One-on-one with…Montgomery Ostrander

From student to psychotherapist to administrator, Montgomery (Monte) Ostrander has followed a calling to address issues of depression and dementia in senior care facilities by integrating therapeutic mental health services into a senior residential care program. As founder of Tree of Life Elder Care in El Cajon, Calif., Ostrander has created an integrative, therapeutic and holistic program for his residents.

He shared his philosophy on eldercare in an interview with Long-Term Living Managing Editor Sandra Hoban.

How—and why—did your career transition from social work to senior residential care?

During my final semester at University of Southern California’s online Master’s in Social Work program, MSW@USC, I interned at different locations, serving the needs of different populations from a mental health standpoint. I was working with foster children, which was difficult for me. A court verdict (Katie A v DSS, 2011) led to new regulations in foster care and clinical case management. Seeing firsthand how policy can affect mental health made me more curious about community welfare.

The foster care model extended my practice of psychotherapy to informal residential settings. This “take the couch to the streets” philosophy made me rethink how to use my new therapy skills. I took a course with Thanatologist Professor Cynthia Rollo-Carson, and noticed a massive need for mental health professionals in eldercare facilities. From grief and loss counseling to family systems counseling, all families with aging members need support. Imagine the suffering a daughter feels whose mother doesn’t recognize her.

I opened Tree of Life Elder Care to provide free informal psychotherapy to the elderly residents of my homes and their families, integrating holistic support for the Bio-Psycho-Social-Spiritual needs of this population.

What guidance helped you transition your skills to the aging field?

MSW@USC helped find me a new internship once I discussed this new idea with their team. There just aren’t that many social workers interested in palliative care and mental health, let alone any who create their own hospice.

I also did personal research and enrolled in certified state classes with Laura Ferrall from Elder Care Inc., who mentored me in developing the business model. I become a certified administrator and applied for a state group home license (RCFE).

How does Tree of Life differ from traditional nursing home care?

The idea of integrating psychotherapy into Tree of Life has been rewarding, but also challenging. I attribute both my own learning curve, and our collective learning curve to understanding dementia. It’s very difficult to build a therapeutic alliance with someone suffering from cognitive impairment and the emotional healing work becomes more prescient while working with the families. Aging and dying are such difficult topics for most people to discuss that my mental health practice has been truly helpful for family members during the dying process.

Having realized that these patients who are essentially nonverbal and respond more to less external stimuli, my therapeutic approach focuses on anxiety relief, mindfulness and stress reduction. Originally my idea was to engage with each client one-on-one and begin addressing psychodynamic or case management issues, but as things usually go, the patients taught me how to treat them. Engagement was my top priority-I imagined that building new bonds, relationships or trust would improve their quality of life, make them feel more connected to a world that increasingly looks like it wants to ignore them.

In the first six months, all of my residents were able to discontinue antidepressant medication. This was not a success for psychotherapy. I believe the most important change that affected their well-being was their change in diet.

Why place such a strong emphasis on specialized diet rather than traditional food service?

I researched diet change and learned that gluten and sugars in processed food create free radicals that create inflammation, the source of all disease. Of course, no one is going to send their elderly parent of the “Greatest Generation” to a gluten-free raw, vegan board and care, so we implemented these changes subtly. Spinach infused orange juice, fruit smoothies with fresh kale from a hydroponic table on the patio, ground turmeric on eggs; many of these are hardly noticeable to the patient but they represent radical changes.

Here is what we know about dementia: It is caused primarily by free-radicals as they break down protective cellular lining, which causes inflammation and disease. When it happens in the hippocampus or amygdala, as people age, memory loss occurs. Memory is cellular, it exists as chemicals inside the brain. Until about five years ago we all believed that brain cells were gone forever once destroyed. Now we know about neurogenesis. New brain cells can actually be formed and there are certain foods that assist in this process, antioxidants, fresh whole fruits and vegetables. I found this journal article to be helpful.

An ironic twist in special diets is water thickener, which is powdered gluten. It makes water easier to swallow for patients with dementia to prevent aspiration. The simple fact is when you eat better you feel better.

Several months ago, a hospice patient was put on a total anti-inflammatory diet; he recovered and moved out. Food is medicine, without question.

How many residents do you have?

Currently we have 24 individuals in four homes across San Diego. We accept all types of seniors; however, there are numerous medical and legal restrictions within which we must operate. There is currently a pilot program in San Diego County called “Assisted Living Waivers,” which allows private RCFEs like mine to accept Medicare patients. It will likely be six months before Medicare patients are accepted program.

What staffing requirements transcend those of traditional nursing homes?

There are three caregivers per home; the state requires one caregiver. In addition to traditional caregivers I have hired social workers, Reiki practitioners, shamans, clergy, masseuses, music therapists, nutritionists, yoga instructors, pet therapists, a holistic health practitioner and even an Elvis impersonator. The music, massage and pet therapy programs were highly effective and I am planning to conduct a simple pre-test/post-test on the Beck Anxiety Inventory to measure the efficiency of each. As we expand, more of the holistic element and psychodynamic will be included.

Do families have a role in care delivery?

Families often have mixed emotions. Family systems are complicated and when aging, dying or dementia is present, everyone responds in his or her own way. Many families participate in care, many do not.

The nonparticipants tend to have guilt issues and even those who do participate also report feelings of guilt. Everyone wants to do more for their loved ones and it is especially hard because their needs are ever-increasing. For this reason, Tree of Life is a professional care home, licensed and certified to provide care that is simply too difficult for a partner or child.

What results have you witnessed? Are there other innovations or program expansions planned for the future?

What I’ve observed is the struggle each person has in coping with death. Dying is a major life event; when it happens in Tree of Life homes everything sort of stops for a few hours, the energy in the room shifts. I am amazed by individuals who have developed incredible coping skills and supportive, healthy perspectives on loss. These people are the exception, not the rule. We can map our genomes and drive cars on Mars, yet the loss of a loved one still has the power to traumatize. In the future I plan to address this issue by opening public hospice houses.

With the implementation of the Affordable Care Act, there are now millions of Americans who have access to medical care for the first time. Imagine those who have been in poverty their whole lives, unable to afford medical care finally receiving proper care at the end. Hospice for the Homeless is my future plan.

Any advice to other organizations that want to adopt your care your care philosophies?

Absolutely! I would encourage other long-term care facilities to do some research and see what type of holistic incorporation may work best for their residents. As I mentioned before, every facility should research diet change. The impact of diet change is so much more important than I ever thought and has truly had a positive impact upon Tree of Life residents.


Topics: Alzheimer's/Dementia , Articles , Clinical , Executive Leadership , Leadership