Workshop Three - Communication Skills for Caregivers

1. Welcome - 5 minutes

• Facilitator greets participants as they arrive. Welcome them to Workshop 3.

2. Discussion of Week's Experience - 20 minutes

• Facilitator encourages participants to share some of their experiences since the last workshop.
• Facilitator encourages participants to reflect on any changes they have noticed because of information gained in the last two sessions. Are they sharing this information with anyone? How do the care receivers feel about their participation in these workshops?

3. Introduction to Topic - 5 minutes

• This topic focuses on an area that many of us take for granted - after all, we constantly give and receive messages. However, we seldom reflect on the effectiveness of our communication patterns, our style and learned responses. This workshop will explore some basic information about communication. We will discuss some techniques that are easy to use and will enhance the effectiveness of communication.
• Because communication is a two-way process, we encourage you to participate in this presentation. You are probably using many "techniques" that work well in your situation. Please share these with the group. We always learn from each other.
• Share Objectives with participants.

4. Presentation - 30 minutes

• Communication Skills for Caregivers
• Refer to Part I: Communication.

5. Nutrition Break - 5 minutes

6. Presentation - 35 minutes
(see #7 after presentation)

• Refer to Part II: Communication Challenges

Presentation

Workshop Three - Communication Skills for Caregivers - Part I: Communication

What is Communication?

• What do you think communication is? ("Brainstorm" with participants; record ideas on flip chart).
• Communication is an active process, an exchange of symbols and signs, a sharing of ideas and information. It is the way that humans build, interpret and understand meaning in our world.
• Communication is a two-way process between a sender and a receiver.
• It is impossible not to communicate; whenever we are in the presence of another person we are sending messages - verbal or non-verbal.
• Everyone's ability and style of communication is affected by his or her world view, the frame of reference by which he or she judges the world. Everyone is unique. Cultural practices, beliefs and values affect communication to a great degree.
• What we strive for is effective communication. Many of our "relationship problems" have their roots in poor communication. Today we are going to examine some of the potential problem areas and discuss some techniques for improving the quality of our communications.

Communication Roadblocks

• There is an endless variety of factors which act as roadblocks or barriers to effective communication. We will look at some of the factors which may affect the quality of a message:
  1. Past Experience: If your relationship has a history of poor communicating, it takes a major effort to lift this roadblock. People often respond out of habit - a conditioned or learned response.Example: People who moan and groan and complain frequently can find that even their valid complaints may be overlooked. Conversely, the person who consistently puts on a brave face may be viewed as "getting along just fine" when, in fact, they are hiding a lot of distress.
  2. Mood: Any mood, from "good" to "bad" and including a range of emotions, can affect our interpretation of messages. A mood may be temporary and often responds to subtle overtones.
  3. Personalities: Each personality is unique; sometimes we just need to accept people as they are.
  4. Perceptions: Perceptions arise from attitudes, feelings, knowledge and past experiences. Perceptions affect the way we interact with each other. It is said that perception is reality. People respond and/or behave with feelings appropriate to their perceptions. If the perceptions are based on faulty information, the feelings may be viewed by others as inappropriate.

     Empathy, putting oneself in another's shoes, is an essential quality to improve communication. Challenge yourself: the next time you are in a situation where you feel the person is responding inappropriately, stop and ask yourself what might their perceptions be?

  5. Self-image: A poor self-image affects all aspects of your persona. It may drastically alter an individual's capacity to communicate with others; there may be no energy for empathy, sharing or reaching out.

     A poor self-image may lead a person to be misjudged. Several aspects affect our self-esteem, including health, feedback from other people, achievement, finances, and opportunities to be useful. The care receiver and caregiver may experience losses in these areas which leave them feeling very vulnerable.

  6. Distraction: There could be a fear of being overheard or perhaps excessive background activity or noise affecting the quality of communication.
  7. Sensory Deficits: We will discuss sensory losses in detail a bit later.

     Decrease in sensory acuity is a normal part of aging. A loss such as reduced hearing can have a profound effect on communication.

• Additional Possibilities for Roadblocks Include:

  Health Stereotypes Drugs, Alcohol Cultural Influences Environment (internal and external) Fear Lack of Opportunity Listener may not be ready Time

  Roles Purpose of Communication (e.g. good news or bad) Contradictory Messages Judgmental Responses Language (e.g. familiarity of phrases, slang, swear words, inappropriate phrases) Stress Age-related Complexities

  Can you think of others? Given the complexity of communication and the many possible roadblocks, it's rather astonishing that we manage to get messages across at all! It is essential to realize that many variables consciously or unconsciously affect our ability to deliver a message, receive a message and/or absorb its meaning. Sometimes we just have to accept that totally effective communication is not always achievable. We only have control over our messages; we can only change ourselves, not others. There will always be strong opinions, particularly in such areas as religion, politics, sexual issues and finances. Sometimes, it may not be possible to achieve a common ground. What we can achieve is respect and tolerance for the diversity of opinions.

The Complexity of Communication

• Experts say that our verbal communication - our words - forms only about 30% of total communication. The balance is non-verbal communication - body language. However, both verbal and non-verbal occur together.
• Sometimes our verbal and non-verbal signals are "out of sync", sending mixed messages.
• Example: The person who says "It really doesn't matter" through clenched teeth is giving a mixed message.
• Our bodies often betray us in our non-verbal messages, reflecting our true feelings and preferences. Sometimes, if we try to deny or ignore strong feelings for a long period of time, our bodies signal us with symptoms of physical distress - that is, poor health.
• Many times, non-verbal communication can be more powerful than words.
• Example: The "silent treatment" is often a more powerful conveyor of displeasure than words.
• Springer and Brubaker (1984) and Warren Bennis (1997) describe several non-verbal categories that are part of our awareness:
  1. Personal appearance, including posture
  2. Tone and volume of voice
  3. Changes in speech patterns, (ie. agitation may cause someone to speak faster than usual)
  4. Eye contact and facial expression
  5. Gestures and movement
  6. Touch (a touch can speak volumes)
  7. Spatial distance (comfortable distances between people: too close can be threatening or intimidating, too far can signal aloofness)
  8. Silence: can be comfortable or awkward
• When we increase of our awareness of verbal and non-verbal communication, we become more attuned to the content and feeling of communication. We may be challenged to look for the true messages beyond the words.
• Many times, strong emotions such as fear will induce people to act in unusual ways. Independence is a major concern for older people and the threat of losing independence can induce fear, anxiety, anger and often depression. It is clear that these feelings could foster inadequate communications.
• Being "message detectives" in trying to find the real meaning behind words or actions can enable us to understand others better. If we can convey to others that we understand their feelings, we go a long way in creating a good climate for trust and respect.
• Invite participants to identify examples from their own experience which illustrate the concept that determining feelings and perceptions may help in understanding an action or reaction.

Listening Skills

• Listening is probably the most important communication skill we can acquire.
• Good listening requires empathy, attention and valid feedback.
• There are many benefits to listening: people feel valued and cared for.
• When you listen effectively, you do not necessarily need to agree with the other person, but you do need to convey interest (respect and empathy).
• Do not interrupt, especially to correct mistakes. It is important to accept and understand the uniqueness of the speaker's feelings and perspective.
• One technique for good listening is reflecting the feelings that the other person has shared (follow your instincts).This can involve both paraphrasing (clarifying what the messages mean to you) and perception-checking (describing your impressions of another's feelings).
• Some ways to begin this are:

  "It sounds like you are...."
  "It seems that you feel...."

• You may be off-base in your interpretations. Never insist that you are right! On the other hand, the person may be denying their own feelings. Be sensitive and gentle, asking questions that stimulate further communication and clarification.

Life Review

• Life review is an attempt to put one' s life in order; the process of trying to integrate one's past and present.
• It is a healthy psychological mechanism which may be used as a way of coping or adapting to the present situation. The remembering may be tapping the reservoir of memories to brighten a dull present.
• When we feel we cannot stand to hear one more story about "life on the farm" or "Aunt Rose", we must remind ourselves that as people reminisce they are actually addressing major issues like joys, concerns, and unresolved conflicts in an attempt to integrate their lives.
• There are many benefits of reminiscence for both the older person and the listener (McMahon and Rhudick, 1964):
• Benefits for Older Person:
  • helps to maintain self-esteem
  • helps to cope with present situations by reminding them how they coped in the past
  • can be their contribution to society
  • tells about a time when they may have felt they had more control
• Benefits for the Listener:
  • can provide a source for topics of conversation
  • can be informative and extremely interesting
  • can provide link between generations through sharing of traditions, family stories
  • can increase understanding of how people are shaped by experiences

• When you continuously hear "the same old story", ask yourself: What is so important about this story to the story-teller? That may open a whole new avenue of communication.
• You can use several techniques to encourage life review by elderly persons: look through picture albums, read old letters, talk about past generations, take trips to places where members of the family once lived, discuss work, changes in lifestyles, technology, etc.

Session IV Part II: Communication Challenges

• When someone has a health problem that affects his or her ability to deliver and receive information, communication becomes a challenge for all concerned.
• This discussion will focus on communicating with people who have significant sensory impairment, primarily hearing and vision loss; people who have a dementia, or cognitive impairment, which means that their mental faculties are affected; and people who are suffering from aphasia as a result of various illness such as a stroke.
• Dementia is a deterioration of intellectual function and other cognitive skills leading to a decline in the ability to perform activities of daily living (Merck Manual of Geriatrics, second edition, 1995:1146).
• Aphasia is the difficulty in using and possibly understanding language. It can involve impairment of expression as well.
• One of the difficulties that we encounter when communicating with a person who has one of these disorders is that there may not be the familiar "landmarks" that we are used to observing and that aid us in understanding messages.
• Example: Facial expressions, visible emotion, gestures, tone, choice of words or phrases, inflection, appropriate responses are attributes which may be altered, absent or "out of context".
• To those for whom they are caring, caregivers offer important opportunities for communication which help to promote an individual's sense of self-worth, particularly when opportunities for other interactions may be limited by disabilities.
• The effort you put into communicating with a person who has experienced significant health problems which affect the ability to communicate is immeasurable in its benefits for both parties.

Sensory Impairment

• Sensory changes accompany the normal aging process to a certain degree. There is a decrease in sensory acuity in all five senses. We will talk only about vision and hearing, as they have the most significant impact on communication. Sensory changes can sometimes lead to changes in behaviour such as anxiety, depression, hallucinations and paranoia.
• We rely heavily on our senses to adapt to and cope with our environment. Sensory changes can affect the way an individual perceives and responds to the environment.
• One major message as we discuss impairments is that only a small percentage of elderly persons suffer significant impairments of function. The majority adapt to changes and manage very well.

  A. Hearing Impairment

• The National Advisory Council on Aging (March 1990) reported that a conservative estimate of 50% of persons aged 60+ suffer some kind of hearing loss (which begins at age 20). The incidence and severity increase with age and are affected by disease and environment (including medications).
• The most common type of hearing loss is presbycusis, typified by a loss in ability to distinguish higher frequencies. As the loss progresses, eventually some lower frequencies are lost as well.
• Hearing loss can:
  • cause difficulty in communicating
  • increase social isolation
  • sometimes result in inappropriate responses which can trigger faulty opinions of "senility"
• The problem can be complicated if people are embarrassed to admit their hearing loss or if it has occurred gradually, so that they don't fully realize the extent of it.
• The hearing-impaired person can understandably feel frustrated and "left out" at times.
• The good news is that hearing-assistance devices have improved dramatically in recent years and various types are available. However, the aids amplify all noises, not just words, so they do take getting used to.
• There are several techniques which you can use as aids to communication. Those listed below are adapted from Living with Sensory Loss: Hearing. National Advisory Council of Canada, March, 1990.
• Techniques to Aid Communication with a Hearing-Impaired Person:
  • Get the person's attention before speaking.
  • Look directly at the person; make eye contact.
  • Avoid covering your mouth or having something in your mouth.
  • Speak clearly and at a moderate pace.
  • Do not shout.
  • Use facial expressions and gestures.
  • Give clues when changing the subject.
  • Rephrase when not understood.
  • Avoid noisy background situations.
  • Be patient, positive and relaxed.
  • Get suggestions from the person.
  • Use good lighting.
  • Use written notes.

  B. Visual Impairment

• There are normal changes in vision which occur during the aging process. The most common occurrence is presbyopia - this is what is happening when you hold the newspaper at arm's length! It is the inability of the lens to accommodate for close vision and it begins about age 40.
• People who suffer both vision and hearing impairment present a special challenge, as you may not be able to use gestures. The following suggestions are adapted from Living with Sensory Loss: Vision. National Advisory Council on Aging, March, 1990.
• Techniques for Communicating with a Visually Impaired Person:
  • Don't come up behind the person.
  • Identify yourself.
  • If the person is hearing impaired as well, you can spell out letters on hand.
  • Describe surroundings.
  • Let the person guide you if s/he needs assistance; they can take your arm, etc.
  • Give direction clearly and accurately.
  • Make the most of remaining sight; use colour cues.
  • Ask the person how much they can see.
  • Provide adequate lighting, reduce glare.
  • Increased lighting needed.

Dementia

• There are many causes for symptoms of dementia; some are reversible, some are not. Dementia such as the Alzheimer type develops gradually over time. If there are symptoms of intellectual decline in someone you know, it is always important to speak to a medical professional.
• When dementia is present, there can be great fluctuation in abilities from day to day. Sometimes it is difficult to know what to expect and how to respond.

Note: If the person you are caring for suddenly becomes quite confused, you should always notify the doctor. This can be an indication of an illness.

Some communication problems associated with dementia include:

1. difficulty in expressing oneself to others
2. problems in understanding what others say

• It is important to remember that feelings usually remain intact in the memory-impaired person. Even if a person cannot communicate verbally, he or she can often still relate on a "feelings" level.
• It is a challenge to communicate without "talking down" to the person. The following suggestions are adapted from Facilitating Communication With The Frail Elderly. Roberta Way-Clark, 1990.
• Techniques to Aid Communication with a Person Suffering from Dementia:
  • Reflect back content and feelings to determine meaning.
  • Ask simple questions; be clear and direct.
  • Give clear, simple instructions, one task at a time.
  • Talk to the person in a non-distracting place.
  • Begin conversation with orienting information.
  • Call the person with dementia by name.
  • Explain the purpose of your visit.
  • Use short words and simple sentences but avoid "talking down"; the person can sense this.
  • Treat people with the respect and dignity you would wish to have.
  • Speak slowly and say individual words clearly.
  • Lower the pitch of your voice; a raised pitch indicates you are upset.
  • Use non-verbal cues like touch and facial expression, i.e., smiling.
• There are two other techniques that should be mentioned:
  1. Reality Orientation. The speaker provides information about name, location, date, daily events, etc. verbally or on strategically placed display boards. Environmental aids are used: large calendar, clocks, display boards, tags, etc.
  2. Validation Therapy. This approach accepts the validity of the old, frail person who has returned to the past. It accepts memories as important components of a person's life in order to understand their motivation and behaviour in the present. It validates feelings generated by loss.

Example: You are caring for your mother, who suffers from dementia. She informs you that her mother is coming to visit this afternoon. How would you respond?

1. Mom, you know that your mother is dead (said kindly).
2. Mom, tell me about your mother. What was she like? (Validation Therapy)

Aphasia

• Some people who have had a stroke suffer from aphasia (which can be caused by other neurological conditions as well). This is an impairment of the ability to handle language - using it and possibly understanding it.
• Not all people who are aphasic have the same area or degree of impairment; every person is individually affected.
• It is important to realize that just because the aphasic person cannot speak, it doesn't necessarily mean that he or she cannot understand what is being said. The brain is very complex.
• The aphasic person may have difficulty understanding the words but they remain alert to non-verbal cues. They will "pick up" on your mood and attitude quickly. You may have experienced this in your own situation.
• Techniques to Aid Communication with a person who has aphasia:
  • Use many of the techniques already described: setting, tone, clarity and distinctiveness of language.
  • You may have to experiment through trial and error to work out the best methods in your situation as each situation is unique.
  • Work with the person affected to determine effective methods of communication.

Summary: Communicating Effectively

• Sometimes we place too much importance on words. Often how we say something is more important than what we say. Non-verbal communication, as we have learned, is tremendously significant.
• Silence is OK, too. Communication is much more than words.
• The greatest gift we can offer someone is to listen to them. Usually, people don't expect others to solve their problems or make the problems go away, but they do want to be valued.
• The importance of touch cannot be overemphasized. Often older people have reduced opportunity for touch. A hug or gentle touch on the arm can go a long way in making a person feel valued.
• Sometimes, the topics you have to discuss are not pleasant or you may have to convey bad news. Remember always to be kind and gentle. Older people have lived through many experiences - they have learned to adjust to vastly changing circumstances. "Bad news" is a part of life they have experienced - probably many times before. Excluding the older person from an unpleasant topic or bad news can be patronizing, or it can hurt them by depriving them of the opportunity to make decisions and be part of the family.
• At the other end of the communication spectrum is the use of humour. Humour can be an effective communication tool when used appropriately. Avoid ridicule or sarcasm at the expense of the other person. Humour can "defuse" a situation, cover an embarrassing moment or lighten a routine task.
• In closing, we can summarize that much of the responsibility for effective communication rests with us. We can learn many techniques that help us to communicate more effectively in specific situations.
• Remember, also, that our own responses can often set the tone for an exchange.
• Example: We have the choice to respond to a complaint with anger and defensiveness or with understanding of what the other person is experiencing.
• Understanding ourselves better helps us to interact more effectively with others.

7. Discussion of Presentation - 30 minutes

• Encourage participants to discuss the material presented as it applies to their situations. They will offer suggestions to each other. You could ask "Would someone like to discuss a particular communication problem they are encountering?" Encourage the group to respond with possible action.

Message - Interpretation/Response

• Facilitator could suggest that the participants examine their own ways of responding to situations.

8. Evaluation of Workshop - 5 minutes

• Participants are asked to complete evaluation forms and leave them in a designated area. Thank them for completing the form; reiterate that the information is useful for future planning.

9. Closing - 5 minutes

• Facilitator will advise the group that next week's topic is Losses as We Age. Ask them to think about some of the losses that they may have experienced in their caregiving role; ask them to identify some of the benefits as well.