Essential TRAUMA INFORMED Skills for Counseling Older Adults

Foreign. I'd like to welcome everybody to today's presentation on the trauma of aging, exploring symptoms through a trauma informed lens. I'm your host, Dr. Donnelly Snipes. In today's presentation, I'm going to define trauma, explore how loss is traumatic. And we've talked about this before, but we're going to go over it. For people who haven't been with us for a while, we'll identify losses in each piece of life. And we talked about that a lot last week, so we're not going to go quite as in depth this time, but we're really going to focus on identifying specifically the losses, not just the changes. We'll discuss how this impacts people in each piece of their life and explore strategies to cope with the loss. The existential anxiety, regret, resentment, grief, all. All those things. So losses represent the elimination of something important. When you think of a loss that you've experienced, you can generally think you lost a job, you lost a friendship, you lost a pet, something that was important to you was taken away. And generally it wasn't something it was against your wishes, it wasn't something you wanted. If I quit a job, I'm not going to say I lost my job, I'm going to say I quit. So a loss represents the elimination of something important against our wishes. And that leaves us feeling a little bit powerless, maybe just for a minute or maybe for a long period, depending on what the loss was, how important it was, and how powerless we felt. Losses may prompt anticipatory anxiety or, or grief. And when I wrote that, I was really thinking about as people age, as we start to lose this or that. My husband noted the other day that my eyesight's gotten way worse over the past couple of years. And you know, that was kind of startling to me. He's right. But it made me think about other losses that I may be getting ready to start having. And then I was like, no, I'm not going to go down that road. I'm not going to. What if, you know, if my knees eventually go out, they go out. But sometimes people will identify one loss and they'll say, oh, this is the result of aging and I'm aging. And all these other losses are associated with aging. So I'm going to lose all of these things. And they can get themsel really caught up in a tail spin. Losses can be primary or secondary. For example, when somebody loses their balance, their, their ability to balance. And, and we see this a lot in older adults. It actually impacts a lot of areas of their life. When they try to reach up for that high cabinet to get something off that top shelf, they're a lot more prone to falling. So maybe they can't keep stuff up there anymore when they are in the shower trying to get in and out of the shower. They need grab bars now, whereas they may not have before. So losing something like your ability to balance yourself quite as well can impact, for example, golf and golfing friends. If you, when you golf, you swing that golf club. And if you, you know, if you're driving, you know, it's not so much if you're putting, but if you're driving, there's a lot of momentum and it can be. Can throw people off balance if you're having difficulty with your balance. And poor balance can also impact your golf game, but different story. And you can lose, if you will, some of your golfing friends. If your balance gets so bad that you can't golf anymore or you don't want to golf because your game's gotten so bad, then those people you used to play with, you're probably not engaging with as much. So you're losing that social support. That's a secondary loss. A hobby that you treasured. That's a secondary loss that occurs as a result of losing your balance. Home decor and I kind of just put that out there. I didn't know what else to call it. But when people start having difficulty with their balance, one of the things we do when we go into their homes is to look around and identify trip and fall hazards. You may not be able to have that throw rug in the middle of the living room anymore. It's just, it's too difficult. My grandparents shuffle now more than they pick their feet up. So having throw rugs down, even if they are sort of tacked down to the floor, there's enough of a lip that it creates a tripping hazard. If they're using a walker, that can create a tripping hazard. Another thing that you may lose or, or have to figure out how to deal with our pets, you know, for, for us with perfect balance, the pets can get under feet underfoot and be a trip and fall hazard. But with. For somebody with problems with their balance as well as slowed reactions times, it may be even more risky to have pets in the house. And I'm not saying get rid of your pets by, by any means, but it's something that you need to consider now. The not getting rid of them, but how am I going to avoid tripping over the. The dog? Secondary issues, it also include Loss of independence due to increased risk of falls like that inability to get in and out of the tub. And when we have difficulty accomplishing our activities of daily living, we may need somebody to come in and help us with those things. If having a walk in tub or having grab bars is not enough and that represents a great loss of personal independence. A loss of dignity is another thing that we may see as people's balance gets worse. They may have to wear the medic alert pendants so if they fall they can summon help. And we're going through this with my grandparents right now. They are adamantly opposed to wearing one of those things. And ultimately it comes down to that's a reflection of them not being as, as independent as they used to be. That's a reflection in their minds of their frailty. And they're refusing to accept it. Which whole different issue. But stepping back and asking yourself why is it that this person is rejecting a medic alert pendant or grab bars or something to help people get in and out of their bed or up from the toilet? For a lot of people it's embarrassing and it's a loss of dignity in their, in their own minds and a lot. It also represents a loss of or potential loss of independence and one more step toward as, as my grandparents put it, quote, being put in a home. And that's not necessarily what it needs to mean. We can reframe it as tools that they can use in order to maintain their independence. We don't want to have to have them go to a home, so to speak. We want them to be able to age in place if that's what they want. So we have all these wonderful new tools and strategies. Let's see how we can make them work with the home decor again. Granny's fighting tooth and nail about, about that throw rug in the middle of the floor. But we know it's a trip and fall hazard using motivational interviewing, using creating a win win trying to figure out how can we know that she's going to be safe and she can still keep her throw rug. And we've had to try to brainstorm, but we brainstorm with her instead of for her losses. And, and we're just going to go through a bunch of these and we'll talk about them later. But a loss of reproductive f functioning, you know that for most women that happens earlier rather than later. But it is a huge issue that needs to be grieved and it can be a major self esteem issue for a lot of people. Arthritis impacts people because that's their primary loss is the ab, joint mobility, if you will. Secondary losses can be activities that they used to do, like crocheting or knitting or sewing or woodworking. So we don't want to just look at something on its surface. We need to say, what does this loss represent? In what ways is this loss going to cause other losses for this person? How can we explore the totality of the impact on this person? And when we look at the different losses that this might cause, what strategies are available to empower them to minimize those losses? For example, there are ergonomic crochet hooks that you can use if you start getting arthritis in your hands. And that can prolong how, how long somebody can crochet, limiting the time they crochet each day. There are gloves that you can wear that keep your hands warmer and keep your joints warmer, which actually helps. So there are things we can do to empower people, not just to say, okay, well you've got arthritis, so you might as well just start grieving the loss of these things. No, we're not throwing in the towel. Let's figure out how to live in the. And how can you crochet and have arthritis? Loss of vision and hearing. This really impacts people's ability to do a lot of things that, that they want to do. I know anymore, I can't even read my phone without my glasses on. And it's frustrating, it's exasperating to not be able to do that. But I've got glasses. Woohoo. I've got reading glasses tucked around the house. So if I don't have my glasses on, I can put those on and at least sort of be able to read stuff. That is a mitigation strategy. So I feel empowered. So I feel in control of what I can do. So instead of saying, looking at what I've lost and what I'm powerless over, looking at what I do have power over, okay, I can't control how quickly my vision goes, but I do have control over, you know, protecting my, my visual health. I do have control over using assistive aids that can help me continue to live my rich and meaningful life. Loss of balance and mobility we already talked about, but that's a big one. And if you've ever, and I don't think most of us have really experienced a lot of it, I've had vertigo a few times and you know, it's kind of terrifying when the room starts spinning or if you suddenly start feeling like you're really off balance. It can, you can Feel out of control. You can feel unsafe and trauma is feeling unsafe and powerless. You're more prone to injury as you get older. You know, you're losing that ability to bounce back right away. And it's frustrating acknowledging the frustration and figuring out with the person, what can you do to protect yourself from injury, like wearing supportive knee braces when you go out walking or something. And when you get, when you get back, what can you do? When I was 20, I didn't stretch. Never, you know, I go out, I'd run, I'd come home, I'd be done with it. Now that I'm not 20, I stretch, I take it easy, I pace myself. I, you know, recognize and, and respect my own limits, even if I don't want to. I do pain with sex and a low sex drive. That's another issue that a lot of people may experience as they get older. And there, there is no reason why older adults shouldn't have a very healthy sex life. There's a lot of benefit in having that contact. There's a lot of benefit in having those relationships. And when people feel like they can't because it's too painful or they don't, they just have no desire to interact with others. Not only does it reduce their levels of oxytocin and stuff, but it may impact their sense of connection and desire to interact with other people. Progression of chronic illnesses, it happens as our body starts to age, as our body starts to slow down. Those illnesses progress. Diabetes tends to get worse. Parkinson's, heart conditions, they tend to get worse as we get older. There are a lot of steps we can take to mitigate how quickly they progress. But, and that's where that trauma informed approach to working with, with older adults comes in. Let's not focus on what you're losing and the fact that, you know, eventually you could get here. Let's focus on what you can do to prevent that. Let's focus on how you're empowered to slow the progression of those things. And then loss of smell isn't something that people typically grieve. But it is important to recognize that when people lose their smell, sense of smell, they often lose the desire to really eat that much. And if you rem, remember videos we've done on aromatherapy, we have a lot of sensors in our nose and one of the greatest memory triggers is our sense of smell. So if we can't smell, then those memories aren't getting triggered as much, if at all. And that can really lead people to start feeling empty and disconnected. It's an interesting area to look at interpersonally. There's a loss of friends, there can be death. That happens, yeah, eventually we're all going to die at some point. When people experience a significant death in their or significant loss in their life, they may go through something called stress cardiomyopathy or broken heart syndrome. And when somebody experiences broken heart syndrome, it's really interesting. Not good, but interesting that the heart actually changes shape and the left ventricle increases in size in order to increase the amount of oxygenated blood to the organs. Well, let's think about how that works from a survival standpoint. When we experience a death, a loss, it's can be traumatic, it can be terrifying. So the heart says we need to prepare to fight or flee. So it's sending oxygen out to the rest of the body so it can fight or flee. Unfortunately, stress cardiomyopathy can also lead to heart attacks and, and other problems. So when they say somebody died of a broken heart, they may not be kidding. They may actually have passed from stress cardiomyopathy. Dementia is another experience that people need to grieve recognizing. Even if it's normal cognitive decline of aging or it's dementia or it's Alzheimer's. Obviously those are all three different things. But recognizing the slowing of our cognitive processes is something that a lot of people need to grieve. I'm not as sharp as attack as I used to be. It takes me a minute and okay, it can be frustrating. But getting frustrated just creates a more neurotoxic environment. For people with dementia or Alzheimer's, the awareness that they are going to quick, relatively more quickly than others lose their cognitive abilities is terrifying and it can cause a lot of anger, it can cause a lot of anxiety. That is important to help people recognize and work with the more stressed they are, the quicker the dementia progresses. There are other things that contribute to the progression that we're going to talk about in a couple weeks. But it's important, it's vital to recognize the more stressed they are, the faster the progression. Helping them be mindful in the moment and recognize what they do have right now and what they're empowered to do to slow the progression is really important. Talking with them about what their fears are. Don't assume you know, don't assume you know what's causing their irritability or their anxiety. What is it that is causing you to feel stressed out, threatened, anxious, angry, Whatever word helps the person start talking is, is useful. People can lose friends due to long term care, admin admission. If they get admitted to a nursing home or their friend gets admitted to a nursing home, they may not see each other as much anymore. And zoom is not the same as face to face. There's. When you're doing zoom, you're generally not making continuous eye contact. So which is one of the things that triggers the oxytocin. But there's also, again, smells. You're not detecting those pheromones from another human being. And that actually, and those pheromones actually help promote the release of oxytocin. What is it about this long term care facility admission that causes you stress, causes you anxiety? If your friend was admitted, how can we help you? Or how can you continue to see that person? It doesn't mean that they're gone. They didn't go to Mars, they went, you know, down the street. What can you do to continue to see them? Sometimes if their friend gets admitted to a nursing home, they start becoming afraid that that means they're on the path to being admitted to a nursing home. And that can trigger a lot of anticipatory anxiety. Really digging down into what are the thoughts you're having that are triggering this anxiety. And let's talk about how we can address that, how we can help you feel safer and more empowered. There are often fewer visits from family members as we age. You know, I'm, you know, an empty nester now. My kids don't come over all the time. You know, they don't live here anymore. And as they get progressively more involved in their own lives, they just come over less. And I know my daughter and her husband are actually getting ready to, getting ready to move. So, yeah, I don't love that, but it is, it is what it is. And helping people who aren't seeing their family as much figure out how they can. Now in that case, sometimes zoom may be the only thing. You know, if you have family that lives in California, you may not be able to go visit them. My in laws are at the stage where they probably can't travel to Tennessee. So if we're going to see them, we need to go to them. And, but we can call my, my husband calls his mom reliably every Sunday night. And we can make sure that we're touching base. We can make sure that we're reaching out. There can be resentment from caregivers. That is an interpersonal loss. That relationship that somebody had with their child, that parent, child relationship is no more. And if the child, if I have to move in with my child and they have to take care of me. You know, number one, I'm going to grieve the loss of the relationship that used to be. But number two, if my child is resentful of having to care for me or gets frustrated and stressed out because of whatever the high needs are that I have, then that's going to create extra stress. And so we can't overlook other people in the household and other caregivers, even if they're not living in the house. My, my grandparents live, you know, far away and sometimes mom and dad have to go down and take care of them. And there's a lot of sort of resentment there because it's like, why can't you rely on, you know, call somebody else to come fix your toilet. Why do I have to drive three hours to fix your toilet? And we need to explore what that means. And my sense is, you know, I'm just guessing here, it has nothing to do with the toilet, but they feel anxious about having a stranger come in to do home repairs and they want to know that family's still there. They want to know that they're not being abandoned. So when there's something, then they call and demand family come to make sure that they still have the power to summon people to help them. That's my guess. And it would be important if I were in the middle of all that to explore what their thinking is and what their needs are and ways to adjust. And one of the things we did was get a, a nursing company to come in and there's somebody with them eight hours a day, five days a week right now. And that helps make sure that they're getting their activities of daily living, their nutritional needs met, etc, so they finally agreed to allow somebody to come in, which was, you know, just a godsend, less acceptance from youngins. As we get older and we're still going through, or we're already going through that, I guess I should say with my son periodically he'll come back, he's like, it's a generational thing, you just don't understand. Explain it to me. But as we get older, we've gone through and lived through such different times than our children and our grandchildren. It may be hard to relate and that can contribute to a sense of isolation. There are so many things that I didn't know about my grandmother and I didn't even know to ask about my grandmother that I found out at her wake. And I'm like, oh, why didn't somebody tell me this? And then I thought, well, why didn't I ever try to inquire, but you know, I was a kid, I was young. And encouraging people to younger people to try to listen and take the perspective and get curious. What was it like growing up in the Great Depression? What was it like when your loved one was overseas in fighting battle? You know, tell me what that was like living through that kind of time. How did you find the strength to do it? Whatever you want to do. But we tend to be too self centered as a culture, in my opinion. And that means that people who've gone through different experiences may not feel like they have the ability to connect. So let's get curious. Retirement is another loss that people experience. And retirement may represent a loss of purpose, a loss of independence. I'm not getting a paycheck anymore. It may represent a loss of friends, a loss of the ability to get out of the house, something to do. There are a lot of retirement. Retirement may mean different things to different people. Talking with what is it that you enjoy most about retirement? What is it that you dislike most about retirement? And then how can we address those things that you dislike? Difficulty going to meet friends. If the person can't drive anymore, they may experience that loss of independence and start feeling very anxious and stuck where they're at. And they may have. They may lose relationships with family members who are trying to help. They feel like the family members are trying to control their lives, are trying to treat them like children when the family members are just trying to help. But it's help that wasn't asked for. And we generally, I think in most cases can prevent the loss of these relationships if we encourage a collaborative approach, a collaborative, empowered approach to addressing aging. So let's identify what the problems are and then let's talk about what are my needs as somebody who cares about you so I know that you're safe and what are your needs for your independence, for your dignity, for. For whatever. And let's figure out how we can best get both of our needs met. And there's going to be some compromises in there but. But at least it can help. And there may be a loss of a sense of self as we age and we start losing things. Empty nest retirement. My grandfather, when he was. I told you he made miniatures. When his Parkinson's got too bad and his vision got too bad, he couldn't do that anymore. That was a huge part of his identity. When. So as we start losing some of our abilities, we may feel like we're losing some of our identity. What I don't Know what I do anymore? I don't know what I like. You know, all this stuff that I used to do, I can't do anymore. Helping people avoid overgeneralization is really important. Everything you used to do is not out of your reach. How can we, what can you still do that you used to like to do? And the things that you're having difficulty with Again, what assistive technologies are available to help you navigate some of that? Self esteem? When people start losing their independence and they start losing their dignity, their self esteem is typically going to go down. They feel embarrassed, they feel helpless. They feel, you can imagine what it would be like as you age. And sometimes even something like having to switch to Depends because you're developing urinary incontinence. You don't have to have somebody else changing you, but you can't wear the same undergarments you used to wear. And that is a huge issue for a lot of people. That is a dignity issue for a lot of people. And processing what that means to them and helping them grieve the loss of, you know, their bladder functioning, if it can't be addressed and identify, okay, what does that mean about you as a person? And hopefully you can get to the point where they recognize that even if I have to wear Depends, it doesn't mean I'm any less of a person. It just means I got a leaky bladder. And as people start to head down that dementia road, if they have dementia, that can be scary. And they are generally very cognizant of it early on. And that can cause a lot of stress. And a lot of times they don't want to tell you that their dementia is progressing, so they hide it and they suffer in silence because they're afraid they're going to be put in a home. It's important to be able to have open conversations with people emotionally. As people age, sometimes they lose happiness. They just start getting negative and pessimistic and stressed out all the time. They don't have the ability to feel happy. Sometimes they get to that point where they're just so depressed and they're so angry or so flat that they have lost the spark, if you will, They've lost the sparkle. And looking at what was different when you were happy versus what's different now. And again, how can we make now a little bit more like, then what things do you think might make you happy? What did you used to do? Obviously, we need to look at physiological causes of emotional changes. But so taking a look at those things, losing Motivation, of course, when our dopamine starts to go down, when our serotonin starts to go down, and we know both of those go down as our go nadal hormones go down, and those are going to go down for everybody as we age, unless you're on hormone replacement therapy recognizing that low motivation, there's a natural level, if you will, that corresponds to the reduction in gonadal hormones and changes in neurotransmitters. But then there's a more than expected loss of motivation, if you will, that's created when people start feeling depressed and helpless and hopeless, which compounds that depression and really just saps any motivation that they have. Exploring what motivation looks like to them can be really helpful. And we're going to talk about some interventions on the last few slides. And people lose patience. And I know, you know, do you really grieve the loss of patience? Yes, you do. You know, I can think back to times when I, before I had children, you know, I tended to be a little bit more patient. And then I had my kids, and I remember walking through Target sometimes going, God grant me the strength. God grant me patience. And it was frustrating. I'm like, I wish I could be as patient as I used to be. And that takes some introspection. What does it mean when we lose patience? It means that we're more anxious or angry. Okay, so what am I more anxious or angry about? And how can I deal with that to get my patience back? And for older adults, another issue that comes up is people lose patience with you because we don't think as quickly. It takes us a minute to process things. And so others may finish our sentences for us or just do things for us that we could do for ourselves. It can feel very paternalistic. It can feel very demeaning. And that can trigger feelings of anxiety or anger, which come out as irritability and a loss of patience. What does it mean if the person you're working with or the person that you're caring for has lost their motivation, has lost their patience? What does that mean? Where's that coming from? And how can you help them feel safer and more empowered cognitively? As I mentioned a couple of times already, as we age, our recall slows. We need more time for information processing. And that's something that a lot of us grieve and. And I know you're kind of scratching your head and do you really grieve that? Think about it. Grief is denial, anger, depression, and acceptance. And initially your, your recall and stuff starts slowing down. You deny it exists, then you recognize it's starting to creep up on you and you start getting frustrated about it. And then maybe you feel hopeless about being able to think quickly anymore and do the New York Times crossword or whatever it is. And then you get make it angry again and bounce back and forth until you can move to that stage of acceptance, acknowledging again what it is. Yes, your recalls slowed a little bit. Doesn't mean you're not smart anymore. It doesn't mean you lost it. It just means it takes more time to get the information from the back to the front, you know, from your brain out your mouth, and that's okay. Encouraging people around the older adult to be more patient, to take a minute, allow the person to think, allow the person to have the opportunity to do for themselves. And dementia. As people start losing their cognition, they're going to grieve the loss of themselves and they're going to grieve the loss of their cognitive abilities. And that may start. That anticipatory grief may start as soon as they get that diagnosis. Going back to helping to empower them to slow the progression is really important. And environmental losses at home, and we talked about this a little bit already, accepting those little fall alert bracelets or pendants. Some people have to stop cooking because they can't remember to turn the stove off. Some people need in home care, which can feel very intrusive. It's like, this is my home. You know, I do things my way. And a lot of older adults get very set in their ways. Why not? Because they're trying to be difficult. What does that mean? It means I'm trying to maintain control of something because it feels like other things are out of control. So I'm trying to maintain control of something. It also may mean that I've been doing it this way for 30 years. I know how to do it this way and change. And adapting to a new system is so much harder than it used to be. I'm going to keep doing it the old way because that's how I. That's what I know. And that's the least stressful way to do it. Some people lose their ability to drive or shop for themselves, and there they may grieve that loss of independence, that loss of freedom. Thankfully, they can have a lot of stuff delivered. It's not. Just because they can't drive doesn't mean they have to rely on people to bring them stuff now, like their, their loved ones to go shopping for them. They can use. Whatever those apps are. I'm drawing A blank right now on a lot of those apps, but Walmart delivers, Amazon delivers. A lot of grocery stores deliver. So it's not hard to get nutritious food and medicines and stuff delivered to their door. Difficulty hearing the television. As we age, our hearing changes. And one of the things that my husband and I get frustrated with now, and we're not that old, but we have difficulty hearing the words over all of the background noise on a lot of the television shows. And so we have to have the captions turned on, especially in the living room where there's really bad acoustics. And that can be frustrating when you have to turn the volume up and you have a hard time even understanding what they're saying. Sort of takes the fun out of it if you've got to read the subtitles. But the fact is the subtitles exist. And if I want to watch a show, I'm able to. I just have to be willing to adapt. And people are, as they age, they're losing money. And by that I mean they're not working anymore if they're retired. And aging is expensive, and the medications are expensive, the doctors are expensive. Medicare is expensive. Yeah, believe it or not, Medicare is expensive. There's a lot of stuff that's expensive. So it's V. And in home care is really expensive. So people's savings is very quickly drained, and that can be terrifying. Will I have enough? That was one of the things that my grandmother was terrified after my grandfather passed. And they were in a very traditional marriage. He paid the bills, he did, did the h. House maintenance and everything. And when he passed, he made sure that she had enough money to allow her to live independently for as. As long as she kept living. And I don't know how much that was, but that's what I was told. And, okay, fine. But every time something would come up, if something would break around the house, she would get in a total panic that that extra expenditure was going to mean that she wouldn't have enough money to live the rest of her life, you know, that she was going to run out of money before she died. And that was a fear that we regularly had to address. And you may think, well, she was told that she had enough. Yeah. She also lived through the Great Depression, and she remembers what it's like to think you've got enough. And then all of a sudden, one day you wake up and you ain't recognizing that trauma connection that, you know, her main breadwinner was not there anymore, was not taking care of things anymore. So that was a whole different thing. She had to learn, but there was a promise that things would be fine. And then she was afraid that just like when she was a kid, one morning she'd wake up and things wouldn't be fine anymore. Environmentally, people also may have to grieve losses if they are moved to a long term care facility, assisted living, skilled nursing, various levels of treatment. They may lose their stuff and their pets, they may not be able to take those things with them. They may lose their hobbies and going back to stuff that includes your house. I know my grandparents lived in the same house for 40 years. They paid it off and that's where they intended to live the rest of their life. And having to leave that house was significant for them. That represented a significant. Loss, but also it was kind of a stark reminder that they were aging and you know, their life was coming to a close. And it was, it was very difficult. When you go to assisted living facilities, you may not have the same hobbies, be able to do the same hobbies you did. You know, obviously woodworking, probably not going to have those tools at, in a nursing home. There are other hobbies. You may lose privacy. You've got nurses or doctors or orderlies coming in and out, trying to get you to come down to, to dinner, whatever. Some places you have to share a room and so you're in two beds just like in the hospital. You may lose your rights. And I have three asterisks by this because this just makes me so angry. A lot of people who are in long term care facilities and there are some really good ones, don't get me wrong, but there are some where people are heavily, heavily medicated just to keep them quiet and sedate and so their rights are not being respected. And it's important to make sure that older adults know that they can call their ombudsman, they can stand up for their rights. It's important if you're a loved one or a caregiver or even a therapist going in to see somebody in long term care, it's important to make sure that their rights are being respected and that the facility is actually following the regulations for, for their care. And I'm getting ready to start volunteering to be an ombudsman because that's how passionately I feel about it and that's, yeah, how bad I think it's needed. And in a home, their money is going to go a whole lot faster because it's expensive to house somebody in residential care. So what does all that mean? Safety Means feeling protected from danger, risk or injury. Thinking about what these losses mean. If I start losing my vision or I lose my ability to drive, in what way does that leave me feeling less able to protect myself? Or how does it make me feel more vulnerable to danger, risk or injury? Thinking about as you have a loss, you know, maybe I start losing my hearing. What was my self schema before this loss? What did I think about myself before this loss? And as now that this has happened, how does that this alter my belief? And my grandma and my granny were our very strong, very capable, very independent women who, you know, lived through a lot. I mean, they were born in the 19, you know, tens and the 1920s. So they lived through a lot and they made it. And getting to the place where they needed help from others was totally against, totally opposite of their self schema. So they felt vulnerable. They just. The knowledge that they actually couldn't take care of themselves completely anymore was terrifying to them. Trauma is the state of feeling unsafe and powerless. So they're, they're starting to feel. It's traumatic when you start realizing, I'm not as able to do all the things the way I used to do them when I was 20. Thinking about just some of the basics, how they contribute to a sense of unsafeness. When you start losing your balance, when you start fearing that when you're walking from the bed to the bath that you're going to fall down and break a hip, that can be a rumination, that can add extra stress. It can cause you to feel unsafe in your environment, in your skin, and powerless to change it. A lot of times from when we're working with people, we can help them feel more empowered. We can help them address issues that make it more likely that they're safe in their environment. When people experience losses, it represents the unwanted disappearance of something that was important. It represents that powerlessness. And as we start to experience some of these losses. When my grandma couldn't drive anymore, you know, that was traumatic for her because she was always, you know, she wanted to go to bingo. She'd go to bingo, she wanted to go to the store, she'd go to the store. And now she couldn't do that anymore. And she started again feeling like she had to depend on others, but others weren't always available. Like right then, you know, my uncle Jim might be at work or, or what have you. And so she started feeling powerless and thinking, well, what if I have an emergency and you're at work and. And we had to talk with her about Strategies what she could do if she was having, you know, a medical emergency. Obviously she could call 91 1, but if she had some other emergency, making sure she felt like she was able to contact my mother or, or my uncle was really important. So she didn't feel powerless. Maybe she couldn't fix it, but she knew that she could get help there. And once she was started being willing to accept help, it became a team effort. Instead of I'm coming in to fix it for you or do it for you or be paternalistic. It was a team effort. We which helped her, I think, stay independent for a lot longer. Caregivers need to think more broadly. Instead of looking at the surface problem or about problem behaviors like irritability or refusal to do this or that resistance, think about how the behaviors may represent fear or grief as the older person recognizes their powerlessness in some areas and fear losses in other areas. And a lot of the issues that we deal with in nursing homes, long term care, as well as, you know, with our own grandparents and aging parents, maybe irritability, anger outbursts, grief outbursts, depression, withdrawal, isolation, those are all indicative of I'm feeling unsafe, I'm feeling vulnerable, I'm feeling anxious or angry and it is coming out in some way. Exploring with them what's triggering it for you at this time is really important. Trauma triggers the stress response. We know the stress response causes physical issues like worsened blood sugar control, impaired sleep, increased systemic inflammation and pain, impaired immunity and even a reduced pain threshold. These are all things, you know, in the core of our body factory that become problematic the more stressed we are. One of the key features of what we need to do as therapists, as caregivers is to help people reduce unnecessary distress. Physical interventions include sleep hygiene and maintaining circadian rhythms. Soapbox warning. In a lot of these assisted living facilities, the lights are dim. The people are not encouraged to get up out of bed, to do things, to maintain a routine. So with the exception of light and it's freezing in every single one of them I've been in, it's freezing. So there's no change in temperature, very little change in activity and very little change in light. So how are the circadian rhythms supposed to know when it's time to be up and time to go to sleep? No wonder a lot of people are groggy. Emphasizing the importance of circadian rhythms. Sleep hygiene is important. Where people are not sleeping 2, 3, 4 hours during the day and then up half the night, helping people figure out why are you not sleeping well and what can we do to help you sleep better and address cognitive and emotional causes of distress? If we can help them activate that parasympathetic nervous system, the rest and digest, we can help them reduce the stress response and reduce the neurotoxicity of the stress response. Emotional issues, increases in anger, anxiety, irritability, depression, grief. You know, we've talked about why this is so what do we do about it? Explore with people and then identify and evaluate the primary and secondary fears and losses in each area of their life. And then look at it, evaluate it using fitcat facts in this context at this time, you. You're worried that this may happen in six months, six years from now? All right, you know, we can talk about that. Let's also look at what's going on right now. What do you have and what do you have control over? Empower people to understand and work through their distress at their own pace. We do not have the right to take people's grief away or to take their anger away. People have the right to their own feelings. We need to be there to support them to as they work through the process, in moving in the grieving process, moving toward acceptance at their pace. Disregulation. Now this is an interesting one. Apparently, as we age, a natural symptom of aging, if you will, is sympathetic overdrive and reduced vagal tone. What does that mean? Means emotional dysregulation. Means as we age naturally, our stress response becomes hyperactive, goes into overdrive, and our rest and digest becomes underactive. Well, helping people develop distress tolerance skills and helping them work against the flow, help them strengthen that vagal tone. Biofeedback, intentional relaxation, yoga, transcutaneous vagus nerve stimulation. There's a lot of ways we can do it. But helping them develop skills to get that vagus nerve to kick in, to get that relaxation response to kick in and tone down the stress response. Cognitively, people are experiencing grief. They may deny what's going on. They may deny the need for different things. And that's where a mo motivational interviewing can come in. Really helpful. I hear that you really do not want, do not think you need grab bars. Okay, let's look at the facts in this context at this time. You know, you've fallen in the bathtub three times in the past six months and had to go to the hospital twice. So clearly there's a problem there. What is it that we can do? You want to stay in your home and I want to help you stay in your home. So how can we address this issue in A way that will help you do that. When people are denying a need for something or they're trying to deny that there's a problem. When we recognize that, we can help them identify referrals, accommodations, and alternatives to help them feel empowered and more independent. We can help them out Address outdated schema knowledge and beliefs through improved health education and recognize reactions and responses that arise out of past traumatic experiences. Just like I told you with my grandma and the. And the Great Depression, you know, recognizing, you know, why are you getting so freaked out about this? Well, that's where probably where it came from. Address emotional reasoning by educating people about the fight or flight response. Teaching them how to use the facts in this context at this time. Fit cat Help them develop skills for living in the and I can have hearing impairment and still enjoy the movies I like because there are these resources that are available. Help them develop hardiness. People that are having increased difficulty with information processing. Slow the pace, slow it down. One thing at a time. Don't give them just like when you're talking to somebody that has ADHD sometimes. One thing at a time. Tell them to do one thing and then tell them the next thing. Slow down what you're talking about. Y' all know I talk really fast. So when I'm working with an older adult, I have to make a intentional effort to slow down what I'm saying and to be patient. I say what I need, I ask the question, and then I've got to wait for their response and give them the time and the space to hear it, to process it, and then to respond. If there are instructions or you need them to do something, write it down and keep it simple. And when you're talking, especially in counseling, summarize frequently. So far we've talked about these things. How are you feeling about that? Just keep bringing it up and summarizing so they don't feel like I, I just. Just, you know, we've been talking for a long time, but I can't remember what we talked about in terms of fears and assumptions. We want to work from a perspective of empowerment and informed consent. I'm not here to put you in a home. I'm not here to say that you're incompetent, incapable or crazy. I'm not here to try to take your money from you. A lot of people are afraid their family's trying to take their money from them. That's not why I'm here. I'm here to help you age in place. I'm here to help you live with dignity and independence. And this is how we're going to do it. And that's where the informed consent comes in, even for caregivers. You're not going to have a written one, but just making sure that mom or grandma or whomever knows I'm not coming into take your power away. I'm coming in to make sure that I'm giving you the resources you need to be as powerful as possible if you're a therapist. Establish rapport. A lot of older people, especially in my mom's generation, my grandma's generation, have that white coat syndrome. And as soon as you walk in, they start getting freaked out and, and they start fearing that you're there to say they're crazy or something. Establish rapport. You know, hey, I'm here. And this is why, you know, I want to get to know you. And this is why. So there's no question about your motivations. And don't use jargon. The word cognitive assessment can really set people off because that to that to a lot of people means you're trying to figure out if I can live independently or you need to put me in a home. That's what my grant how my granny responded. So it's important to recognize what seems like a very benign term to you may be very scary to them and make sure to focus on their strengths and resources in terms of addressing fears and assumptions. Again, create, win wins. You may say, I want to help you find ways to maintain your independence, not take away your power or as we age, you know, our thinking slows. I know mine has. There are many things we can do to help you age in place, even if your memory's going a little bit. But I need to know what problems you're having before I can help you meet those needs. This is why I'm doing this. I'm not trying to take your power away. Address cognitive distortions, especially all or nothing mind reading and personalization with fitcat pnp, which is facts in this context at this time and the possibility versus the probability that your worst fears are going to happen. Look for exceptions, find alternatives for the worst case scenario and encourage communication. And of help people avoid mind reading in terms of increased ruminations and intrusive thoughts. Poor sleep and disrupted circadian rhythms are going to make those a lot worse. So help people improve their sleep hygiene and improve their circadian rhythms and teach them thoughts, thought stopping and again, fit cat in terms of neurotoxicity and the increased rate of cognitive decline. Help them recognize that if they work on Those exercises to trigger the relaxation response. If they work on those exercises to improve vagal tone, they are going to slow that cognitive decline and encourage them to engage in brain builders, whether it's Sudoku or crosswords or whatever it is, or even just learning a new hobby that keeps the brain more plastic, if you will. It increase, encourages neurogenesis and really does slow the progression of cognitive decline interpersonally. Frustration with others for not understanding frustration with others for treating you like a child can be big issues that we need to improve communication with others if they don't. If you're feeling frustrated that other people don't understand why you're feeling the way you're feeling, okay, I get that. How can we help them understand? How can we improve the communication? If you feel like others are treating you like a child, then, okay, let's look at how their perspective and let's look at how you can arrive at a mutually agreeable place where you feel respected and assisted. They can get frustrated with themselves for not understanding their reactions, you know, why am I blowing up about this? Or they can get frustrated with themselves for aging. I should have taken better care of myself sometimes. I know my. My grandmother went through it. Frustration with God. She wanted to go be with her husband. And in. In her. In her words, God just wasn't ready for her yet. And she was angry about that. She was ready to go. So there's anger that can really happen there and acknowledging it and empathizing with it instead of saying, oh, grandma, you know, you don't want to go yet. Well, yeah, she just said she did. So let's not tell her how to feel or what to think. Let's empathize with her and talk about what's making her say that or why she's feeling that way. If people are withdrawing from social support, that's natural. Sometimes it can just be too painful to engage with others. If every time you turn around, one of your friends is dying, you may feel like, you know, I just don't wanna. I just don't want. It's too painful. Okay? Or if people. You don't feel like people are understanding, then you may not want to be around them because it's like, well, you don't get me, so what's the point? Identify why they're withdrawing. You know, work with them to figure out why and work with them to figure out ways they might connect and with whom they might connect. Recognize and explore irritability as a stress response and encourage social interaction just a little bit. If they're in an environment where there are others around, they're living with their kids or they're, they've got neighbors that come out, encourage them to do 15, just spend 15 minutes to talking to somebody each day and if after that you can't take it no more, fine, but just try it. And sometimes it may be if they can't get out, having in home care come in or visitors come in, allowing somebody to come in and connect with you on a regular basis, maybe not every day. And environmentally increased stress work worsens physical and cognitive health and makes it even more difficult to maintain independence. So if for no other reason, then maintaining independence and maintaining the ability to live, you know, independently, we can help people increase their motivation to reduce their stress levels and to work with us to find modifications so what's going on in their life doesn't cause them continual frustration. As my mother in law regularly says, getting old ain't for sissies. I love that woman. Changes in each piece of life can cause people to feel less in control of their own safety and their own life. This is traumatic and requires grieving and regaining a sense of personal power and safety. Unresolved trauma can cause hyperactivation of the stress response and a cascade of problems that all interact to worsen the health and well being of the individual. So at the root, really pretty basic, figure out how to help the person reduce distress in as many pieces of their life as possible. Strengthen vagal tone, that relaxation response, and regulate that autonomic nervous system. I know I went way over today. I'm sorry. Obviously I didn't think it was going to go that long. But I appreciate everybody who hung around and I understand those of you who had to go, you know, finish up class and go see other, other other clients. Are there any questions? What can a person do if a parent with mental health issues and paranoia only trusts a sibling who doesn't visit them for years? And that is a really challenging area. I might explore with them what it is about that sibling that they trust and what it is about other people that they don't trust and recognizing that that sibling doesn't seem to be willing or able to come visit, what might help them feel safer with somebody else. One of the reasons, and obviously have no idea about this situation, but one of the reasons I might think that that person's digging in and saying I only trust Jim Bob is because in some place in their mind they may think that if they refuse help from everybody else for long enough, if they say the only one that can Help me. Is the sibling over here? Then maybe finally the sibling will give in and come visit. Maybe they can control the sibling that way. Now, it may not be as overt in their mind as that, but that could be a motivation for being resistant to other help. From a trauma informed perspective, I would look at reasons. Again, reasons. They don't trust other people. Have they been taken advantage of by others? Not saying you did, but maybe they have been taken advantage of by friends that they had or other family members. And so they're just afraid to let anybody in. Maybe that's how they were raised. As I mentioned, my grandparents are very protective of their home, of their boundaries. They do not like strangers coming in and they do not like, as I mentioned, they. They do not like having handymen coming in. They don't like having contractors coming in. Even when it has to be done. It causes them extreme amounts of stress because they feel really vulnerable. So again, exploring what causes them to feel vulnerable and identifying the reasons, you know, why somebody else may need to step in and how if they allowed somebody else to step in, that might improve their quality of life, I, I really would explore it through an empowerment strategy and, and trauma. Their reaction tells me they don't feel safe. Let's look at that a little bit more and figure out why they don't feel safe. Alrighty, everybody. Have an amazing rest of your day. I know this was a long webinar, but, you know, I think there's a lot that we don't consider in terms of trauma and aging and the complex interaction of things that don't seem like that big of a deal, like suddenly having to start wearing glasses all the time and what that might mean to the person's perception of their own independence and ability to maintain their dignity.