population.

Playful box for elderly and its possibilities

The playful box for elderly was used in our research as follows: seniors have received a playful box each, properly identified with their name, and they were asked to fill it out with what was important to them so that when we look inside it, we could be sure that this box actually belonged to the senior. Each box was unique as each person is unique, being a space destinated for its content which may be revised when the senior wants. In this phase of the research 10 elderly were involved and the deadline for box construction would be closed in a week, in other words, every senior had a week to perform the task proposed. We noticed that the elderly were motivated, curious and interested in the research, because it is a study about them, and in the proposed activity, they approached us and requested their participation. That day the institution seemed to take a new breath, since every elderly circulated with their box, showing it to other residents and telling the news.

After a week, we have returned to the institution for opening and presentation of the boxes contents. We were greeted by the elderly who were mostly in possession of their boxes, either on the bed in their rooms, or in their lap in the TV room, or somewhere near. We have organized the opening order, according to mealtimes and the institution activities, and we have started opening the boxes.

Each box opening led us to completely unique experiences. Many seniors filled it up with the transitional objects, gifts , messages, personal objects, photographs, papers where were the names of significant people, mother, father, husband, children, grandchildren, nephews, friends, brothers, uncles, neighbors, and circumstances, such as the birth of children, marriage of children, the birth of grandchildren, someone graduation, unforgettable trip, a romantic rendezvous, a special date, among others, revealing significant emotional intensity in the contacts. When reporting on the box contents, the elderly revived the scenes, affections forgotten, reconnected to people, as if they had forgotten their ability to feel, to recall, and to take ownership of their history and all the colorful underlying emotional. The wealth of material evoked by the playful proposal allowed a nearness to the psychic reality of the elderly, their fantasies, anxieties, conflicts, defense mechanisms, among others.

This survey moment sent us to the elaboration of another work stage, in order to explore the newly discovered potential through the playful box for elderly. Out of ten seniors three were selected whose demands were more strongly evoked in the box opening encounter and whose interview feedback demonstrated the need for more time to understand, deepen and organize their questions. They were asked to another phase and subjected to more three meetings, once a week for three weeks. It is worth noting that the elderly guests accepted the proposal and the other seniors who had participated in the first moment had known that we had selected some for that other phase, which would require larger penetration using the playful box for elderly over a certain period of time, and had shown understanding and gratitude for their participation.

The meetings were held, therefore, according to the proposal of each one. In the first meeting, using the playful box, the elderly would select from the box those contents which would like to talk more, regardless of the choice reasons (pain, joy, conflict, among others.). In the second meeting there was a deepening of the contents sensibilized on the first date, besides possible interventions. The third meeting was held a feedback on the elderly material, as well as requesting a self-assessment on the process and their experience. In the process we realized the clinical potential of the procedure playful box for elderly, facilitating the design and the deepening of the therapeutic care as well as facilitating projections, and being an intermediate element which allowed the free expression of content, having a motivational component, welcoming, among other factors.

Both the first and the second group were told that everything which had been deposited in their boxes existed within each one and could be revisited when they wanted. Some seniors wanted to remain with their boxes stating that they would continue to fill them and mentioned they had no end, perhaps internally postponing the separation of the process completion. It is worth mentioning that the objects included in the box were within it throughout the process, as well as the boxes were in possession of the elderly.

Conclusions

The CLI procedure developed in the referred research and elaborated in 2007 by the Subject and Body Laboratory (Laboratório Sujeito e Corpo - SUCOR) of the Psychology Institute, University of São Paulo, fills a gap as execution procedure in the elderly population, which seemed to claim attention. Enabled an approximation process to the patients inner world, regardless of the mental health degree providing the reality data rescue that contributed to bring the elderly back to the present moment, contextualizing them according to their chances with attenuation of diagnostic symptoms, returning then to its commitment condition.

In its originality and uniqueness we have realized that the use of this procedure allowed the seniors who participate in the study a symbolic peculiar expression of their subjective contents and an improvement in the communication conditions, favoring the approach and understanding regardless of the normality conditions of the patients, offering a facilitator in the reading increment of situations experienced by and actual needs of the elderly, besides creating conditions for redesigning processes of internal objects in a continuous and active process of the person searching for a state of biopsychosocial equilibrium. It reflects the search for a language of the patient's forgotten years, resembling the work of the archaeologist who seeks evidence to reconstruct what was destroyed or buried, as Klein (1981) removing the inferences from the fragments of reminiscence, associations and behavior of the elderly. In this sense, it seems to have gotten access to those forgotten years and go beyond suggesting the elderly understanding of the life process which does not end when the research ends, bringing reflection, revision and future prospects.

The elderlies have remained motivated throughout the process, not offering any form of resistance, feeling perceived, heard in their stories and personality dynamic. The playful box for elderly permited the welcoming feeling and respect once it assembled the internal contents of each elderly person in a space for each one in their own playful box for elderly customized and endowed with unique content.

We concluded that the procedure developed offered a motivational component and playfulness that facilitated clinical intervention involving creativity, curiosity, freedom of expression, allowed the professional's perception of the client's basic anguishes and the main mechanisms used by him or her favored the experiences rescue, sensitization and contextualization of these from an acceptance perspective and appreciation of the multiple expressions of the inner world (Leonardi et al., 2007).

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Publication Dates

• Publication in this collection
  05 July 2012
• Date of issue
  June 2012

History

• Received
  03 Sept 2010
• Accepted
  01 June 2011