aces participant manual en 2019 · 2019-04-25 · and emotional health. while this workshop can’t...

Active Caregiving: Empowerment Skills

OPTIMAL AGING CENTER

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A Participant Packet

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This is an updated, revised, and shortened version of a prior program

Entitled: “Coping with Caregiving”

Original edition was created in 2015 by: Dolores Gallagher-Thompson, Ph.D.

Jeanette To, MS, Ph.D. candidate Kala Mehta, DSc, MPH Marian Tzuang, MSW Nusha Askari, Ph.D.

Larry W. Thompson, Ph.D.

Revised in 2016 by: Ann Choryan Bilbrey, Ph.D.

Dolores Gallagher-Thompson, Ph.D. Marika Blair Humber, MS

Revised in 2017 by:

Ann Choryan Bilbrey, Ph.D. Dolores Gallagher-Thompson, Ph.D.

Marika Blair Humber, MS Jennie Leeder Clark, MA

Optimal Aging Center http://www.optimalagingcenter.com/

Stanford University School of Medicine

Dept. of Psychiatry and Behavioral Sciences (650) 400-8172

Stanford Geriatric Education Center http://sgec.stanford.edu

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Table of Contents Session 1: Dealing with Stress ............................................................. 5

Session 2: Changing Difficult Behaviors ............................................... 17

Session 3: Healthy Communication ...................................................... 31

Session 4: Staying Positive .................................................................. 47

Home Practice ...................................................................................... 55

Session 1 ..................................................................................... 57

Session 2 ..................................................................................... 63

Session 3 ..................................................................................... 71

Appendix ............................................................................................... 79

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Session 1: Dealing with Stress What we will cover:

1. Welcome and Brief Introductions 2. Understanding Stress

3. Reducing Stress: Mindful Breathing

4. Seeking Happiness 5. Pleasant Activities 6. Summary of Session #1 7. Preparation for Session #2: Home Practice

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Introductions Welcome, your facilitator’s name and contact information can be placed here: ____________________________________________________

Understanding Stress

As you know, caring for another person for a long period of time can

take a toll on your physical and emotional state. Research has shown that caregivers face unique challenges that often increase stress. When stress is excessive and extended, it can become very damaging. Over time, it can impact your health and well-being. As you are caring for someone at home right now, it is especially important for you to pay attention to your physical and emotional health. While this workshop can’t take away all the challenges of caregiving, steps can be taken to manage stressful situations in a more healthy way.

How does your body react to stress? There are a number of possible consequences of stress. Physical Consequences of Stress

When a person is under stress, the body releases the primary stress hormone called cortisol. Cortisol is very important, because it organizes systems throughout the body (including the heart, lungs, circulation, metabolism, immune system and skin) to manage the stressful event.

If stress lasts for a long time, it can lead to many health problems. Since caregiving can be a prolonged stressor, caregivers are at risk for stress-related conditions such as:

• High blood pressure • Heart problems • Increased susceptibility to colds and flu

Psychological Consequences of Stress

When left untreated, chronic stress can lead to:

• Depression • Changes in appetite • Anxiety • Sleep problems • Anger • Lack of energy • Irritability • Hopelessness/Helplessness

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The psychological consequences of stress can take away from your quality of life by lowering your ability to experience pleasure or a sense of accomplishment. It can also take away from your ability to provide the kind of care you feel your loved one deserves. Social Changes Experienced by Caregivers

Caregiving often challenges friendships and relationships. Social support can relieve stress by giving caregivers a chance to discuss their thoughts and feelings. It is common for caregivers to feel that no one understands what they are going through. However, caring for someone with memory problems does not have to be a lonely experience.

Let friends and family members know when you need help, or maybe just a break. Caring for a loved one with dementia is too big a job for one person. There are many local support groups that can give you a chance to meet others who have similar experiences. You might say that you don’t have time for these kinds of things, but it is important for your health and well-being that you make time. You are worth it! Resilience: What is it? Resilience benefits caregivers in many ways but what is it? Resilience is:

• Adapting to life’s challenges • Utilizing inner strength to move forward after a setback • Ability to keep functioning through anger, grief, loss and pain

Key component: reaching out to others for support. You all have resilience or you wouldn’t be in this workshop! Let’s strengthen your resilience by teaching you a variety of skills.

Activity: Recognizing Stressful Events

Think about a recent stressful caregiving experience. Please turn to the person next to you and ask each other the following questions: 1. What do you feel when you are stressed? 2. How do you know when you are stressed? 3. What do you do now to manage your stress?

What are you

feeling?

How are you

managing?

How do you know?

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Reducing Stress: Mindful Breathing

Why practice mindful breathing? Relaxed is the opposite of “stressed.” When a person feels stress, the body goes into a fight-or-flight mode:

• Stress hormone is released into the blood • Blood vessels constrict • Blood goes to the heart and muscles to prepare it for fight-or-flight • Breathing rate and heart rate increase

However, when the body is relaxed…

• Heart rate and breathing slows • Blood pressure decreases • Oxygen consumption decreases • Less stress hormone released into the body

Tips for effectiveness If you are not accustomed to mindful breathing it can feel unnatural and awkward in the beginning. Here is a set of tips gathered from other participants who have successfully added mindful breathing to manage stress:

ü Deliberately & consciously slow your breathing • How? Focus on taking in regular & deep breaths slowly and

then exhaling the breath equally as slowly • People often count to themselves while breathing in and then

out, to make it more regular and paced

ü Add it to your daily routine • The more you practice, the more natural it feels and the more

likely you will use it when you need it

ü Focus on the breathing • If thoughts are overwhelming? Concentrate on your breath.

How does it feel on the back of your throat? Warm? Cool? Can you feel your lungs expanding with each breath?

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Activity: Mindful Breathing Exercise

Stress Rating Before Exercise 1 = Not at all stressed Now, please rate your stress 2 = Slightly stressed level from 3 = Moderately stressed 1 to 5. 4 = Very stressed 5 = Terribly stressed How would you rate your Stress level now? _________ Instructions for Mindful Breathing • Take a deep slow breath in for at least 5 seconds • Feel your abdomen expand as you do this • Breathe out slowly, to a count of 5 or more • Breathe in again, making every breath slow and steady and exactly like

the one before it • When breathing out, concentrate on expelling all the air in your lungs and

keep it going as long as you can • Stay relaxed for a few seconds before you inhale again Stress Rating After Exercise 1 = Not at all stressed Now, please rate your stress 2 = Slightly stressed level from 3 = Moderately stressed 1 to 5. 4 = Very stressed 5 = Terribly stressed How would you rate your Stress level now? _________ 1. Did your level of stress change? 2. What was this experience like for you? 3. Can you think of a specific event when this technique might have been helpful during a stressful caregiving situation?

1 5

3 2 4

1 = Not at all tense 2 = Slightly tense 3 = Moderately tense 4 = Really tense 5 = Terribly tense

1 5

3 2 4


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RELAXATION DIARY: STRESS EVALUATION

1 = Not at all stressed 2 = Slightly stressed 3 = Moderately stressed 4 = Very stressed 5 = Terribly stressed

DATE

STRESS COMMENTS (why I felt this way, etc.)

Before relaxing: ______ After relaxing: ______







1 5

3 2 4


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Seeking Happiness We know through research that the following three topics heavily

influence our sense of well-being and happiness.

Gratitude: the act of giving thanks can have remarkable impact on a person’s well-being.

• Less frequent negative emotions • More frequent positive emotions: feeling energized, alert, and

enthusiastic • Pleasant muscle relaxation when recalling situations in which

they’d felt grateful

A Kind Act: people who volunteer or care for others on a consistent basis tend to have better psychological well-being, including fewer depressive symptoms and higher life-satisfaction. This seems to be especially true in older individuals.

• Although “caring” can involve volunteering as part of an organized group or club, it can also be as simple as saying hello or opening a door for someone else

Positive Experience: Reflecting on past positive experiences can influence current mood and assist in building positive expectations for the future.

What is one simple thing you can do to be happier?

Every day write down a gratitude reflection, positive experience and a kind deed. Journaling serves two purposes:

1. It focuses your attention on the positive in your life, in essence it “trains” your brain to notice the good things

2. It acts as a memory aid- you can go back and see exactly what good you’ve done and what good has happened to you

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Taking Control

Decades of research show an effective way to manage your level of stress is to take control of your life. Many times, caregiving is not an activity we ever planned to take on; we come to it by necessity. At times, it can make our lives feel a bit out of control, or at least it may feel like you have little to no control. One very effective way of dealing with this is to make time in your schedule for pleasant activities. Why Pleasant Activities?

Although being a caregiver is time consuming, it is important that you make the time to do activities you enjoy. This is important because if all your activities are limited to your caregiving responsibilities, you may begin to feel burned out, frustrated, and even resentful.

For example, unpleasant emotions such as sadness can develop when we have too many unpleasant events and too few pleasant events. This lack of balance between unpleasant events can make you feel like you have no control. You may say to yourself “What’s the use?” or, “It seems like there’s nothing I can do to make things better.” However, you can feel better by making sure your day has a few activities that bring you pleasure!

These pleasant or unpleasant activities control how up or down you feel. You can make choices about how you spend your time and this will influence your overall mood.

What Counts as a Pleasant Activity? Pleasant Activities don’t have to be big activities that require a lot of

planning - they can be small activities that you do on your own, with friends, or with your loved one. Examples might be reading, going for a walk, or listening to music. Even though these activities may be brief, taking this time out for yourself is important for your well-being.

Key Point: Anything you like to do is a pleasant activity!

M O O

D

Pleasant Events

UnpleasantEvents

The MOOD Rollercoaster

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Adding pleasant activities into your Everyday Life Begin with some questions:

• How are you and the person you are caring for currently spending your time?

• Identify potential positive activities that you are not doing now by asking yourself:

o What did you enjoy in the past? o Can it still be done now? o If not, how could it be modified to become more doable now?

STEP 1: Identify specific activities or situations associated with positive mood which can be added into your day. STEP 2: Schedule and track these pleasant activities every day and notice if there really is an association between mood & activities. STEP 3: Revise or modify this “list” based on your changing needs and observations about what works & what doesn’t work. This is truly a learning process! It’s helpful to…

• Think about and then write down a “Top 5” or “Top 10” list to get started. See Handout entitled PAL – we’ll be working with this next…

• Think about barriers to doing each of these things • Try to problem solve and devise a plan around the barriers

Examples of possible pleasant activities

• Looking at flowers, clouds, other aspects of nature • Listening to music • Baking or cooking • Reading • Having coffee or tea with friends • Helping someone • Solving a problem, puzzle, or crossword • Having peace and quiet • Getting away for an hour • Planning a trip or vacation

Key Point: 4 pleasant activities a day keeps the blues away!

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Positive Activities Idea List 1. Listen to music (or play a simple instrument)* 2. Shop for yourselves or others 3. Go to the beach 4. Take a relaxed walk – anywhere! 5. Listen or read stories, newspaper articles, poems, etc. 6. Look at travel brochures or magazines 7. Go out to eat together 8. Be around animals or pets 9. Cook and prepare snacks 10. Watch birds or animals (in a yard or the zoo) 11. Write letters, cards, etc. 12. Do handiwork or crafts 13. Look at photo albums and photos 14. Sort out drawers or closets 15. Go to the movies 16. Rent a video and make popcorn 17. Go to church or other places of worship 18. Go for a ride in the car 19. Exercise 20. Recall and discuss happy memories 21. Watch sports 22. Have friends over 23. Watch the clouds or explore nature 24. Have coffee or tea in a comfortable place 25. See, smell, or tend to flowers or plants 26. Give each other neck and shoulder rubs 27. Look at the moon and the stars 28. Be with children and grandchildren 29. Listen to the radio 30. Read scripture or spiritual text 31. Say prayers 32. Reminisce with friends 33. Sit in the park 34. Sort old pictures 35. Dance *Many researchers agree that music plays an important part in the lives of most people with memory problems. Even in later stages when verbal communication is poor, most people will still respond to music.

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Summary of Session # 1

In this class, we learned the following information: • We learned about the stress of caregiving, some effects of stress, and

a simple but effective tool for reducing stress. • We described an activity you can do once a day that will make you

happier. • We described how pleasant activities could affect your mood. • We practiced how to generate a pleasant activities list (PAL) for you to

develop in the coming weeks. PREPARATION FOR SESSION #2: HOME PRACTICE Before attending session #2, please do each of the following:

• Relaxation Diary: Practice the mindful breathing exercise as many times a day as you can. Refer to the handout on mindful breathing if you wish. Record your before and after stress levels in the relaxation diary at least once every day.

• Happiness Journal: Every day write down a: gratitude reflection, positive experience and a kind deed.

• Pleasant Activities Log: Track your positive activities and share your results with the group next week.

• Challenging Behavior: Think about a challenging behavior that your loved one does that causes you stress and be ready to share it in the next session. We will be talking about what happens before and after the behavior, and ways to change triggers and reactions.

• Positive Thinking: Think about what a good job you are doing as a caregiver! We are all here to support one another!

We will talk about these home practices next week in class, so please be sure to bring them with you!

You will learn more and get more out of this class if you

commit to doing the home practice every week.

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Session #2: Changing Difficult Behaviors What we will cover:

1. Mindful Breathing 2. Review home practice for Session #2 3. The “Before-During-After” Chain 4. Develop Individualized Plans

5. Summary of Session #2 6. Preparation for Session #3: Home Practice 7. Relaxation Practice: Visualization

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Practice Mindful Breathing • Take a deep slow breath in for at least 5 seconds • Feel your abdomen expand as you do this • Breathe out slowly, to a count of 5 or more • Breathe in again, making every breath slow and steady and exactly like

the one before it • When breathing out, concentrate on expelling all the air in your lungs and

keep it going for as long as you can • Stay relaxed for a few seconds before you inhale again

Review Home Practice Discussion about the home practice

• Relaxation Diary • Happiness Journal • Pleasant Activities Tracking Form

Difficult Behaviors: Is there anything you can do? Dealing with difficult behaviors such as harsh words and outbursts,

wandering, or even striking out can be some of the more stressful events caregivers have to deal with. Is there anything you can do to stop these behaviors? Trying to figure out why your relative does something can be hard. We will begin by learning how to pay attention to the environment.

If your relative does not have any problem behaviors that you would like to change, then we would like you to think about the purpose of your behavior. What Happens Before AND After the Behavior Occurs?

The first step in identifying the purpose of someone’s behavior is to pay attention to what happens before and after the behavior. Something is always taking place before and after the behavior. Sometimes what happens before the behavior can be referred to as a “trigger” and what happens after the behavior as a “reaction.”

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Triggers or BEFORE In order to understand the purpose of the behavior, it is important to pay attention to what is happening immediately before the behavior happens. What is occurring before the behavior is called a “trigger.” Triggers could be any of the following:

• An event or activity, such as noise or a demand that is being placed on the person (e.g., bathing)

• General things that affect a person for a long period of time (e.g.,

time of day, season, and/or physical illness)

• Cues in the environment, such as keys to the car or the presence of another person

Behavior or DURING

• The Behavior is what your loved one does or what you do.

Reactions or AFTER

• Reactions occur immediately after the behavior. Reactions include what you do, how you feel and what your loved one does. In other words, what

happens after the behavior? It is very important to pay attention to reactions. Depending on how you react, you may increase or decrease the problem behavior.

• Whatoccurredbeforethebehavior?

• Whatdidtheyoryoudo?

• Whathappenedafterthebehavior?

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The Before-During-After Chain It is helpful to think about the different phases of behavior as a “B-D-A

Chain” or BDA for short. We will be applying the BDA in the following examples using a simple form to understand what occurs before and after a difficult behavior happens.

Date/ Day of week

Time

In the first two columns you will write the date or the day of the week, and the time when the difficult behavior occurred. In the next three columns, you will be describing the behavior that occurred in the center column. In the BEFORE column you will list what happened right before the behavior. This could be an event, activity, timing, or cue in the environment just before the difficult behavior occurred. The last column is for what happened directly following the behavior, including your reaction to the behavior.

BEFORE DURING AFTER

Key Point: A person with memory problems has a lot of difficulty learning new information. For example, it is difficult to teach him/her the difference between right and wrong behavior. The only things you as a caregiver have control over are triggers and reactions. Occasionally, we can’t change the triggers. During those times, changing how you react to the behavior will keep the situation from getting worse.

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Recognizing the BDA Let’s use the following example of Robert and his mother, Ginger.

Robert & Ginger

It is 10 am on Monday morning, and Ginger is quietly sitting in her favorite chair when her son, Robert, comes over to her side and says, “It’s time to go to the doctor, let’s put your coat on.” Ginger says, “No, I’m not going to the doctor.” When Robert pleads for her to get up, Ginger starts to yell. Robert cancels the appointment and leaves Ginger alone in her chair. Ginger stops yelling. Robert completes the following behavioral log. 1. The first step is to fill out the first two columns: date, and time 2. Next, what was the difficult behavior? Ginger yelled, refused to go to the doctor. 3. What happened just BEFORE (Trigger) Ginger started yelling? Let’s see, before she started yelling she was sitting quietly and then Robert came in and told her it was time to go to the doctor. 4. What was the reaction to Ginger’s yelling and refusal to go the doctor? Robert left Ginger alone and cancelled the appointment.

Date/ Day of week

Time

Monday

10am

Mom is quietly sitting in her chair. Robert tells Ginger it is time to go to the doctor.

Mom yells when Robert tells her she has a doctor’s appointment and needs to get ready.

Robert leaves Mom alone and cancels the doctor’s appointment.

Through this example we’ve identified the behavior, its triggers and the reaction.

BEFORE DURING AFTER

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Let’s try to identify Jim & Sue’s BDA together using this same form. Jim & Sue

Every morning at 8 am, Jim and his wife Sue have breakfast. After breakfast, Jim sees car keys on the key hook by the breakfast table, and tells his wife, Sue, “I am going out for a drive.” Sue reminds him that he no longer has a driver’s license and is not permitted to drive. Jim responds by yelling, “I don’t know what you are talking about,” and angrily walks toward the driveway. Sue feels helpless and frustrated. Let’s walk through the steps together. 1. The first step is to fill out the first two columns: date and time. 2. Next, what was the difficult behavior? 3. So what happened just BEFORE (Trigger)? 4. What was the reaction to the difficult behavior?

Date/ Day of week

Time

What do you think would happen if Sue changed her reaction? What are some of the ways Sue could react that would be harmful to this situation? What ways could she react that would be helpful? How do you think Jim would react to Sue? As you can see, changing our reaction can change what happens. Let’s explore that further.

BEFORE DURING AFTER

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Changing Difficult Behaviors We will now discuss the different ways we can change behaviors. These include the following:

1. Changing the BEFORE or trigger 2. Changing what comes AFTER or our reactions 3. Changing the trigger and our reactions

Remember the key point discussed earlier this session? A person with memory problems has a lot of difficulty learning new information. The only things you as a caregiver have control over are triggers and reactions.

Let’s look at another case. Jane is concerned with Betty’s wandering at night.

IMPORTANT CONSIDERATION: Ruling Out Medical Problems Before we begin with a new example, we need to discuss ruling out medical problems. Before trying to change your loved one’s difficult behaviors, it is important to make sure that his/her behavior changes are not related to a medical problem. Some common medical problems that can affect behavior include:

Medical conditions (e.g., urinary tract infection, constipation, pain, fever) Medication side effects Sensory impairments (e.g., hearing loss, poor vision)

It is important that these conditions, as well as others, be adequately diagnosed and treated by your physician, as there may be underlying sources of your loved one’s behavior problems. Important Note: Always contact your loved one’s physician if there is any sudden change in your loved one’s functioning.

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It is 3 am and Betty wakes up and begins to walk around the house. Jane, her daughter, is sleeping. Betty paces throughout the house and wakes Jane up. Jane is upset because she has a long day at work tomorrow. Jane says, “Mom, you need to go back to bed, it is 3 am.” Betty says, “I am not sleepy.” Jane yells “I can’t take this anymore.” Betty starts to cry.

Date/ Day of week

Time

Almost every night

3am Betty wakes up at 3 am Jane is sleeping.

Betty wanders at 3 am. Betty does not want to go to bed; she is not sleepy

Jane tells her Mom to go to sleep. Jane yells. Betty cries.

If Jane wants to keep Mom from wandering at 3 am, what can she do? 1. Change the BEFORE (trigger): • Schedule an appointment with Betty’s doctor to find out if there is a

medical reason for her trouble sleeping (urinary tract infection, pain). If there is no medical problem, then. . .

• Develop a schedule to keep Betty awake during the day. No naps! • Encourage Betty to exercise during the day (e.g., walking, stretching). • Develop a bedtime routine that takes place at the same time every night. • Do not allow Betty to have any caffeine. • As a LAST RESORT, talk to Betty’s doctor, and ask her if there is

anything Betty can take to improve her sleep. 2. Change the AFTER (reaction):

• Gently remind Betty that it is dark out and time to go to sleep; lead her back to bed; play soothing music or do something else that will help Betty to relax.

• Remind yourself to approach the situation calmly and focus on the goal of the task (getting Betty back to sleep). This way, you will use your energy in a positive manner to problem-solve the situation rather than reacting emotionally.

BEFORE DURING AFTER

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There is a lot to keep track of here so it may be helpful to use the form below called the Behavioral Log. Parts of this log should look familiar to you, but we’ve added an extra column. The column labeled ‘Strategy’ adds new rows. Notice it has Current, Proposed, and Result headings. The Current row describes the difficult behavior you are concerned about. The Proposed row is the place to describe your strategy to change either the BEFORE or AFTER. The Result row gives you a place to write what the result was for the proposed strategy. What happened when you used it? What was the outcome? There will be times when you will need to sleuth your way through, trying many strategies to change a difficult behavior. By using this log, you will have a record to remind yourself of what was or wasn’t successful. IMPORTANT NOTES: Regardless of which behavior and strategies you choose, the most important thing to remember is to be consistent. Problem solving is a process of trial and error. Once this problem is solved, another one may develop. It’s possible that the strategy that you came up with may work at some times and not others. Be flexible, patient and creative.

Date Day Time

Strategy

Current What

happened?

Proposed What could

you do different?

Result What

changed?

BEFORE DURING AFTER

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Now that you’ve seen what a Behavioral Log looks like, let’s use it to organize Jane’s new strategies.

Date Day Time

Strategy

Almost every night

3am Betty wakes up at 3 am Jane is sleeping.

Betty wanders at 3 am. Betty does not want to go to bed; she is not sleepy

Jane tells her Mom to go to sleep. Jane yells. Betty cries.

Current

• No naps, keep her busy

• Exercise • Bedtime

routine • No caffeine • Talk to doc

about sleeping meds

• Gently remind that it is dark out/time to go to sleep; play soothing music.

• Stay calm, focus on the goal of the task (getting Betty back to sleep).

• Don’t react emotionally.

Proposed

Make appt

w/doc to check for medical reason

Result

As you can see, there is now room to write the result of the new strategy once you try it out. Now that you have a basic understanding of how a behavioral log works, it is time to use it on the difficult problem you were asked to bring in for this session.

BEFORE DURING AFTER

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Tackling Individualized Difficult Behavior Please practice completing this Behavior Log using a behavior that causes you stress that we asked you to identify. Fill in the log below. We will ask for volunteers to share the logs they complete. See next page for helpful questions to refer to as you do this exercise.

Activity: Behavior Log

Please use this log to write down one of the stressful things your loved one does that upsets you.

Date Day Time

Strategy

Current

What happened?

Proposed

What could you do

different?

Result

What changed?

BEFORE DURING AFTER

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Behavioral Log Reminders When completing behavioral logs, keep in mind the following: To figure out possible triggers:

• Was the environment quiet or noisy? Dark or bright? • Was your loved one alone or was someone present? If so, who? • Was an event occurring, such as bathing, or administering meds? • Did your loved one want something, such as food, or keys? • Did your loved one appear to be seeking attention?

To figure out your reaction:

• Did you stop the event (bathing, administering medications)? • What kind of feelings did you experience?

o Did your level of stress increase or decrease? o What did you actually do?

Reminders for strategy:

• Could there be a medical problem? • Be creative (exercise instead of sleeping pills; music instead of a

sedative) • Do you need a break? Is there someone you can ask to give you

some time to recharge? • Remember to look for both trigger and response strategies.

Consistently use these strategies and complete the behavior log to find out if the behavior has changed. You may feel that you can “mentally” keep track of whether the behavior has changed, but we would like you to keep the log. The reason for this is that it is helpful to write the information down, and we would like you to share it with the class next week. If you don’t write it down, you’ll forget some important details that will help us help you and each other. Problem solving is a process of trial and error. Once this problem is solved, another one may develop. It’s possible that the strategy that you came up with may work at some times and not others. Be flexible, patient and creative! Give yourself the gift of time, and permission to fail. IMPORTANT NOTES: Regardless of which behavior and strategies you choose, the most important thing to remember is to be consistent.

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Summary of Session # 2 In this class, we learned the following information and skills:

• The importance of ruling out medical conditions as the cause of behavioral changes

• How to change triggers and reactions

• Strategies to change triggers and reactions PREPARATION FOR SESSION #3: HOME PRACTICE

Before attending session #3, please try the following:

• Continue Relaxation Diary: Try to complete one entry every day. Do mindful breathing as often as possible each day.

• Happiness Journal: Every day write down a: gratitude reflection,

positive experience and a kind deed. • Pleasant Activities Log: We encourage you to modify and update

your tracking sheet this week for final review next week. • Behavioral Log: Please complete the behavioral log when your loved

one’s target behavior occurs. We understand it may be difficult to complete the log each time the behavior occurs, but please complete it as frequently as possible. Extra copies are in your packet.

We will talk about these home practices next week in class so please be sure to bring them with you!



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Relaxation Practice: Visualization Introduction Today we are going to do a guided imagery exercise. This exercise will involve imagining a calm, peaceful, and safe place. We are providing you with a wide range of options, as different people find different images or scenes relaxing. We hope this one will be helpful for you. Stress Rating Before Exercise 1 = Not at all stressed Now, please rate your stress 2 = Slightly stressed level from 3 = Moderately stressed 1 to 5. 4 = Very stressed 5 = Terribly stressed How would you rate your Stress level now? _________ Guided Imagery: Visualization Imagine a place where you can feel calm, peaceful and safe. It may be a place you've been to before, somewhere you've dreamt about going to, or maybe somewhere you've seen a picture of. Focus on the colors in your peaceful safe place. Now notice the sounds that are around you, or perhaps the silence. Think about any smells you notice there. Then focus on any skin sensations - the earth beneath you, the temperature, any movement of air, anything else you can touch. While you are in your peaceful and safe place, you might choose to give it a name, whether one word or a phrase that you can use to bring that image back, anytime you need to. You can choose to linger there a while, just enjoying the peacefulness and serenity. You can leave whenever you want to, just by opening your eyes and being aware of where you are now. Stress Rating Before Exercise 1 = Not at all stressed Now, please rate your stress 2 = Slightly stressed level from 3 = Moderately stressed 1 to 5. 4 = Very stressed 5 = Terribly stressed How would you rate your Stress level now? _________

1 5

3 2 4


1 5

3 2 4


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Session #3:

Communicating with your relative, family members, and providers

What we will cover in Session #3:

1. Mindful Breathing 2. Review home practice from Session #2 3. Empathy 4. Communication and Memory Problems 5. Communication and your Family 6. Communication and your Doctor 7. Summary of Session #3 8. Home Practice for Session # 4 9. Relaxation Practice: Ocean Escape

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Practice Mindful Breathing • Take a deep slow breath in for at least 5 seconds • Feel your abdomen expand as you do this • Breathe out slowly, to a count of 5 or more • Breathe in again, making every breath slow and steady and

exactly like the one before it • When breathing out, concentrate on expelling all the air in your

lungs and keep it going for as long as you can • Stay relaxed for a few seconds before you inhale again

Review Home Practice

Discussion about the home practice • Relaxation Diary • Happiness Diary • Pleasant Activities Log • Behavioral Log

Empathy

Today we are going to start with empathy. Many people believe that empathy is the foundation for all good communication. Sometimes we just want someone to understand what we are going through. In that moment, we don’t want solutions, we just want someone to be there for us, to listen and care. In a nutshell, empathy is the ability for someone to figuratively put themselves in the shoes of another so they can feel what that person is feeling. Empathy is about understanding and accepting without judgement. When receiving empathy, the person feels understood, accepted, important, and above all, connected to another person. People do not do well, either physically or emotionally, when they feel isolated. Empathy from another person breaks that sense of feeling disconnected from everyone.

For a person with dementia, as they lose pieces of their memory, they lose the feeling of being connected to others. Some people react with agitation and some react by withdrawing. Empathy as a caregiver is important for you to offer to your loved one with dementia to help them reconnect with another person. We know through research that empathy is not a fixed trait, it is a skill that can be improved. Like any skill, empathy requires practice. Here are some techniques that will help you develop empathy toward the person you are caring for:

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Empathy Tips Use Open Body Language. Non-verbal communication like body language convey as much information as verbal language – sometimes conveying even more than verbal language. If your body language says one thing and your words say another, people tend to trust what your body says over your words. Some simple tips:

• Turn towards the person you are speaking to • Don’t be too far away • If the person you are talking with is seated, you should sit, too • Relax your body- uncross your arms and legs

Watch the other person’s body language for clues. Put yourself in their shoes. Much of what a person with memory loss uses to anchor themselves is missing, they may not know who they are, who you are, where they are, or what they were doing. How scary would that be? Watch and learn their signs that they are scared. Let that guide you on how to interact. On the other hand, some individuals with dementia live in the moment and express whatever emotion is most important to them in that moment, which could be joy and happiness.

• Touch can be powerful, it can help to anchor someone, it can show that someone cares, and it can connect them to another person and allow them not to feel so isolated.

Be attentive. There is so much in this world that distracts. • If they allow, make eye contact. • Shut off the TV, put away the phone.

Listen to hear, not to talk. Too many times in our busy lives we take the shortcut of listening so we can reply. Listen for the emotion and seek to understand what has contributed to it.

• Allow yourself to listen as if your only job is to understand. • Focus on understanding their unique experience.

Use your voice and words to convey empathy. • Emotions can be contagious, monitor the sound of your voice.

o Lower your vocal register, speak slower and in a calm soothing tone.

• Verbalize your understanding. o Identify and label emotions. “You sound sad.” or “You look happy

when you talk about your sister.”

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o Don’t counter an emotion with a fact, just acknowledge it. This is not the time to be “right.” If they say, “I feel scared to go to the doctor,” don’t say, “The doctor won’t hurt you.” Acknowledge their fear by saying, “I know, sometimes going to the doctor is scary.”

Deal with the emotion not the content. What can you do to help them feel less scared? Less worried? Less agitated?

• Identify what soothes them and offer it. Hold their hand, bring their favorite blanket, bring a favorite snack.

Adapted for use from http://www.caregiverstress.com/geriatric-professional-resources/professionaldevelopment/clinical-empathy-a-key-tool-for-client-care

Activity: Discovering Empathy

Introduction: With dementia can come a general slowing of the ability to understand verbal language, one of the main ways we communicate important medical information. This exercise can be an example of what it can feel like to want to understand something important but find it difficult. Scenario: You received a phone call from your doctor’s office requesting a clinic visit to discuss results of recent tests. Arriving at the clinic, you’re insecure and somewhat bewildered because you feel like other people are looking at you and all the background noise is distracting. When you get in the doctor’s office, the doctor and your caregiver carry on a discussion about your condition while totally ignoring you. You are trying to follow the conversation but the doctor seems to be talking very fast and you don't quite understand all the words. “Well, the consummation connote dementia, practicably Alzheimer’s blazon. There’s no expeditiously percipient progress, but exigency is no medicament for Alzheimer’s. I’ll pharmacon Aricept for pother. Inguritate one bolus qhs for a singular stretch of 30 diurnal courses then inguritate 2 bolus qhs. You might endeavor to acquire formation of stanchion to frequent. I cede a practitioner vigilance bangle contingent upon irretrievability. My RN will make an observation of duration to resume in six stretch of 30 diurnal courses. Expression commiseration. There is a nonexistence of resolution to propound.”

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Questions to Answer Can you figure out what the diagnosis is here? What about the prognosis? What instructions have been given? Now imagine yourself in a doctor's office wishing to understand what is happening to you. Your caregiver and your doctor seems to understand each other clearly and they have a conversation that does not include you. Questions to Consider How did it feel when the doctor and your caregiver discussed your diagnosis as though you weren’t even in the room? What impact on your thoughts could this have? What about how you are feeling? Alzheimer's Disease is mentioned a couple times - what do you think the reaction would be to that diagnosis? Summary: This exercise was designed to help you place yourself in the shoes of the person you are caring for. The dementia itself provides a filter that the person who is living with dementia must negotiate each time they reach out to the world. It is important to allow yourself to imagine their experience. This increases empathy, which in turn feeds increased compassion and patience. Communication and Memory Problems

It is important to remember that what we say, how we say it, what we do not say, or our body language all have meaningful messages – for your loved one, family members, or care providers. It is especially important with those closest to us. Changing the not-so-effective patterns can be challenging yet can be very meaningful when we speak with others. A key factor to keep in mind with our loved one experiencing memory deficits is that they will not be functioning the same way they used to in terms of their actions, behaviors, how they express themselves, and how they experience things in the present.

We need to be mindful of shifting OUR expectations to fit the current scheme of things and NOT try to change our loved one and their behaviors to match OUR expectations. We need to go with the flow of how things are now, where your loved one is now, in the present moment, and be open to change at any time. This can be very challenging, we admit. However, once

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we come to terms with this reality, we can make life so much easier for all concerned. Let’s talk about some challenges and how we can make things EASIER.

Communicating with someone with memory problems can be challenging. At times you may feel as if you have to jump over many hurdles or have to walk on eggshells. Memory problems affect communication in a number of ways:

• They affect one’s ability to understand what is said • They limit the ability to express what he or she wants to say. • They lead to problems finding the right words, as well as an inability to

remember thoughts from one moment to the next. • They cause communication problems can result in behavior problems.

Increased behavior problems can be frustrating and increase caregiver stress. When we are frustrated we do not communicate as effectively, which can result in further frustration and more problems. What Changes Have You Noticed?

• What changes have you noticed in your loved one’s ability to communicate?

• How have you changed the way you communicate with him/her?

How To Talk To Someone With Memory Problems When your loved one cannot understand what is being said, or cannot

find the words to express thoughts, it can be frustrating and embarrassing for everyone involved. We are going to review some things to consider when you are communicating with a person that has memory problems. How are you presenting yourself? If you are stressed, your loved one will sense it by your tone & body language.

It is important to pay attention to how you are presenting yourself to your loved one. People with memory problems are very sensitive to non-verbal signals, such as facial expressions, body tension, and your mood.

IMPORTANT POINT: Because our loved ones cannot change their communication problems, it is important that we find other ways to communicate with them.

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What is your approach? If you’re stressed, the words you use can trigger reactions in your loved one.

If you’re impatient, your loved one will pick up on these feelings and this may alarm him/her. If you’re calm and gentle, you are likely to help your loved one feel calm. It helps to touch your loved one to help him/her feel reassured. You can communicate reassurance by holding hands and patting or stroking your loved one’s hand. It also helps to look your loved one in the eye and get on the same level - if they are seating than you should sit. This will help him/her to focus attention on you before you speak. What is the environment? Reduce distractions!

People with memory problems have a difficult time screening out distracters. For example, if the television is on when you are trying to talk to your loved one, s/he will be unable to pay attention to these two sources of noise. The ideal environment in which to communicate with your loved is quiet and free of distractions (i.e., no television, music, or other conversations). Are you catching your loved one by surprise?

Memory problems result in people feeling confused and disoriented. Approach your loved one from the front. When approached too quickly or from behind, people are easily startled. It is also helpful to inform your loved one of what is happening. For example, if it is bathing time, approach your loved one gently, and inform him/her of each step along the way. How much information are you providing?

People with memory problems do not remember more than a few words at a time. Make an effort to speak slowly and allow extra time for him/her to respond. Try counting to 10 in your mind after asking your loved one a question. Limit your questions to one at a time. What to avoid! • Don’t argue with your loved one.

• Don’t tell the person what he or she cannot do.

Instead of saying, “You can’t go outside,” try, “Let’s sit down and read the paper together.”

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Activity: Gloria & John

Let’s look at an example of a problem communication.

Gloria wants her husband John to go to bed. He is watching television. She yells from the kitchen that it’s time for bed. He ignores her. She yells louder for him to turn off the television and get ready for bed. John continues to ignore her so she begins to cry and locks herself in the bathroom.

What do you notice about Gloria’s communication skills? How could she have done things differently?

Activity: Communicating with Your Relative

We are now going to apply what we just learned to our individual situations. Take a moment to think about a time when you had trouble communicating with your loved one & answer the following questions:

• Who was involved? • Was anybody else close by? • What happened? • How did you react to the situation?

___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

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Getting Help from Family Members: How to Express Yourself Effectively 5 Ideal Steps for Effective Communication There are 5 IDEAL steps to Effective Communication:

v I dentify v D escribe v E xpress v A mplify or Emphasize v L isten

Step 1. Identify. Identify the situation to use assertive communication.

For a caregiver, this is often regarding:

v Asking someone for assistance with caregiving tasks or household chores or even accompanying your loved one while you take a break.

v Talking to healthcare or other professionals about your loved one’s needs.

v Communicating with family and friends about other issues that are important to you.

Step 2. Describe. Describe the situation. Clearly state what you think

and how you feel. Step 3. Express. Express what you need to know or what you would

like the listener to do for you. If you can offer something in return, express that.

Step 4. Amplify or Emphasize. Emphasize why you need this request

and how it can be of help. Step 5. Listen. Listen to whether the listener can fulfill the request. If so,

say THANK YOU and state how or when you will do anything you offered to them. If he or she cannot do the request, ask if a different time or request is possible and begin to negotiate.

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Steps to Better Communicating with Your Family

• Examine your needs: What do you want, and what are your feelings about the situation?

• What exactly is the problem? Formulate this in one or two sentences.

• Describe your thoughts and feelings clearly, so the other person can

understand your point of view.

• Be persistent and flexible: maybe you won't get exactly what you asked for, but you will get something that will be helpful.

• Avoid substituting opinions for facts, and try to use "I statements" frequently. Give detailed information. For example: taking care of Mom for two hours involves feeding her a snack, turning the radio to her favorite station, and taking her to the bathroom.

• Break it down into smaller parts - it's usually easier for people to say

yes to a little request than to a big one!

• If you are at an impasse, take a break - go back to the discussion at a future time. For example, agree to think about it and talk again tomorrow afternoon.

• If appropriate, offer to do the task with the person. For example, sit

together with Mom for two hours first before your brother does it alone so that he can learn what is involved and feel more confident.

• DON'T GIVE UP! It may take many attempts before things change.

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Example of Communicating Effectively

What makes this effective? What do you think she did or thought that allowed her to respond this way?

How would you feel after effective communication like this?

Sylvia takes care of her husband, who has memory problems. Sylvia has arranged for her husband to stay with her brother, Daniel, while she attends a weekly one-hour exercise class. An hour before Sylvia is scheduled to attend her class, Daniel calls to say that he has changed his mind and doesn’t want to take care of her husband after all. Sylvia responds to Daniel’s statement that he doesn’t want to take care of her husband by saying, “It’s very important that I get some relief from caregiving. I would like to talk to you and to try to work this out.”

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Activity: Practice Effective Communication Skills Let’s break into pairs and role-play a specific situation in which you

are trying to ask for help or respite from a family member or friend and he or she is reluctant to agree.

After 10 minutes, we will ask you to switch roles so that you both can practice your effective communication skills. Afterwards, we will come back together as a large group and discuss your feelings and reactions to this exercise. Please try to make this situation as realistic as possible for you. Try to be aware of how to be effective in your approach. ROLE-PLAYING SITUATION

You are in need of a “break” (to go shopping, go to the dentist, pay bills, etc.), so that you can get things done without your loved one coming along and distracting you. You want to ask your sister (brother, son, daughter, whoever is appropriate) to come over and be with your loved one for 4 hours while you go out. Your relative usually doesn’t agree when you’ve asked for this kind of help in the past, or usually says yes and then cancels at the last minute. This time you really want a solid “yes”.

**NOTES**

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Communicating with Healthcare Professionals It may seem like attempting to be heard during a short visit with your doctor is impossible. You may be surprised to hear that lack of time with patients is the number one complaint of many doctors as well as patients. Here are some tips that will help you use your precious time with the doctor more effectively. • Make a list of questions and bring it with you to the appointment

so as to maximize use of time.

• Be clear when you speak with the health care provider. Try not to ramble.

• If you have access to an online service like MyHealth, send your questions to the doctor before your visit.

• If you have a lot of things to talk about, or expect that you'll need additional time, try to make a consultation appointment so the provider can allow enough time to meet with you.

• Educate yourself about your loved one's disease or disability.

• Learn the routine at your provider's office so you can make the system work for you, not against you o e.g. do they prefer phone or emailcommunication? Who can you

talk to if your provider isn't available?

• Recognize that not all questions have answers; sometimes you have to "muddle through."

• Appreciate what the providers are doing to help and say thank you from time to time.

• Remember to recognize the difference between what you want and what your loved one wants - they might not always be the same. Being sensitive to this can reduce frustration all the way around!

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Summary of Session # 3 In this class, we learned the following information and skills: 1. How memory problems affect a person’s ability to communicate. 2. Different strategies for communicating with your loved one that will

decrease stress. 3. Different strategies for communicating more effectively with family

members from whom you need help. 4. Ways to communicate more effectively with health care providers. PREPARATION FOR SESSION #4: HOME PRACTICE

Before attending session #4 please try the following:

• Continue Relaxation Diary: Try to complete one entry every day. • Happiness Journal: Every day write down a gratitude reflection,

positive experience and kind deed. Bring this with you to our final class.

• Pleasant Activities Log: We encourage you to modify and update

your tracking sheet this week for the final review next week. • Behavioral Log: Please complete the behavioral log when your loved

one’s target behavior occurs. We understand it may be difficult to complete the log each time the behavior occurs, but please complete it as frequently as possible. Extra copies are in your packet.

We will talk about these home practices next week in class so please be sure to bring them with you!



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Relaxation Practice: Ocean Escape Introduction Today we are going to do another guided imagery exercise. This exercise will involve imagining your experience at the ocean, far away from the cares of everyday life. We are providing you with a wide range of options, as different people find different images or scenes relaxing. We hope this one will be helpful for you. Stress Rating Before Exercise 1 = Not at all stressed Now, please rate your stress 2 = Slightly stressed level from 3 = Moderately stressed 1 to 5. 4 = Very stressed 5 = Terribly stressed How would you rate your Stress level now? _________ Guided Imagery: Ocean Escape Imagine yourself on a white sandy beach, sitting or laying on the white velvety soft sand, the sun kissing your skin. Close your eyes, and take in a deep breath, holding it for a few moments... and then let go, relaxing as you do so. Allow a calm, relaxed feeling to settle over your body and mind. Let go of any unnecessary tension in your shoulders, arms and hands. As your shoulders and arms hang loosely by your sides, let all of the tension drain out through the tips of your fingers. Let the relaxation flow from your shoulders into the back of your neck as the tension dissolves and melts away, relaxing your neck and scalp, and also your face, including your mouth, tongue and jaw. Let the relaxation flow down the rest of your body... your chest... abdomen... and back. Feel all of the muscles of your body becoming loose and relaxed. Letting the relaxing feelings flow into your legs, ankles and feet. Just allow your entire body to become loose, heavy and relaxed.

IN YOUR MIND’S EYE, look around…, what do you see? Do you have an image clearly in your mind? Do you notice the vastness of the ocean stretching out as far as you can see? Perhaps you see a dolphin or whale swimming by…Now, inhale deeply smelling the fresh sea air. Feel the warmth of the sun, the cool breeze. How peaceful and relaxing it is... And now listen more closely to the sounds… especially the sound of the waves. Pay close attention to the sound of the waves and notice how soothing and relaxing the sound is…as you hear the waves roll in… and out again…in

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and out…the constant rhythm of the waves…the ebb and flow…and each time the waves flow in and out, you find yourself becoming more deeply relaxed…deeper and deeper…as your muscles go loose and limp…and the tranquility of this place surrounds you.

And now spend a few minutes doing whatever you would like. You may just want to lay out on the sand and soak up the sun, you may want to walk along the beach or even go for a swim…or perhaps you would like to do some fishing or go sailing…whatever you would like to do at the ocean is okay…but no matter what you do, just continue being aware of this relaxation…

When you are ready, count backwards from 3 to 1. When you get to 1, you’ll be alert, refreshed, and comfortable. You may open your eyes and return your awareness to the room you are in. Stress Rating After Exercise 1 = Not at all stressed Now, please rate your stress 2 = Slightly stressed level from 3 = Moderately stressed 1 to 5. 4 = Very stressed 5 = Terribly stressed How would you rate your Stress level now? _________ 1. Did your level of Stress change? 2. What was this experience like for you? 3. Can you think of a specific event when this technique might have been helpful during a stressful caregiving situation?

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Session #4:

What we will cover in Session #4:

1. Mindful Breathing

2. Review home practice from Session #3

3. Power of Positive Thinking

4. Forgiveness

5. Gratitude

6. Using your new skills

7. Relaxation Practice: Ocean Escape

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Practice Mindful Breathing • Take a deep slow breath in for at least 5 seconds • Feel your abdomen expand as you do this • Breathe out slowly, to a count of 5 or more • Breathe in again, making every breath slow and steady and exactly

like the one before it • When breathing out, concentrate on expelling all the air in your lungs

and keep it going as long as you can • Stay relaxed for a few seconds before you inhale again

Review Home Practice

Discussion about the home practice • Relaxation Diary • Happiness Journal • Pleasant Activities Log • Behavioral Log

The Power of Positive Thinking

“Positive Thinking” sounds very fluffy and new agey doesn’t it? Yet, there is a very large body of research that shows that positive thinking has an impact on the things that affect your life - like your health and enhancing your ability to build new skills. When your body experiences a negative emotion like fear, anger, or overwhelming stress, the brain shuts down and tightly focuses on that emotion. Your brain defers to its survival instinct

and you stop seeing many options or choices. Let’s look at an example:

For Barbara, her negative emotions prevent her brain from seeking other options and choices. Her brain has shut down to focus on her stress. Why? The brain doesn’t worry about the future when faced with an immediate threat.

Barbara keeps a list of everything she needs to get done. Every day the list seems to get longer and longer. Every morning when she looks at her list she feels stressed and overwhelmed. She finds herself paralyzed, finding it hard to start working on the items on her list. Her list has gotten so long that she is certain there is no way she will get it all done.

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How does positive thinking change the brain? There is some interesting research that shows that positive thinking broadens your sense of possibility and opens your mind up to more options. This broadening of possibilities strengthens your ability to build skills and develop resources. The skills you learn last much longer than the positive emotions and can have a large impact on your life.

Reflection So how do you increase positive thinking in your life? There are three

proven ways: writing, pleasant activities & meditation. For those of you that brought your Happiness

Journal, pull it out. What have you noticed since you started the journaling? Do you find yourself struggling to find positive experiences? How does it make you feel to look back over the many positive experiences you have collected over the last three weeks? Journaling about positive experiences has shown to result in better mood and health for months after the journaling experience.

What about the addition of Pleasant Activities in your life? What have you noticed over the past three weeks? Are you carving out a little time to experience some contentment and joy in your day?

Over the past three weeks you have learned various way to meditate from a brief relaxation breathing exercise to a longer, guided mediation using visualization. Have you found a favorite style you come back to time and time again? People who meditate daily experience more positive emotions then those that don’t. Those who mediate daily for three months display an increased purpose in life, an increase in social support, more mindfulness, and less symptoms of illness.

We hope you’ll continue the daily practice of meditating, enjoying pleasant activities in your day and when the day has come to a close, spending a moment to capture a gratitude reflection, positive experience, and kind act you have experienced.

Forgiveness “Everyone says Forgiveness is a lovely idea. That is, until they have something to forgive.” – C. S. Lewis Why are we talking about Forgiveness?

Anger, frustration and resentment are common feelings that many caregivers experience. Add these emotions to the demanding and taxing

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role of caregiving and you can find an overwhelmed, stressed-out person. Caregiving is one of the hardest and most underappreciated jobs but it’s also one of the most important. Most of us are caring for someone we love. We try the best we can but sometimes our best isn’t good enough for the demanding disease of dementia. Forgiveness has been proven to reduce anxiety, depression and PTSD, increase energy and strengthen the immune system. Forgiveness also reduces physical health symptoms, reduces rates of mortality and offers relief from stress. As we know, stress over time wreaks havoc on our minds and bodies. Tips for Forgiving

Rule number one- forgiving doesn’t mean forgetting or even reconciliation. Forgiveness is not going to bring you justice and on the contrary, the act of forgiving someone can feel extremely unfair since you are the one that feels betrayed or hurt. Forgiveness is a gift to ourselves. Forgiveness is a skill and can take years to master. Some people are naturally more forgiving than others. The good news is that even if forgiving is hard for you, studies have shown that the time spent trying to forgive someone will also reduce levels of depression and anxiety. Let’s talk about a few people that may need to be forgiven: Yourself. As a caregiver, it is common to feel guilty. We may not be able to provide everything that our loved one needs, we may lose our temper with our loved one, or we may find ourselves feeling bitterness and resentment towards the person we are caring for. Guilt is a heavy burden to carry. We must remember that we are human and can only do so much. Even the best caregiver will have a bad day. Coming to this realization will not only help you as a caregiver but it will also help your loved one. Your loved one with dementia. People with dementia can say and do things that hurt us. It is very hard for a caregiver, whether a spouse or adult child to experience these behaviors. Try to separate the person from the dementia and know that you can hate the dementia but not the person. Your family. Many caregivers are on this journey alone, even if they do have siblings. A lack of support from siblings causes anger and resentment. If after you have asked your siblings for help and you are still going at this alone, try to forgive your sibling(s) for their inability to assist in caring for your loved one. View their lack of support as a weakness or limitation.

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Forgiveness is a decision that you have the power to make. Making the decision to let go of past hurts is a daring effort that will enable you to provide better care for your loved one. Your anger, frustration and resentment will no longer own you and you will see positive health benefits including a reduction in depression, anxiety, and stress. Forgiveness is a skill that needs to be practiced. There is an old saying, “Carrying resentment is like drinking poison and expecting the other person to die.”

Gratitude Why focus on gratitude?

We know from earlier classes that gratitude can positively impact a person’s well-being. When tuned in to gratitude, people experience less frequent negative emotions and feel positive emotions more often.

But what is gratitude? Gratitude is an appreciation for the things that you receive, whether physical or nonphysical. With gratitude, you acknowledge the good things in your life. Because you recognize that the source of the good comes from things that are often outside yourself, gratitude helps you connect to something larger than your individual experience. Gratitude can take many forms. For example, gratitude can be applied to the past (recalling positive experiences and being thankful for elements of your childhood) or the future (optimism that good things will arrive and touch you in the future). Regardless of your current level of gratitude or where you direct it, gratitude is a quality that can always be cultivated and elevated further to bring you joy.

One theory of positive psychology states that people’s daily experiences of positive emotions build up their arsenal of personal resources. This goes back to the concept of emotional resilience we introduced in Session One. So, by becoming aware of gratitude, which leads to the experience of positive emotions, you are building up your reserve of emotional strength and resilience. How do I start to practice gratitude?

In our busy daily lives, it’s easy to overlook the things for which we are grateful. Since the concept of gratitude may feel foreign at first, let’s start with a lighthearted exercise to get into the “gratitude mindset.”

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Using your Skills

Skills that can make life GREAT!

Gratitude Fo Rgiveness Empathy Attitude Positive Thinking Gratitude Gratitude is an appreciation for the things that you receive, whether physical or nonphysical. With gratitude, you acknowledge the good things in your life. Because you recognize that the source of the good comes from things that are often outside yourself, gratitude helps you connect to something larger than your individual experience. Remember to keep journaling things you are grateful for each day. On the tough days look back and remind yourself that for as much as you give, you also receive. FoRgiveness Forgiveness is a gift to ourself. Forgiveness is a decision that you have the power to make. Making the decision to let go of past hurts is a daring effort that will enable you to provide better care for your loved one. Your anger, frustration and resentment will no longer own you and you will see positive health benefits including a reduction in depression, anxiety, and stress. Empathy Empathy is the ability for someone to figuratively put themselves in the shoes of another so they can feel what that person is feeling. Empathy is about understanding and accepting without judgement. When receiving empathy, the person feels understood, accepted, important, and above all, connected to another person. Empathy is a skill we need to practice day in

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and day out. Use empathy as the foundation for compassionate communication both with your loved one and with your family members. Attitude To keep a positive attitude, you must keep an active interest in life. Keep on learning about the world, the people, and things outside of yourself. Get in the habit of looking forward to each day, wondering what new adventure will come your way. Use your Pleasant Activity Log to monitor your experiences - remember your goal is 4 pleasant activities a day that you deliberately choose to add to your day. Positive Thinking Positive thinking broadens your sense of possibility and opens your mind up to more options. This broadening of possibilities strengthens your ability to build skills and develop resources. The skills you learn last much longer than the positive emotions and can have a large impact on your life. When things feel overwhelming use your mindful breathing in the moment to give yourself a chance to calm down and find your balance. Everyday take a few moments for yourself and practice one of the relaxations technique shared with you during this workshop. Keep journaling! Write down a positive experience and kind deed each day. Reviewing these experiences can help you to stay positive.

Over the past four weeks we’ve shared many skills that can

help you. Strengthening the ability to take for yourself is vital to caregiving. Many of the skills we shared do just that - help you to care for you. Who do you call for help at no cost?? Alzheimer’s Association 24-hour helpline: 1-800-272-3900.

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Home Practice Session #1 ü Relaxation Diary ü Happiness Journal ü Pleasant Activities Log ü Bring in a challenging behavior

Session #2 ü Relaxation Diary ü Happiness Journal ü Pleasant Activities Log ü Behavioral Log

Session #3 ü Relaxation Diary ü Happiness Journal ü Pleasant Activities Log ü Behavioral Log

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Home Practice Session #1



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Stress Rating Before Exercise 1 = Not at all stressed Now, please rate your stress 2 = Slightly stressed level from 3 = Moderately stressed 1 to 5. 4 = Very stressed 5 = Terribly stressed How would you rate your Stress level now? _________ Instructions for Mindful Breathing

• Take a deep slow breath in and out for at least 5 seconds • Feel your abdomen expand as you do this • Breath out slowly, to a count of 5 or more • Breath in again, make every breath slow and steady and exactly the

same as the one before it • When breathing out, concentrate on expelling all the air in your lungs and

keep it going as long as you can • Stay relaxed for a few second before you inhale again Stress Rating Before Exercise 1 = Not at all stressed Now, please rate your stress 2 = Slightly stressed level from 3 = Moderately stressed 1 to 5. 4 = Very stressed 5 = Terribly stressed How would you rate your Stress level now? _________ 1. Did your level of Stress change? 2. What was this experience like for you? 3. Can you think of a specific event when this technique might have been helpful during a stressful caregiving situation?

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Happiness Journal Gratitude:

Kind Act:

Positive Experience:

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Gratitude:

Kind Act:


67

Hom


69


Behavior Log Please use this log to write down the one of the stressful things your relative does that upset you.

Date Day Time

Strategy

Current

What happened?

Proposed

What could you do

different?

Result

What changed?

BEFORE DURING AFTER

71




DATE









1 5

3 2 4


72





1 5

3 2 4


1 5

3 2 4


73


Happiness Journal Gratitude:

Kind Act:


Gratitude:

Kind Act:


Gratitude:

Kind Act:


74

Gratitude:

Kind Act:


Gratitude:

Kind Act:


Gratitude:

Kind Act:


Gratitude:

Kind Act:


75

Hom


77


Behavior Log Please use this log to write down the one of the stressful things your relative does that upset you.

Date Day Time

Strategy

Current

What happened?

Proposed

What could you do

different?

Result

What changed?

BEFORE DURING AFTER

79

Appendix The following can either be downloaded or ordered from National Institute of Health at: https://order.nia.nih.gov/ Tip Sheets for Stress Stress Management Using Self-Help Techniques for Dealing with Stress https://www.helpguide.org/articles/stress/stress-management.htm Tip Sheets for Staying Active NIH Participating in Activities you enjoy https://order.nia.nih.gov/publication/participating-in-activities-you-enjoymore-than-just-fun-and-games NIH Managing Personality and Behavior Changes https://www.nia.nih.gov/health/managing-personality-and-behaviorchanges-alzheimers NIH Adapting Activities for People with Alzheimer's Disease https://www.nia.nih.gov/health/adapting-activities-people-alzheimersdisease Tips Sheet for Communicating NIH Helping Family and Friend understand Alzheimer’s Disease https://www.nia.nih.gov/health/helping-family-and-friends-understandalzheimers-disease NIH A guide for older people, Talking with your doctor https://order.nia.nih.gov/publication/talking-with-your-doctor-a-guide-forolder-people Information on Dementia NIH Understanding Alzheimer's Disease: What You Need to Know https://order.nia.nih.gov/publication/understanding-alzheimers-diseasewhat-you-need-to-know NIH AD Fact Sheet https://order.nia.nih.gov/publication/alzheimers-disease-fact-sheet NIH Caring for a Person with Alzheimer's Disease: Your Easy-to-Use Guide https://order.nia.nih.gov/publication/caring-for-a-person-with-alzheimersdisease-your-easy-to-use-guide

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