Stop Caregiver Burnout from These Interpersonal Stressors

Foreign welcome everybody to today's presentation on the interpersonal aspects of caregiver burnout and what we can do to try to prevent that. I'm your host, Dr. Donnelly Snipes. In this presentation we'll identify inter and intrapersonal signs of burnout. So signs of burnout in your relationship with others as well as yourself. We'll explore inter and intrapersonal causes of burnout and caregivers and then we'll identify strategies to maintain maintain healthy, supportive relationships with self and other. So symptoms, causes and strategies in terms of signs of caregiver burnout. One group of signs that we see in when we're talking about inter and intrapersonal is a lack of self awareness. When people are getting burned out, they tend to not realize how burned out they are. They're just on autopilot, gotta get it done. Don't think, don't talk, don't feel, just do. And that causes problems. Obviously if people are not engaging in self care, then they will have more difficulty dealing with life on life's terms. There's a loss of empathy with others, a loss of compassion for self and other. Now remember, empathy is the ability to experience and understand someone else's feelings. And compassion is the ability to have feelings of care for someone, for self and others. So they are different people. Stop self care activities. That's another sign of intrapersonal burnout and reducing hobbies, recreation and social interaction. What do all these things have in common? They all take energy and time, which caregivers often feel like they don't have. And sometimes they may not. I mean, there are times that, that are hopefully few and far between that you really don't have a minute to come up for a breath. But hopefully most of the time there you can carve out some time for yourself and we'll talk about that. Now when I talk about, you know, you just can't take a second to breathe. If you're a doctor in an er, if you are a teacher on a field trip, if you are a caregiver and something's going on at home. There are some times where your caregiving requires 100% of your attention. And you can't just say, hey, going to take a break for a minute. But we want to try to make sure that that's not 247, 365. People are much more efficient at doing what they need to do, including caregiving, and much more accurate. Fewer mistakes are made when they're rested and recharged. And I point that out because a lot of people when we start talking about burnout prevention, say, well, I don't have the time. I can't, I can't, I can't. You can't. And it's important that you do. When you get burned out, it's like a phone with a dead battery. Not very useful. It's a brick. Charging a battery while you're using the phone takes a lot longer than if you're allowed to. If you allow it to rest and recharge, you just plug it in. So set it on the table, it recharges a lot faster. The same thing is true for us. Sorry, got a scratchy throat today. A lack of self awareness when we're on that autopilot leads to a loss of self care, a loss of empathy with others as and a loss of compassion for ourself and others. What do we need to do? Well, we need to maintain that self awareness. Ideally, you pay attention to your battery meter and when it gets to be about 50%, you reduce your activity and start recharging. Now what does that look like? My battery gets down to about 50% during the day. What am I going to do? Maybe I'm going to sit down in the easy chair over in the corner and close my eyes for 10 minutes. It doesn't have to be an hour. Don't want it to be an hour. I'm going to screw up my circadian rhythms. Maybe I'll go downstairs and I'll make a cup of coffee and I will sit and watch the birds for a minute, recharge. Allow my brain to kind of go blank for a minute and recharge. It's a lot easier to, to again recharge if you're not also trying to do six other things. If I think I'm recharging while I'm making dinner, that's not recharging. I, I'm still engaging my brain and my body. How can we increase self awareness aside from just checking in? Well, start with a mindfulness check in for sure in the morning when you wake up, before you get out of bed, before you start caregiving, unless you've got an infant at home. And then who knows? But ask yourself, how rested and charged am I? You know, what is my body battery? And I have a body battery that is determined by my Garmin. And it's never seemed to be very accurate. So you need to check in with yourself and think, you know, how do I feel? Am I thinking, oh, that coffee better be strong, or am I thinking, hey, today's gonna be a good Day. What are my needs right now? I may have a lot of wants, but what do I need? If I am sore, if I am sleep deprived, if I'm feeling overwhelmed, what do I need from myself and from others? Doesn't mean I'm going to get everything. But since it's a need, it's something we really need to prioritize. Once I identify what my needs are, I may look at what must be done today. There are a lot of things that would be nice to get done. I remember when my kids were little, my son, I've shared with you, y', all, before he had wicked gastric reflux. And until we got it diagnosed and got him on appropriate medication, he required a lot of attention. Anytime he would recline, that stuff would back up. Even if his tummy was empty, that stomach acid would back up and he'd start to cry. So there was a lot of trying to keep him in the right position. And, you know, I also wanted to play with him and, you know, enjoy having a child at home. So there was the must take care of and then there was the, you know, must be a mom sort of thing. But I was prioritizing him. I was caregiving for him. And we see the same thing if you're taking care of an older adult, for example, there may be times where there's a lot that they require and. All right, so what must be done? I have to do these things for my caregiving, whoever that happens to be. I also need to get the laundry done and get the shopping done so we can, you know, whatever. All right, well, do you have to get the laundry done? Well, maybe you do. Maybe you don't have any clean drawers left, and that's okay. Do the laundry dry. The laundry, does it have to be folded and put away today? Would I like to do it? Yes. Would it be ideal if I could do it? Yes. But if that stuff doesn't get folded and put away today, there is. It's not going to harm me and it's not going to harm my caregiver. Looking at going to the grocery store? Well, yeah, ideally I'd go to the grocery store so I can make dinner or whatever. But if I've got other things, if my caregiver needs a lot of something today, I may have to adjust. I remember one time my son got sick and he had an ear infection and stuff. I wasn't gonna drag his happy little butt or unhappy little butt to the store and go grocery shopping. So what did we do? We ordered in and I Is it ideal? Do I like paying for. You know, it's expensive to order in, but sometimes you have to make that compromise. Or sometimes maybe you call somebody up and go, hey, neighbor, when you're on your way home, would you mind stopping by the store and picking up a gallon of milk for me? You don't have to do everything. So going to the grocery, it wasn't that you had to go to the grocery. It's the that you had to get food. And there are multiple ways to get food these days. And I'm forgetting about all this. These days you can get food delivered from the grocery store directly to your house. And a lot of times it's free if you order a certain amount. But even if it's not, it's still a lot cheaper than ordering fast food anyhow. And. And again, cooking takes time. Doing dishes takes time. Sometimes you don't got that time. Yeah, like my English today. Sorry. Ask yourself, once you figure out what must be done today, what do we have to do so everybody stays safe and healthy? You know, that's really what we're getting at. Is it? You know, some. Sometimes people won't be totally happy, but are we keeping them safe and healthy? Who can help with what must be done and my needs? A lot of people forget that last part. It's like, okay, who can help with what must be done? But also who can help with my needs? If I need a break, who can help me? And yeah, the first person on this list is the caregiver. I know. That's a radical thought. Isn't it? Too often we don't give caregivers credit for what they can do, and we may baby them too much. I remember again, when my kids were little, there were times I was like my kingdom to be able to go to the bathroom in peace, you know, and not have those little hands coming under the door. Mom, when are you coming out? And that's okay to say. You know what? I am going to go back to the back. I'm going to go to the bathroom and I'll be out in 15 minutes. I want you to stay. If we're talking to a child, I want you to stay right here, play with your toys, and if there's an emergency, you can come get me. And my kids got the hang of that pretty quickly about what was emergency and what wasn't. And I was suddenly able to take a shower. You know, maybe not a long one, but I was able to take a shower and I was able to go to the bathroom without Getting interrupted with mommy. And that's important. We need to have our time for our self care, our time to decompress. The same thing is true if you're taking care of an older adult, for example, they have needs. But if they need a drink, for example, and maybe they can't get it for some reason, they're not ambulatory. If they go 15 minutes without that drink, 99.9% of the time, that's not going to harm them. Do they want it right now? Maybe. But can they wait 15 minutes? Maybe. So the caregiver can help by giving you some space, for example, the caregiver can help if you've got people who are ambulatory. Children or older adults help you with some things. Would you mind helping me make dinner? Would you mind helping me put away the dishes? And we can empower people to assist us in our own care and their care. And that isn't harmful, that is actually helpful because people feel again more empowered, less vulnerable if they are partaking, if they are interacting. We can ask family, friends. And I put church fellowship here because I know a lot of churches have a caregiver board where people will pitch in to make meals. When somebody comes home from the hospital after having surgery or a baby or something, a lot of congregations will. People will volunteer to make meals and bring them over. They'll volunteer to help with some of the lawn care if needed or, or what have you. And that can be super helpful. Reach out, find out what's out there. Reach out to your family and friends. Believe it or not, unless you're constantly asking for things, which you're probably not, if you're a caregiver, you're probably giving more than you're taking. Believe it or not, it actually strengthens your relationship with people when they feel like they can help. When they feel useful, it's like, hey, they need me. Cool. Obviously there are limits. You don't want to overburden somebody. But thinking that people will get angry if you ask them to do something, a lot of that is our own stuff. A lot of that is mind reading where we're assuming that they're going to get angry. If somebody asked us to do something, would we get angry? You know, ask yourself that. A lot of times. Most of the time when I ask that of caregivers, they say, of course not, I'd be happy to help. Well, hello. Other people feel the same way. So give people a chance to help you out if you can afford it. Paid caregivers or domestic assistance can Be really helpful regardless of the age or the condition of the caregiver. It can be really helpful. And, and again, it's expensive. So that's not something everybody can afford. If you are working with somebody who is especially an older adult that's on Medicare, you can get physician ordered home health services. And it's intermittent. It's not something that's going to happen all the time, but it's certainly something that can be taken advantage of. And then there's also short term respite care. Unfortunately, again, this is more for the older adults and for people who are in hospice where they especially hospice may have a hospice facility that somebody can go to for three to five days in order to give the home caregiver a break in order to let them sleep through the night. And that's something you've got to determine for yourself. And with that caregiving. Is this something that works? Also find out in your local area, just kind of google whatever your city and state is. And Medicare benefits. There are a lot of benefits that you may not know you actually can access, especially with a doctor's order. And it's important to check on that. If you have Medicare Advantage plans, then there are even more benefits. I know I sound like the commercial on TV now, but it's true that they do have more benefits that are available to you. Think about what can be simplified. And I mentioned that a little bit earlier when, when I talked about the needs. Do I need to make a three course meal tonight or can I order in? Can I simplify and make a casserole? How can I simplify what needs to be done? And a lot of times we make things too difficult. When I make pizza, I love to make pizza from scratch. You know, I make the dough from scratch, I make the sauce from scratch. Right now I don't make the cheese from scratch, but everything else comes from the garden or the flour from the grocery store. But I like to do it myself. And it takes a long time, you know, for the bread to rise and everything else I can simplify. I can buy a pre made pizza crust and I can buy pre made sauce and just add a few seasonings to it to make it taste better if I have to. And sometimes that is a choice I need to make because I have these other things that must get done. And you know, it starts feeling overwhelming if I think, hey, I've got to spend three hours in the, in the kitchen. So that is important. What is it that I can simplify? And then the daily huddle, daily Huddle is important for people who are involved in caregiving and people who might be able to help you with your caregiving. Communicating to them, you can't just assume they know what your needs are. Communicating to them, what is needed. If you've got multiple people caring for somebody, like, you know, at home, you've got multiple adult caregivers, or, you know, if you've got an older adult, you may have multiple adult caregivers. Written and shared schedules can be very helpful and lists of things that need to be done because they reduce the cognitive load. You don't have to think, did I ask somebody to do this or did I send that bill or did I do this? You can write it down and mark it off. And if people can access it, assuming not everybody's living in the same under the same roof, if people can access it like through Google Docs, that's even more helpful because then they can see what needs to be done and say, hey, I'll take this, or I can help with this. And it can be super relieving. I'm not, not necessarily empowering relieving for, for the primary caregiver to go, oh my gosh, thank you, I've got some help. I can breathe now. In terms of losing empathy and compassion, we're going to start with talking about losing empathy and compassion for the caregiver. Because it can become very easy when we start getting frustrated, when we start getting exhausted, to get angry at the caregiver for being needy, for being difficult and stepping back and asking ourselves, you know, what is this behavior in the caregive? Communicating can be really helpful to resolving the problem. Some of the triggers for people be becoming difficult, and this can be a child or an adult, doesn't matter. They may be trying in some way to regain control or in the case of adults, deny impending losses. Causes of this the loss of control triggers stress in people. I mean, most of us, when we lose control, it triggers the stress response. So we may become more irritable. When a child loses control over something, maybe they're worried about starting a new school, or maybe they're not feeling well. And when we don't feel well, we don't feel like we're in control. We want to feel better and we can't make it happen. The older adult may be starting to lose control of cognition or physical abilities, and that can trigger stress because they see themselves becoming more vulnerable. They may also have lack of sufficient information, understanding or memory about their condition, which can contribute to increased fears. Whether this is A child who just got diagnosed with diabetes or an adult who just got diagnosed with dementia, they may not understand exactly what that means. I mean, it sounds bad, but what does it mean? And they may not understand what the progression is going to look like. Some people may just assume a catastrophe. For older adults especially, memory also can be an issue. They may understand it right now and four hours from now they done forgot everything you said and you need to repeat it. We talked about this a few, a couple hours ago, but a lot of times if you say that they're like, no we didn't. So instead of going remember blah, blah, blah or we, we've already talked about this, just say okay, let me help you understand what's going on. Visual can be helpful if you can write simple things down. Use pictures. Having a visual representation in a book can be really helpful or a spiral binder can be really helpful, especially for older adults. Strategies when people are feeling out of control, help them focus on what they can control. You may not be able to control, you know, get how quickly you get better. You can't just magically make yourself feel better, but you can control the progression of the condition. You can control. For somebody with diabetes, there's a lot you can do to control your blood sugar and slow the progression. With dementia, there's a lot you can do to control inflammation and, and increase cognitive reserve to slow the progression. Help them identify what they feel powerless over and what the aspects of that they actually do have power. And do the same thing for yourself when you're feeling out of control. Focus on what you can control on this situation. If your caregiver is just in a bad mood, well, you may not be able to control that. What can you control? When my children were sick, when my mother was sick, it broke my heart to see them in pain. I couldn't control that. I did what I could to help them relax and feel better, but I had to remember I can't control that. What can I do to improve the next moment for both of us? Focus on fit Cat P. I know that's a new one. Facts in this context at this time and, and the probability of those things. They're possibility of just about anything. And you could spend all day trying to plan for possibilities, but what you want to do is look at the probabilities, plan for probable losses. If the person's willing, if they have dementia, you know that at some point they're going to start losing their memory. It may be 10 years from now depending on, you know, strategies they take so planning on when that happens, you know, what do you want to have occur? Work on advanced care planning. Because then the person knows that when I start losing my memory or when I become incapacitated, for some reason, I know that my loved ones don't have to make a decision about should I do this or this. They know what I want. And that is super helpful for, for both parties. The caregiver is absolved of some of the responsibility, even though we may not like it. I hated when my mom signed her dnr, but I respected her wishes and I understood. I mean, she was very, very far along in the terminal process. And helping them understand what that they have the ability to, to sort of dictate their care, even if they're not able to actively participate at that point, helps people feel a lot more in control and a lot more, a lot less apprehensive about, well, what's this person going to do when we know we have the plan? And then once you've planned for those probable losses, you've set up that advanced care plan. Live in the moment, Focus on what is going well right now. If you're caregiving for a child. Oh my gosh. I think most of us parents have thought about it at times, the, the worst case scenarios and we feel like the cl. The, the sky is falling or something. I can't predict what's going to happen. My son got his degree in IT and we see it. Jobs are just disappearing like crazy right now because of technology. I could worry about that. I could worry that he's not going to get a job in it. Is that going to do me any good? Is that a good use of my time and energy? Heck to the no. So I need to live in the moment and focus on having empathy for where he's at right now, recognizing how stressful it is to be, you know, trying to find a job in this economy and living in the moment, appreciating him and doing what I can to improve the next moment, not a week from now, not a year from now. But what can we focus on right now? And that is, can be very helpful when you are caregiving, even if you're not a full time caregiver. Recognizing that, you know, if you're of that ilk, you probably caregive for a lot of people and at a certain point you got to step back and go, I need to check in on me too. I need to live in the moment. That also means having compassion for myself and recognizing in the moment I need a break sometimes. Caregivers may not be irritable. They may have no filter and the technical term is disinhibition. They may say inappropriate jokes or comments. They make impulsive decisions. They may have impulse emotional outbursts, reduced social inhibition, things that they normally wouldn't say, they say anyway or do anyway. And they may have difficulty reading social cues or have difficulty resolving conflicts, which strains relationships. Now this sounds, when you read it, like you're pretty stereotypical six or seven year old. But you know, okay, we can teach these children to have a filter. When people get older, as dementia sets in, as stress sets in, as chemo disrupts the prefrontal cortex as well, their inflammation actually impacts the prefrontal cortex and it can lead to some of these things happening. When people experience cognitive overload, they've just got, they're trying to figure out too much stuff and they're just overwhelmed. It's just like, ah, they have a hard time stepping back and thinking, is this the appropriate thing to say? Or they may be more impulsive because they just want it to stop, okay, and, and we've all been there, we've all been there where we felt overloaded and we've done something or said something impulsive or maybe not as inhibited as we should have been. Reduced functioning in that prefrontal cortex. That's where all of our executive functioning, our reasoning, our planning, etc. And that connects to our emotion processing areas. And when that's not working as well, then our anxiety and our anger can actually sort of domina. So in we're in our emotional mind instead of our thinking mind. And disrupted sleep wake cycles in caregivers and caregivers can contribute to stress, can contribute to systemic inflammation and can contribute to all of these issues which can cause disruption in relationships. We need to recognize that physiological issues are contributing to what's going on. If it's a child, they don't have that filter yet. Their prefrontal cortex is still itty bitty compared to what it's going to be. We can help them grow that for an adult. Their prefrontal cortex may be shrinking as a result of aging, inflammation, disease. We need to depersonalize what's going on. A lot of times it's not actually about us. I remember when I was sitting in my dad's hospice room with him and we're sitting on the sofa and we were talking and I, he said something and I kind of smiled and laughed and he's like, you know, I never wanted to say anything about that, but that that's just odd. I. What are you talking about, Daddy? And he, in his mind at that point, perceived my mouth to be too big for my face. And I was like, okay, now you could say maybe he was saying, you got a big mouth. Yeah, well. But ultimately depersonalizing that he wasn't trying. I mean, he even said it in a way where he wasn't trying to be critical. He. He was just letting me know that, you know, that was a flaw with my face. Okay, well, thanks a lot, dad. But it wasn't personal and I couldn't take it personally. If somebody is being nasty, they're scared, they're angry, they're in pain, whatever. Not taking it personally, it has nothing to do with me. It has to do with their frustration that they're in pain and they can't fix it. Intervene with others as needed. And I've shared this one with you before. My mother, when she was, I don't know, several months into her chemo, was in the hospital and the orderly came in to do something and she just read him the riot act because he didn't knock on the door and she was telling him how rude he was and how he needed to go back in and try again. This is not my mother. This is not my mother at all. And I could hear it in the background because I was on the phone with my stepfather and depersonalizing and he, he needed to get off the phone so he could intervene. And hopefully the orderly had been trained to understand what was going on. But still, you know, Walter stepped in and, and was like, you know, Fran, it's okay. He's doing his job and he was able to de. Escalate her, but she wasn't herself. She never would have done that in. Prior to cancer and chemo. She was a very sort of meek person a lot of times. And it's important to recognize that, you know, sometimes you gotta. When you're having empathy and compassion, sometimes you gotta inter. Intervene with others as needed so they don't get angry. You know, get. Help them get the lay of the land. Consider when your person is being disinhibited or irritable. Consider what fears or prior traumas the current situation is triggering for them. Is it triggering issues with biological needs? We all need to have our biological needs met. Are they worried that they're not going to get better? Are they worried that they're going to die? Are they worried that they're not going to get fed? Are they worried about their safety? Children, young children, go through this whole Period of separation anxiety where they cry when you leave because they're worried that you're not going to come back. They're worried that they're not going to be safe. And it's a natural developmental process. But we need to understand, instead of getting angry at the child for being clingy, understand that, hey, that's what's going on for, for older adults, they may not feel safe when you leave. My grandfather had agoraphobia, crazy bad. And when my grandmother would go out to bingo, he would pace the floor for the two hours that she was gone. And if she wasn't home by 9:30, literally on the dot, he would start going into absolute panic mode because he didn't feel safe. She. They'd been together for 50 some odd years and he didn't feel safe without her there. And he worried about her. He felt like it was his job to keep her safe, but he couldn't leave the house. And so he felt disempowered. And it was all this thing helping him understand what was going on and developing a plan between them. This was before cell phone, so it wasn't like she could just. But she could call before she left the bingo hall if they were running late. So there are things that we can do. And sometimes people are fearful of losing a sense of love and belonging. They're fearful that you're going to resent them. They're fearful that you're angry at them. And this is where it's important that we own our stuff. If we're in a bad mood, okay? We have a right to be in a bad mood sometimes. Everybody does. But we need to make sure that people understand. I'm not angry at you. I'm angry at the situation. I'm frustrated that you're in pain and there's nothing I can do to make it better. That goes such a long way with children and adults when we own our stuff because we're just exuding stress and they may think that we're angry at them. And if we can say it's not you or it's not your fault, I feel frustrated because of this. It clears up that tension and it makes a world of difference. And we need to recognize that the caregiver is under a lot of stress as well and may not have the energy or ability to empathize. Kids, especially young children, don't have a good ability to empathize. As they get older, they may, but a lot of times we get into those teenage years and they have the ability to empathize but not the energy because they're so stressed out about everything else that's going on at school, with their friends, online, blah, blah, blah. So they're exhausted. Okay? The caregiver may not be being empathetic with you. It's not because they don't want to. It may be because they can't. They don't know how, or they don't realize that they're not being empathetic because they're all up in their own stuff. It can be helpful to tell the person instead of saying, well, you should know how I feel. Tell the person I'm upset right now. Tell the person this is going wrong right now. And they can say, wow, that must be frustrating. If a person is in pain and unable to communicate it effectively. Children who have an ear infection, you know, young, very young children, or somebody who has a, an older adult with a urinary tract infection, which happens a lot with older adults, they may not recognize the pain or be able to articulate it. So pay attention to their non verbals. My son, whenever he would get an earache, he'd go around and he'd start holding his ear and rubbing his ear like this. And as soon as he started doing that, I knew something was wrong. I mean, he's still playing, he's still eating. You wouldn't otherwise be able to tell something was wrong, which I have no idea how. His pain tolerance was that high. I get an earache and I am just like, I am the biggest baby when it comes to having an earache. I can't stand it. But he would hold his ear and then eventually he'd start getting fussier than normal. But that was my clue because he was non verbal at that point. And with adults with UTIs, they may get crankier, they may refuse to go to the bathroom, or they may start going to the bathroom a lot, looking for those clues that, hey, something may be a little wrong here. And then asking them if you can, even young children, you can say, does your ear hurt? And you know, if the child is two or three, they can process that. You can ask them, you seem like you're in pain. Is something hurting again? Most people who are even mildly verbal can usually respond to a yes or no or point to where it hurts. In a lot of people, emotional pain will rarely be masked. When they're already stressed out because they're in pain or because they are, you know, facing dementia or old age or cancer or something, they got enough on their plate it they're not worried about Trying to cover up and hide how they feel. They're just putting it all out there a lot of times. Okay, so validate how they're feeling. I see that you are really ticked off today. You know, do you want to talk about it? Sometimes just acknowledging that can be really helpful. Seek support from counselors and faith leaders. If you're a caregiver and you're not a counselor by profession, seek support from people who are trained in this. You're not expected to do everything, to know everything, to be everything all the time to everybody. So reach out to people who could help. If your caregive is irritable, if they're in pain, if they're having difficulty, call in somebody who's used to working with that population and try to get some consult. And worst case scenario, consult with their physician if you think that. Obviously if they're in physical pain, consulting with their physician is the first step. But if it's an emotional pain, you know, I don't. I'm not a huge fan of psychotherapeutics, but every once in a while, a sedative can be helpful. If the person is experiencing intense grief or intense emotional upheaval and they're not sleeping because the longer they go without sleeping, the worse all those other symptoms are going to get. But those medications are PRN or as needed. It's not something they have to take every day for the next, you know, months or years. The caregiving may be fearful of expected losses. If they expect to lose, they expect to die. They're terminal or they're old and they expect to die at some point, that can cause anxiety in some people. If they're fearful of a loss of functioning that they won't be able to toilet themselves, or they're fearful of when their memory goes, that can be really challenging. It can also be fearful or people can be fearful of losing those things in others. If my spouse who's taken care of me for the past 50, 60 years suddenly is not able to take care of me, that's terrifying. If my significant other dies, you know, how am I going to function? If my significant other has to go live in memory care, how am I supposed to function? And that can be friends too, not just significant others. And then as far as their self losses, of course they may fear their own death. They may fear loss of functioning and loss of their own memory. But a lot of people struggle with the loss of their self concept because they saw themselves as vital and powerful and, you know, whatever. And now they're starting to feel a little more frail. Now they can't do some of the things they used to do and that can make them irritable, it can make them defensive. And the lack of choice, and we talked about this earlier, making sure that people are involved as much as they can be in their choices about what they eat, about when they go to bed, about medical treatments that they may or may not use. Obviously with young children there's only so much they can do. But with older adults, trying to make sure that they know they've got choices and, or that we, we will respect their care plan and the choices they've made. Caregivers can also get fearful because they're having hallucinations or delusions. Whether it's because of lack of sleep or significant depression, a psychotic break, Parkinson's disease, dementia. There's a lot of things that can cause hallucinations and delusions and they can be terrifying. Most people that I've worked with and you know my family as well as they've gotten close to death, have begun to start to hallucinate or see people or things in the room that the rest of us can't see. And that for some is comforting. For some it's terrifying. We need to accept if they think they see something or if they are seeing something, we need to accept that and help them figure out if you're feeling unsafe because of that, how can I help you feel safe? And again, they can be fair, fearful of our rejection because they're too much of a burden or because they're too needy or whatever. We need to articulate to them, to them that that's not it. You're good. For caregivers that are fearful of things, focus on fit cat facts in this context at this time, encourage them to identify self congruent activities, that is activities that align with their sense of who they are. If they're gardeners, great. So let's go get some plants. Maybe we need to do raised gardening. Now. Maybe you can't be out in, in the pasture, but if gardening is important, maybe you can do some tabletop gardening. Empower choice through daily activities, making sure that they have an advanced care plan so they know that their choices will be respected. Focus on what is, not what could be, not what they're worried about, but what is. And knowledge that anxiety will only worsen most conditions, whether it's diabetes or dementia or depression. Anxiety and worrying about things only makes it worse. So are they going to use their energy to worry about this, which moves them away from what's important in their rich and meaningful life? Or are they going to use their energy to nurture the things that are important in their rich and meaningful life? Using their energy to move toward As I mentioned earlier, own your feelings and frustrations so people don't assume that you're angry at them and arrange for monitoring and easy ways for the caregiver to reach you or help if they feel afraid. If you need to go to the grocery or you're not there 24 hours a day, how can they reach you if they are concerned? And cell phones, medic alerts, video cameras, There's a lot of different tech that can be used to help people feel like they've got a lifeline even if somebody's not physically there right then? Resentments towards caregivers current demands on time if the person feels or if the caregiver feels like they shouldn't have to be caregiving, you know that's an issue that they've got to deal with themselves. If the caregiver feels like they're being manipulated and again that feels like backing out to fact based reasoning. Yeah, maybe you are being manipulated, but what's the reason? Why are they trying to manipulate you? What's their goal? Generally the goal is so they feel safe, so they feel like they won't be abandoned. Some caregivers become resentful because the caregiver wants them to do something for or with them constantly. Every time you get up to try to go to the bathroom or you Want to take 30 minutes to read a book, the caregiving is like no, you need to play with me or no, you need to do this with me. And we see that in all ages. As people feel less empowered they may demand more attention and sometimes it's warranted and other times we need to empower them to be able to self soothe. You can get resentful towards your caregiving because you are already overloaded and thinking about taking care of somebody else is just more than you can bear. You may be rewarding the behavior by not setting limits with them and saying, you know what, I would love to play a game of checkers with you in 30 minutes. Right now I need to do this, but in 30 minutes I am all yours. The caregivers feelings of fear of being alone can cause them to be needy and prior issues. If you grew up with this person that you're taking care of and they were a crappy parent, call it what it is. You may resent having to give them all the things that they never gave you and it sounds harsh, but let's just talk about what is. And understanding that, figuring out how you're going to deal with with these resentments so they don't eat you alive, and so they don't you don't end up inadvertently taking them out on the caregiving Examine your rich and meaningful life and what you can and are willing to do and potential regrets or guilt for refusing all help now, refusing to do everything all the time. That is good boundaries. But if you say, no, I'm not going to take care of mom and dad, you know, too bad. Go to a home, whatever, you're on your own. All right. That's a choice. That's a choice you can make. Are are you going to potentially have any regrets or guilt later on if you refuse to help.