Developing Rapport with Older Adults Made EASY!

Foreign. I'd like to welcome everybody to today's presentation on developing rapport with older adults and those with cognitive impairment. I'm your host, Dr. Donnelly Snipes. In today's presentation, we're going to define rapport, explore how lack of rapport negatively impacts treatment, and identify strategies to improve communication who have cognitive, vision or hearing impairments. So rapport, just at its core is that sense of safety, connection and trustworthiness that we develop with people as we get to know them. Most people are not going to walk into their therapist's office or their doctor's office or anywhere and have instant rapport. Every once in a while you meet somebody that you click with and that rapport develops really fast. But there is not such a thing as really instant rapport. I want you to think about how a lack of rapport, how somebody not perceiving you as being safe, understanding or trustworthy, how does that impact assessment, treatment, and them getting their needs met. And Daniel kind of threw a curveball in here before class, but I'm going to try to address some of those issues too. As far as working with people in a correctional environment, when you don't have rapport, I mean, there's a lot of concern for your safety. There's a lot of concern for what people think in a lot of different situations. Developing rapport means meeting the person where they are emotionally, mentally, physically, and helping them feel confident that you're there to help them achieve their goals. And you're not there to do things to them. You're not there to take away their power. You're there to help them achieve their goals in the best way possible. Given whatever setting you're in, whether it's long term care, nursing home, post acute care, correctional, you are there to try to help them live their richest, most meaningful life in that setting. Secure attachment behaviors really help us develop rapport. I know there's a shocker when we are consistent in our presence with the clients. If we say we're going to be there at 11, we show up at 11. If we are their counselor, for example, or their in home caregiver, the same person shows up. As people age especially, it becomes a little bit more difficult for them to adjust to new people, for them to develop that sense of trust in new people. So consistency and presence is really important. I don't know if you've ever gone to a treatment center or worked in a treatment center in which there was really high turnover and clients would quit coming because they'd get so frustrated that the Same person. They'd see a therapist for six weeks and then they disappear and somebody else would show up and they felt like they had to start all over again and didn't know what to expect. So you can understand how consistency and presence with people is important, but also consistency in your behaviors both within sessions. You don't start off the session being attentive and then start getting bored halfway through. And consistency within sessions and between sessions. When you show up, you have roughly the same demeanor. You're not doing this Jekyll Hyde thing. That can be really frustrating. And if you're having a bad day, cuz we all do. Noting that with the client, I'm sorry, I feel really rushed today. I really want to hear what you have to say or, you know, it's been a heck of a day. Let me, you know, get grounded for a second. Always good to model those skills. Let me get grounded for a second and then we can start. So the client is aware that I'm not mad at you, I'm not not wanting to see you and trying to hurry out of here. It's me, it's me, not you. So being consistent so they know what to expect and when they tell you something, how you're going to react in general, acceptance and attention. It's important, especially when we're talking about older adults, whether it's in corrections or even your grandparents, learn about their culture. One of the things I regret most about my relationship with my father's mother, my paternal grandmother, is that I didn't know the questions to ask. I didn't know what I didn't know. And I never really spent a lot of time with her. I mean, we, we hung out, but. And, and she took care of me, but it wasn't like I really ever even knew her until her wake. And then I heard all these fabulous stories and anecdotes and just gave a whole new perspective. So learn about the people's culture when, if you are 20 right now, then you may be working with people who grew up in the 50s and 60s as older adults. Learn about what was going on then, what was important to people then, what kinds of music did they listen to? Music is one of those things that most people listen to, develop a little bit of understanding. So you can ask questions and say, hey, what kind of music did you really like to listen to when you were younger? Or tell me about your favorite memories from when you were younger. And that may tell you a lot about them or it may tell you about their culture, how they spent the holidays, how they coped with different things. But getting insight into them can be validating for them. It's like, hey, somebody wants to pay attention to me. But it can also help you understand them better. And as people age, especially if they've got Alzheimer's or dementias, they may have difficulty remembering things in the near past, in the recent past, but they can remember things from the distant past and that can bring a sense of happiness and contentment to them. So those things are all important. Providing a sense of acceptance when you walk in, even your non verbals, if you walk in, it's like g, you know, I've got to, I'm here, I've got to see you. I have nothing in common with you and I don't want to spend any time with you. Well, that's going to come through loud and clear if you come in and you say hey Mrs. Smith, why don't you teach me how to play gin rummy today or, or whatever. I used to play gin rummy with my grandmother all the time. That provides a good sense of or a good opportunity to connect in a way that's non threatening and that's really important. Even if you're doing therapy in long term care facilities, asking about what their preferences are, asking about, do they like dogs, do they like cats, do they like holidays, I don't know. Learning more about them so you can provide that sense of acceptance. We may have differences. You may like summer and I like fall. You like the beach, I like the woods, that's fine, you know, no big deal. Tell me more about why you like the beach so much more than something else. And I know I'm spending a lot of time on this, but this is one of the areas, especially when we're working with people who are of different quality cultures. And by, by that I also mean different age groups. As I mentioned a few minutes ago, people who grew up in the 20s and 30s and 40s, like our great grandparents, had different experiences and have different stress triggers and trauma memories and good memories too than the people who grew up in the 50s and 60s. And then you have people that are in my age group who grew up in the 70s and 80s. And we all have different memory points, things that we can think back about and go, oh my gosh, that is so for me, so 1980. And it can create a sense of something to talk about and conversation so the person feels accepted. Be responsive to their emotions, their questions and their problems. Being aware if they say they're having difficulty sleeping or maybe they're just, they seem agitated and you don't know why they haven't articulated it, but they seem agitated. Being responsive to that and noticing and saying, hey, John, you seem, you know, really restless today and agitated or irritable. You want to tell me what's going on or is there a problem? Are you having pain? For a lot of people who are older, pain can contribute to agitation and sleep problems, but being open to it, not just assuming, oh, he's agitated, he's having a bad day, he'll be fine tomorrow. That's dismissive. Be responsive to what's going on when you meet with them. Obviously you're not going to helicopter around them all day long every day, but when you do engage with them, if you notice something is off, respond to it. If you notice that they're happier than usual, ask about it. Because you're there not just to help them through the tough parts, but also to help them celebrate and magnify the good things that are going on. Provide encouragement. There are, for all of us, there are good days and there are bad days. If somebody is recovering from stroke or open heart surgery or they've got dementia, they're going to probably have a lot of change between their goods and bad days. When they have bad days, providing that encouragement when they're having good days and they step out of their comfort zone. My grandmother, when she had to go to assisted living, was very angry and very afraid and lots of stuff was going on there and they provided a lot of encouragement to get her to go out and eat in the dining room instead of eating in her room. And that was scary for her. My grandmother is, was not a super introvert, but she was always very much a homebody and they encouraged her to go out. And honestly, I think the first thing that got her to leave her room was not eating in the dining room, but going to bingo. She played bingo as long as I can remember. And that encouraging her to go out and hey, you know, it's not so scary out here, was really helpful and rewarding. That noting when people take a step outside their comfort zone and they confide something in you, or they tell you they've got a problem, or they do something that they've been a little resistant to do, validating that and highlighting that and complementing that is so important and then providing safety and a supportive and again, consistent environment. If there is constantly change going on, if there are people moving rooms or if there's chaos, it's going to add a lot of stress. So doing as much as you can to ensure consistency in the environment. And I know we already talked about consistency, but that will help people feel safer. Because remember, older adults especially cognitive process is slow. It's not dementia, it's just aging. And it can be harder to adapt to changes. And it can feel very stressful when things change all of a sudden. If you're in assisted living or even in corrections, if suddenly a routine changes and there's no lead up to it, there's no explanation for why it's happening, it can feel very jarring, especially for the older adult, thinking about how you could communicate each one of these things or demonstrate each one of these things in session with clients, or if you're in an assisted living facility or a correctional facility, when you see the clients, you walk past them, you in the hallway or what have you, how can you be consistent in your presence? How can you, within reason, you got stuff to do, I get it. But how can you be accepting and attentive and responsive? How can, what can you encourage them to do? And trying to keep that sort of in your mind. It's not as hard as it sounds. If you truly care about the people that are under your charge, it's not that hard to do. You're not going to do it perfect every time. You're not necessarily going to remember Sam's grandson's name, but if you remember that he had a grandson that had a baseball game, that's going to be mean a lot to him. Also think about what you do or what you've seen others do. And I'm not asking you to out yourself here. That may destroy rapport with clients and regardless of the age, but definitely with older adults, again, who do not respond well to sudden changes in terms of fostering effective communication, it's hard to demonstrate consistency, attention, responsiveness, encouragement, and safety. If we're not able to communicate effectively, if they're not able to or don't feel comfortable telling us, hey, I don't feel safe for these reasons, or if we, we aren't able to effectively communicate what we need them to do. I need you to do X, Y and Z, and this is Y, well then the, the, the person is going to be a lot more likely to do it. But if they're not getting the message, either they're not hearing it, they're not understanding it, or they're not having time to adapt to it. You know, it takes a minute. It's not. The processing is a lot slower in older adults, especially older adults that have a History of substance misuse. You know, that's a whole other. Other discussion. But recognizing the impact of aging on older adults and the cognitive slowing. Give them a minute so they can they get this new information. And it's kind of like they feel like they're knocked off balance. They need to get their balance again, and then generally they're good to go. But if you start forcing them to do something before they get their balance back, it can be the beginning of destroying rapport and creating an adversarial relationship. People experiencing cognitive slowing or impairment or hearing or vision impairment have difficulty with communication, both externally sometimes, but especially receiving communication. If they're trying to watch TV in the group room and they can't hear or they can't see very well, that's going to add to their cognitive load. That's going to add to their distress. They may not be able to hear or understand what's being said. And I know we talked about a lot of that in the video on hearing. And it's so important to pay attention to how much our ability to receive information helps us and, and understand it accurately, helps us feel safe and empowered. If you can't hear very well, you may not feel safe. If you can't hear very well, you may not understand what's being said. If you can't see very well, then you may have difficulty reading papers people are wanting you to sign, which can be really frustrating. You may have difficulty with some of the activities that you are told to do, like reading. Well, that's all well and good, but I can't barely see. So that may be another issue that we need to look for accommodations. And there are books on tape, there are large print books. There are ways that we can adapt in some of these things. When people can't effectively understand or express themselves, it creates a sense of unsafeness and powerlessness, powerlessness, which is the root of trauma. It's not a big T, it's a little T. But when you constantly are feeling unsafe and powerless and unable to get your needs communicated or met, you know it's going to have an impact. And this negatively impacts everybody who is experiencing it, physically, interpersonally, emotionally, cognitively, and even environmentally. This is problematic if you can't communicate effectively for anyone. But for people with a history of trauma, it can be a huge trigger. Thinking about what types of traumas not being able to effectively communicate or get your needs met might be associated with. Maybe when you were a kid, you couldn't understand what was being said. It was garbled in the next room. But you could tell when voices got loud, bad stuff was going to happen. I've mentioned in other videos that my husband's grandparents grew up in, and mine too, but my husband's grandparents grew up in the Great Depression. And the sense of loss of control was just huge when, you know, people were really struggling. And one of the triggers for them now is feeling powerless, feeling like they don't have the power to live independently, they don't have the power to take care of themselves. It brings up some of those vibes from back then. It's not exactly the same, but it's partially the same. If people grew up in an environment in which they didn't feel heard or listened to, then when they get to be older and they're in that situation again where they don't feel like they're heard or listened to, it can reopen those inner child wounds or those past wounds. Thinking to yourself about times when you felt like you were trying to communicate something and you just couldn't get your point across. How frustrating is that? How exasperating is that? And sometimes it's just a point of view, but sometimes it's about a need. I'm trying to communicate what's going on and I can't seem to communicate it. Or somebody's talking to you. I hate it when doctors talk to me in jargon and they use all those big doctor words. And I know I'm guilty of doing it sometimes in the. In the Psycho Fizz videos, but they don't break it down. It's. They start using these words like hematoma instead, instead of saying bruise. And it can be really frustrating because I have to think so much harder to translate that to words that I usually use when people can't hear. They may not. It may not be they don't understand the words. It may not be that they're not even hearing the words clear enough. And it's like trying to listen to a conversation through a closed door. What can we do? And again, we talked a lot about that in the hearing video. Making sure that we have good eye contact with people is important. Thinking about how my feeling unsafe and powerless contribute to resistance to treatment, irritability, or withdrawal. If we notice that somebody has suddenly become resistant to treatment or has become irritable or withdrawn, obviously that's communicating something. Behavior is communication. What are they communicating, though? That's where we need to be responsive. We need to get curious about what's going on with Jim Bob. He's. He's not himself lately or, you know, he's withdrawn a lot. He used to hang out in the, in the day room with people and now he spends all of his time in his room. Effective communication enhances the person's sense of safety and independence. Some of the things that people may, for example, start withdrawing and getting irritable if they see other people in the pod or in the assisted living facility, et cetera, getting visitors, and they never get visitors. Then they may feel rejected, isolated, lonely. It may bring up a lot of regrets that they have and we need to pay attention to that and help them acknowledge and process that so they can move forward instead of living in regret and resentment, figure out how they can use that energy to move toward how a rich and meaningful life, the way they define it, as best as possible. In this situation. Many people, especially older adults, but many people won't ask questions of doctors or therapists. Partly cultural, whether it's their age. My, my grandmother and my great grandmother, they were taught to be seen and not heard. They were taught not to ask questions of authority figures. They were taught to listen and do. And so there's a lot of times where they wouldn't ask questions when they really needed to because they didn't understand what was said or what they were supposed to do. And with my grandmother, my mother would end up calling the doctor and being like, okay, I know you changed her medication, but she doesn't understand why and exactly what she's supposed to be doing with dosing now, big things can get missed and there are other cultures, other ethnicities in which again, asking questions of authority figures is not okay. Making sure that we use open ended questions that we do teach back is really important. So we're not getting a yes or a no. Typically a yes. Do you understand what I, what I'm asking you to do? Yes. And they really mean no, but I don't want to ask the question. Some people get that white coat syndrome where they think the doctor went to school for, you know, a million years. So they must know best. Oh, that ain't, that ain't it. That ain't it. Encouraging people to advocate for themselves is really important. And sometimes with older adults it can help. Especially if you're a counselor, a case manager or a caregiver. Being with them when the doctor comes in and making sure that they have the opportunity to get their questions answered and that they fully understand because you've been communicating with them and they don't feel threatened or intimidated by their caregiver or their counselor. So you can serve as an advocate to help them voice their needs and help them feel like it's okay to voice their needs. Some people won't ask questions because they fear being judged. They fear that somebody's going to say, oh, this person is, you know, not smart enough. And generally that goes back to losing independence. They may fear being fired as patients if they ask questions. Oh, I don't want to ask questions because they might think that I'm a problem and then they don't, that they won't see me anymore. They won't let me be their patient. What? My grandfather, when he was in hospice care, he actually got a lot better and he passed his six month period and they were getting ready to terminate his hospice care. And so suddenly he just started getting sick again. And we really think that part of it was just feigned because he enjoyed having people come over, he enjoyed the attention. And for a lot of older adults, they don't get a lot of interaction, a lot of attention and fear of bothering being a bother and fear of annoying someone so they won't come over and spend time with you. Often keeps them from asking questions or asking for help or telling you that they've got a need. Some people won't ask questions because they just have such a sense of hopelessness. It's like, fine, whatever, I'll do whatever you say. I don't care why I'm doing it or what the side effects are. I'm just, I'm putting one foot in front of the other and nothing is actually going to make me feel better. And if we get the sense that somebody's feeling hopeless, it's important to, to intervene. It's important to provide them hope and encouragement and empowerment. You know, do making sure we ask questions about what are your concerns about this change in medication? Not do you have concerns, but what are your concerns? Because then they have to say something. And as I mentioned, sometimes they won't ask questions or tell you about problems they're having because they fear losing personal control. They you're going to come in and do it for them or do it to them or being institutionalized because they're afraid that you will believe that they can't care for themselves. For example, cleaning their own insulin pumps. That can be a big issue for a lot of people. Thinking again, when people that you're treating, people that are under your care, are afraid to ask questions or tell you about problems, problems they're having, how might it impact their treatment? Thinking about you? Ask somebody to start journaling and you just, you don't ask if that's something that works for them or if they think that might work. You just say, I want you to start journaling every day and I'll look at your journals next week. And they don't do it. They don't do it the next week either. Well, let's think about why that might be. Because we're not communicating, we're not asking them and empowering them to choose interventions. We're dictating number one. So it may be a power thing, but it may be that their arthritis is so bad that they can't write, or maybe their vision is so bad that they can't see to write. So there could be a lot of reasons that people are treatment non compliant that have nothing to do with being resistant intentionally not doing something, but they're not doing it because they can't. And if we were fostering that effective communication, we would have that open dialogue with my, with my patients of any age. I start out therapy, day one saying we're going to work through this. As we hit particular issues, I'm going to give you suggestions. Some of them may sound great and some of them, you may think, there's no way in the world I'm going to do that or that's stupid. I'm okay with that. Let me know that. If it's something that doesn't work for you, let me know and we'll find an alternative. So they don't feel like I am dictating. I am telling. When you go to the doctor for psychotropic meds and they don't even ask you, you know what, do you have any idea which antidepressant might work best for you? And they just choose their favorite one and why don't you try this? You know, that's not very empowering. They may not communicate their concerns or needs, like if they have sleep disruption due to pain because they're afraid. They're afraid that if you find out that there's pain that they're going to end up in the hospital and they're going to have surgery. And so they can get into some catastrophic thinking. Many times, especially for older adults, bladder infections are much more common. So this can be a very common cause of irritability, restlessness, poor sleep, problems eating due to bad teeth. They may be embarrassed to tell you, hey, I can't chew my food anymore or my dentures don't fit anymore. They may not communicate those needs because they don't think that they can afford to get New dentures. And there are programs available to help people get those very basic things. Because if you can't eat, you can't live. Communication basics. When you are talking to an older adult or somebody who has a special hearing impairment, when you're talking with them, use simple language and speak slowly and distinctly. Don't speak really fast using these long, complex sentences. Ask a question, say something. Give them a chance to respond. When I say simple language, what I'm referring to is not using, you know, long dissertations. Keep it short, short and sweet. You don't have to quote, dumb it down, because people who are older are not dumb. It just takes them a minute to process everything. Speak slowly and distinctly, not in a way that is cartoonish. You don't want to talk to them like this or start talking really loud. Talk to them, but make sure you are enunciating when you talk to them. And that can make it a lot easier for them because if you start to mumble, then it's harder to understand. Even if they don't have hearing problems. Oh, this is one of the biggies. Ask them questions directly, not their family member. If their daughter is in the room with them. And you know, Jane has been struggling with depression since moving into the assisted living facility. Okay, that's problematic. But you want to ask questions to Jane. Jane, tell me what symptoms you're having. And if daughter tries to jump in and answer, you may let her finish what she's saying and then say, okay, I hear your perspective. I really want to hear what Jane has to say. Making sure to advocate for Jane. Look at Jane when you're asking questions about her. If she's in the room, don't ask questions about her to somebody else. Likewise, don't pull somebody out of the room unless there's some reason. And I think I'm hard pressed to find many reasons where you would overtly pull somebody out of the room to have a discussion about the patient and exclude the patient from the discussion. That raises a whole lot more anxiety. Make eye contact with them when talking. Yes, you may have to jot down notes and things, but jot down notes, make eye contact, talk to them, and then make some notes Again, they need time to think and process anyway, so it's not a big deal. Eliminate background noise. And this is true. Whatever setting you're in, it can be really frustrating. Even at my age, in certain environments, I have a hard time hearing what's being said or I have a hard time hearing what's on the television or when the Background noise is too loud, so trying to adjust that. Turn on lights if it's too dark, but avoid causing glare. This is true if they're reading, but also if you're talking to them. It's hard to see somebody's face and their facial expressions and their lips moving if it's really dark in the room. Set a positive mood with laughter or shared interests. A lot of the patients that I work with have pets and love pets. And I go in and I'll share pictures of, you know, the most recent pictures of one of my cats or dogs, whatever they like. Or I'll pull out some pictures. We used to have donkeys of, of our donkeys, and we can laugh about how cute they are and they can show me pictures of theirs. Just getting that initial, hey, I remember you like animals, and so I'd like to share that with you. To open this session can be huge at creating developing rapport for people. If it's somebody who doesn't like animals, like my stepfather. Okay. Find something else to ask them about. How did your granddaughter's ballet recital go? Whatever. That can be really helpful because so many people just ignore older adults and don't ask them a lot of questions and don't ask them a lot of questions about themselves. Avoid using med medical jargon and have them explain what they understood you to say. You know, we'll talk about. Teach back in a minute. Repeat and rephrase is needed. If somebody seems confused and need you to repeat something, you may ask, did you not under hear what I said? Did you not under understand what I said? Or is what I said confusing? Or you may just try to rephrase it and st and say it again more clearly, more directly. When my daughter was learning math, you could teach her how to do a math problem one way and it would just go right over her. Right over her head. You could say the exact same thing using different words. You teach it in a slightly different way. You're teaching the same thing and it would click with her. We're all like that. So rephrase is needed. The person's not trying to be difficult. They're just trying to understand what. What you want them and need them to do. Write down instructions. If you're asking somebody to remember to do these three things over the next week, write it down. I don't care how old your clients are, write it down. It is helpful for them to serve as a memory cue. Don't keep secrets from your clients. And this is really important. Sometimes some things may have to be kept secret. I can't think of a situation, but I'm not going to rule out the possibility. But a lot of people feel very self conscious when you walk in and you've got your computer or your tablet and you scribble a bunch of things down while they're talking. And then as soon as you're finished talking, you close up your tablet and you're like, okay, I'll see you next week. My first thought is okay, what in the world were you writing down for the past 45 minutes? And older adults because they're worried that somebody's going to take their independence because they may have difficulty communicating their needs, they may be worried. I always let people read what I write and not everybody's down with that. But if you're writing objective information down, if you are supporting it with facts, then there should be no problem letting the client see what you've written down in your progress note or in your assessment. Even interact with them during their preferred times. Especially older adults may have times where they are more cognitively aware. Not everybody is a morning person, not everybody's an evening person. So you want to figure out what that sweet spot is for that person and you also want to make sure it's not competing with one of their favorite activities. If they like to go play bingo, don't schedule your sessions for right in the middle of bingo every Wednesday. That's you're guaranteed to have some non compliance, some frustration, etc. They're going to be distracted and ensure privacy. Oh my gosh. This is one of my big pet peeves and I'm hoping I'm going to find a way around it. This training I go to on Thursdays and Fridays but in some some of these long term care facilities people are two to a room and they may not be mobile, they may be bedridden, getting privacy to have a conversation with them seems pretty much impossible. And if I am an older adult and I'm in a bed and I can't get up because my hips broken or something, I may not want to be telling my doctor or my counselor about what's going on, what my fears are, etc so my roommate can hear, you know, and I'm not that closed off of a person. I can only imagine for someone who was raised in an environment where you were told you don't share your stuff with the world how embarrassing that would be and how much it would impair their willingness to confide in you in and, and I'm just again brainstorming here Because I hadn't really planned on it. But in correctional facilities, knowing privacy, because I'm guessing there are some similarities between correctional and, and residential treatment facilities where it can be an opportunity. If you know somebody has a weakness, it can see be seen as an opportunity by people who are more nefarious. So they want privacy. They're not going to communicate things to the whole world that say, hey, I'm a sitting duck here. Same thing with not keeping secrets from them about them. Obviously you're not going to tell them about everybody else. But if you know, for example, that you're getting ready to go on vacation or you're getting ready to get transferred or the warden needs to see them for some reason and you know the reason and you're not forbidden to tell them, you know, tell them, have this open dialogue so they're not going well, you know, what's this all about? Helping clients feel safe and empowered starts with ACE Ask, collaborate and empower. Ask them, you know, I'm here to help you feel safe and help you live your best quality of life in this situation. Is there something I can do or what are some things that I could do that could help you feel safer? What are some things you could do that can help you feel safer? What are your concerns right now? What are you having pain? Are you having depression? Anxiety? Are you concerned about your family? What concern? Financial concerns? What concerns do you have that are bothering you right now? And even once they state their concerns, if they say, you know, I'm really struggling with depression, okay, that's and a very important concern that we need to address. Let's look at the causes of the depression. Long term care facilities, treatment centers and correctional facilities are notorious for being horrible for people's circadian rhythms. They don't get enough bright light during the day, they don't get enough quiet time and darkness at night. They do tend to have similar routines that are, are stable. But getting that circadian clock set is, tends to be really difficult, especially if there's limited outside time. So consider, you know, what part of your depression might be being caused by circadian rhythm dysfunction by vitamin D deficit. Remember, as we get older, we have harder time trans translating or making vitamin D from the sun. So even if they're getting yard time or recreation time outside, they may be vitamin D deficient. Obviously that's something only the medical personnel can evaluate. But we do want to consider all the possible causes for their concern and try to address them. We want to ask them what their goals are. I can't help you move toward your rich and meaningful life. Unless I know what that looks like. If I know that visitation with your kids is important, then we can talk about how I might be able to help you use your energy to make that happen. Ask what they think would or wouldn't help. You know, you're feeling depressed right now and there are a lot of things that could be causing that. What things do you want to focus on first? What things do you think might be most likely to help you start feeling better? It's amazing how much hope can help. Collaborate with people. Don't lecture them if they're not doing their assignments instead of saying, you'd feel a lot better if you journaled every day or you wouldn't be so tired if you would be sticking to your sleep schedule like we talked about. That's punitive, that's paternalistic. Don't lecture and don't wag that finger at them. Collaborate. I noticed that you haven't completed your assignments or you haven't been getting to bed on time over the past two weeks. And I'm curious as why that is. What, what's keeping you from doing that? Is it not working? Is there something that's bothering you? Be curious, not punitive, and then empower them with synergy and win wins. How can we create mutually agreeable goals? Yeah, I can't give you this privilege that's not within my, within my scope, for example, but I can talk to the warden or talk to the charge nurse about getting you this privilege. But you've got to give me something. When I work with people with eating disorders, you know, sometimes they really don't want to focus on that nutrition aspect and refeeding is terrifying. And one of the things we talk about is, you know, I don't want you to be in medical jeopardy. I need you to be healthy and be medically stable so I don't have to refer you to the hospital. You don't want to go in the hospital. I really don't want you to go in the hospital. But I need you to do these things and we can do the same thing if you've got an elderly person who is frail and treatment non compliant for some reason. We can create these mutually agreeable goals that, okay, I know you don't want to drink this, you know, meal replacement shake because you think it tastes awful. We can try to find you something different. However, in order to keep you out of a higher level of care, you need to eat. And neither you nor I want you going to that higher level of care. So you're empowering them, you're identifying what their goals are and how doing what you need them to do will help them achieve their goals. Communication techniques, obviously the basics reflecting what you hear from them. Clarifying if you don't hear, if you don't understand correctly, clarify. Working with people, older adults, especially ones who have dentures that fit poorly or don't have any teeth at all, sometimes it can be hard to understand what they're saying. And asking them to clarify themselves is not rude as long as you do it compassionately. If you, if you're like, I didn't understand a thing you just said, you want to try it again, of course that's rude. But if you say, you know, I'm sorry, I'm really having a hard time hearing you and understanding today and I want, I want to be here for you and help you meet your needs. Can you tell me one more time what you just said? I haven't ever had a problem with somebody repeating themselves. We want to potentially focus or direct people to a particular topic. Sometimes we avoid those sore spots. And I'll talk about my kids, I'll talk about the weather, I'll talk about anything but this thing over here that's really bothering me. And sometimes we need to direct people to that and say, I hear you want to talk about all these things and I know they're super important to you. I'm wondering, however, if you're trying to avoid talking about this thing over here. And if they say yes, okay, let's talk about that. Does it not feel safe going there? You don't have the energy to go there. Let's talk about. I'm not going to force you to talk about it, but I want to bring up the point that I see what you're doing when your question. Oh, and summarize frequently. When you're working with people who are older and their cognition is slowing, it's helpful to every 10 minutes or so kind of summarize what you're talking about and what your goals are for the session. You know, we started out today, we were going to talk about this, this and this. And so far, you know, we've talked about X and these are the solutions we came to. Do you think we're ready to move on to why? And addressing the. The why question, not the letter Y, not Y. Sorry. Keep your questions open ended. Instead of asking yes or no, ask what are your thoughts about or can you tell me more about. Only ask one question at a time. When people are having some cognitive slowing, if you barrage them with questions and it feels overwhelming and they're like, I what did you. What did you ask first? Heck, I do that. So one question at a time, let them answer paraphrase, resolve that question, move on to the next one. Avoid why and confrontational questions. Why did you do that? I know that it's an easy and it may not be meant to seem confrontational, but I'm wondering what happened that caused this or that prompted you to is a lot less confrontational. Most of us have had bad experiences with authority figures being like, why did you do that? So we project that when anybody says why now? And use alternative perspective questions. If the adult is communicating that the situation is hopeless and it's just what you're asking them to do is impossible, you can ask them about, all right, let's take an alternative perspective. If those things are too difficult, if this is hopeless, what is there hope for? What things can you do from an alternative perspective? Let's approach this from an alternative perspective. What could we do differently that might be empowering instead of feel hopeless? Teach backs are also important and you've got to find your own rhythm with how to ask this in a way that it doesn't sound condescending, but you can say things like, just so I know that I have taught you to do this right, can you demonstrate it for me or can you show me how you're going to do this when you get home? If you're talking about mental health skills, counseling skills, give me an example of how you think this might have been helpful for you over the last week. And they may say, oh, I got into a fight with my sister and it would have been so much. It, it would have been really helpful if I would have had this tool. Okay, great. Can you tell me how you would have used it? Let's replay that interaction with your sister. Tell me what happened and we'll role play it and practice using that tool. So that's another way we can make sure that they've got that basic concept. In terms of non verbals, your rate and volume of speech is really important. If you are speaking really quickly and you seem really rushed, then they're probably, they may feel like you don't want to spend time with them or you don't have time to hear their concerns. We want to slow it down. We want to communicate through our volume and our rate of speech, our concern for them, our posture, our gestures, our eye contact and our facial expressions. All of Those things register 80% of communication is non verbal. If you're sitting there with your legs crossed and your arms crossed and you're like looking at your iPad the whole time, huh huh, that communicates something far different than if you're looking directly at somebody and going, oh wow, that must have been really stressful. Or even huh huh. Communicate something completely differently if you're making eye contact and seeming engaged. Other non verbals that may help you meet the person where they are, your dress and presentation. Now this goes both ways. It communicates for both parties their state of mind, potentially their cultural values, their body image, self concept. If you walk into a room, I have a good friend who's a nun and you know, it's very obvious when she walks in in her habit what her cultural, some of her cultural values are. And when she walks in and she's got her, you know, hair combed and she looks like she took time to get ready for the day, tells me she's in a good state of mind. She's ready to be present for whatever she's got to face and that's important. When we walk in, we want to communicate, hey, I got up, I didn't drag my butt here because I had to to and I stayed up partying too late last night. I don't want to communicate that. I want to communicate, hey, I rolled out of bed and I was excited to come see you and try to figure out how we could make this work. In terms of the patient, we want to look at their dress and presentation for their state of mind, their body image and self concept especially. Are they bathing, are they changing out of their night clothes? And this is a big problem in long term care facilities where people may stay in their night clothes all day long, may go for days without a bath. And some people it's depression, some people don't notice. Some people feel really grimy and ooky, but they don't want to bother anybody to take them down to the salon to get their hair washed or something. We do want to pay attention to this. And if we notice that somebody seems to be acting like they don't feel like they look good, like they feel ashamed, we want to pay attention to that. If they are getting dressed, if they're brushing their hair, if they're brushing their teeth, that gives us some good clues about where they are mentally and emotionally. Likewise, if you're dealing with older adults, you want to look for bodily signs of physical abuse. Do they have bruises? Now remember, older adults bruise easily, but they shouldn't have an unreasonable amount of bruises on them. We, we do want to make sure we're looking for that. You know, any signs of guarding of their physical person that may be there. And there are other signs that you may see when people walk in. But ultimately we're talking right now about looking at the patient and what their physical presentation may communicate. And we want to look at poor nutrition. Is the person losing weight or are they seeming, you know, you walk in and they've got candy wrappers and, you know, bags of chips and stuff strewn all over their bed and sodas. And by the way, they're a type 2 diabetic. All right, There's a problem there and that may be something that we need to address. What's contributing to this? Are they stress eating? Are they eating to cope? Are they having some other symptom that is prompting them to be non compliant with their diabetes treatment plan? But you can also see when people are, are losing weight or you walk in and you see that their breakfast tray and their dinner tray are still there and neither one have been touched. All right, tell me what's going on here? Why aren't you eating? You know, I can understand not liking what was served for lunch, but not liking two meals in a row is, you know, makes me wonder if something's going on in terms of building that strong relationship. Once you have determined how to effectively communicate with somebody, you have identified what some of their interests might be. So you can make small talk, you can open conversation, you can show interest. Both parties need to contribute to the relationship. If you are the one doing all, if you're talking at them the whole time, it's not going to be a helping relationship. Active listening needs to be a part on both parties. Demonstration of credibility and dependability. Now that's more us. We need to be credible in what we say. If we tell somebody we're going to do something, we need to do it. We need to be respectful and responsive to their needs, encourage their expression of thoughts and feelings and validate and recognize what they're experiencing without necessarily encouraging negative feelings or behaviors. You don't want to just jump down in that pit of despair and go, oh my gosh, yeah, that's horrible. Tell me more about how awful it is. You validate, recognize, empathize and, you know, try to provide some strategies, try to provide some hope. Developing rapport is an essential process that takes place over the first couple of sessions. And again, initially I wrote this for clinicians, but I think it can be really applicable. Not that a 10 year old would watch this whole video, but there are a lot of things in here that would be applicable to grandkids. Trying to figure out, well, okay, I got to go spend time with grandma. How do I make that, you know, meaningful? Because a lot of kids are like, oh, I gotta go spend time with grandma. It's so boring over there. Helping them identify some things that they can talk about. My son was really into airplanes, and so he would talk with my, my stepfather about airplanes. Find something that they have in common. Maintaining the rapport is equally as important. Once you develop a rapport with somebody, maintaining it, showing interest, being consistent, is important. Consider prior clients and relationships in which you felt like you had rapport. What was different between those and the ones in which you didn't have rapport? And, and we've all had them there have some clients or some people you click with, and others not so much, what's the difference? And sometimes it may be partly on them. They may have put up a wall. Sometimes it may be partly on us. We didn't ask, we didn't inquire, we didn't show curiosity about them, about their needs. And finally, I encourage you to think about two things that you can change, because I would, I dare say that most of us have at least two things that we could change to more effectively develop rapport with people. Not just the clients we serve, but with the cashier at the grocery store or our grandkids, etc. I hope this was informative. You know, it was a little bit different than what we've been talking about. But older adults so often feel overlooked, and because of cognitive slowing and because of hearing impairments, have difficulty participating in conversations. So they withdraw, which makes them feel even more isolated and overlooked. So by developing rapport and actually focusing on the older adult, I think we can do wonders for helping pull them out of their shell and feel more empowered and safe. Are there any questions? And, and John, you're right, there are a lot of reasons. Even if the person is not passing, sometimes it's a person is discharging. And if the nurse or the caregiver, you know, counselor, doctor, whatever has grown attached to that person, you know, they've really developed that strong rapport. It can feel like a loss. I know when we discharged from the NICU with my son after being in there for three months, it felt like, kind of like I was losing a friend, if you will, not seeing his nurse every single day. I mean, she had been there, you know, come rain or shine, for three months. And I won't say that she got super clinical, but it became more about, okay, these are the things you need. Let's get your bag packed so you're all prepared to go. It was less about feelings and concerns and more about, okay, there's, let's follow the procedures and kind of get you out of here. And it didn't strike me as odd at that time, but I can see how in other situations, especially in yours, where it might feel like somebody flipped a switch. And my sense is for a lot of people, especially, especially in hospice and palliative care, they do flip a switch. They have to compartmentalize their feelings about the loss of that person in order to get on with the rest of their day. And. But people, loved ones who are there may feel like they just, you know, turned off that caring switch. So, yeah, I can see where that can be, could be problematic and where that nurse, I think you said, could have done a little bit better in acknowledging your feelings and maybe not switching it off. Quite having such, quite such a hard transition from I'm caring, I'm loving, I'm supportive. Okay, it's over. Let's get back to procedure. But again, I try to think well of people and people who work in hospice and palliative care have really hard jobs. And given that he got really good care leading up to that, I'm wondering, you know, obviously I can't speak for that person, but I'm really wondering if that was their way of coping with the loss in the short term so they could do their job and most likely they went home and, or went out to lunch or whatever and had their grieving period. But it is something we need to be as clinicians, we working in these settings, we do need to be cognizant of so that. You raise a great point. And you're right, Jason, I think you've already logged out. But the demand for clinicians for psychotherapy in long term care and assisted living communities is going to become incredible over the next, you know, 10, 20 years. And, and we're already seeing a lot of it now. And there's a lot of people who just aren't comfortable with virtual. Even my age group. Do I like virtual? Yeah, I like it for the convenience. But if I were in an assisted living facility, I might like to have somebody come by and actually have another human come by and see me. I don't know, I'm, I'm projecting now, but there is going right now. There's a huge demand for psychotherapy services in nursing homes and long term care facilities and there's very little training. So if you need training, we have that long term care certificate available at all CEU right now that provides 120 hours. So you're doing a deep, deep dive on working with people in long term and post acute care. The clone AI, whatever we're calling it, has been trained on the all of the stuff that's in the long term care certification track. So if you have questions about working with somebody in long term care, the clone can be a assistant for you. And obviously it's not going to do it all, but it can help you get some of that information really fast because I know 120 hours is a whole lot of time. Everybody have a wonderful, wonderful rest of your day, rest of your week and Thursday and Friday. I'm actually training to be an ombudsman for the long term care facilities. So I'm hoping to come back with lots of great tips for how to advocate for people who are in long term and long term care and skilled nursing.