[Session 2: version 2]

START Strategies for Relatives

Session 5:

Communication

Facilitator Version

Numbers in blue boxes let you know how long each section should take.

Information in yellow boxes give instructions on how to facilitate tasks, as well as prompts for feedback and discussion.

Quotations in orange boxes are phrases you should say directly.

Facilitator Key

Copyright 2018 Gill Livingston and Penny Rapaport. Licensed under CC BY-NC-ND 4.0 For permission requests, write to the publisher addressed “Attention: Permissions Coordinator” at the address below: UCL Division of Psychiatry 6/F Maple House 149 Tottenham Court road London W1T 7NF United Kingdom

This manual was adapted from original (Dolores Gallagher-Thompson and colleagues, Stanford

University School of Medicine, 2002) by University College London Division of Psychiatry in 2008, with

kind permission of the author. This is the revised second edition of the manual, created in 2018.

Session 5 2nd Edition 3

Plan for today’s session

Recap on behaviour strategies and unhelpful thoughts

p. 4

How to express yourself effectively

p. 5

Practicing assertiveness skills

p. 10

Communicating with someone with memory problems

p. 12

Stress reduction: Meditation

p. 15

Summary

p. 18

“This is the contents page for you to refer back

to”

Refer to the contents but do not read the full list

For each session:

Encourage the carer to write down what works or key strategies or plans to refer back to.

If content is clearly irrelevant or does not fit, miss it out.

When setting exercises at the end, check that they remember what is in the plan if not explicitly covered in the content.

Session 5 2nd Edition 4

Recap on session 4: Behaviour strategies and unhelpful thoughts

We talked about:

Choosing a new behaviour to change

Changing unhelpful thoughts

Managing stress 4: Guided imagery – meadow and stream

Did you have a chance to complete the thought and the behaviour

record?

How did it go?

What went well?

Did you notice any patterns?

What do you think got in the way?

What would make it easier in the

future?

5mins

Discuss their experience completing the Thought Record.

If they have completed one or both:

o Look at the thought record, how did they find completing it, did they notice

any changes in their thoughts and feelings, how did this affect what they

did?

o Look at the strategies they were trying out to prevent the problem behaviour

from occurring or reduce the behaviour and ask them how this went.

If they did not complete it, help the carer to complete it now. Ask them to think back on the

week:

o Problem-solve any difficulties that might have occurred e.g. :

- “There was no time to record in the log. I was too busy.”

- “I didn’t understand what I was supposed to do.”

- “I found it difficult to identify my thoughts.”

Identify with them a recent situation where they had unhelpful thoughts and write it in,

working through the example and discussing potential alternative thoughts.

Encourage continued practice using the thought and behaviour records.

Session 5 2nd Edition 5

How to express yourself effectively

We all communicate in different ways. Today, we are going to talk about three

styles of communicating which we use at different times or in different situations.

We will call these:

20mins

Passive Communication

Aggressive Communication

Assertive Communication

Session 5 2nd Edition 6

Passive communication avoids conflict and arguments. It leaves people feeling

upset and unsupported and involves putting other peoples’ needs above your

own. It can send the message:

How might you feel after this kind of experience? What might be the effect?

Emphasise that this is the message other people get

from this kind of communication.

Example: Passive communication

Sabrina takes care of her husband, who has memory problems. She has arranged for her husband to stay with her brother, Daniel, while she attends a weekly exercise class. An hour before the class, Daniel calls to say that he has changed his mind and doesn’t want to take care of her husband after all. Sabrina responds by saying, “That’s okay, I really didn’t need to go after all.”

“In summary, passive communication can involve:

Talking indirectly and apologetically, allowing others to easily ignore you.

Hiding your own feelings.

Putting other peoples’ needs above your own.

Pleasing others and avoiding conflict at any cost”.

Session 5 2nd Edition 7

Aggressive communication leads to conflict and anger. It can send the message:

How might Daniel react?

How might you feel after this kind of experience?

What might be the effect?

Example: aggressive communication

Sabrina responds to Daniel’s decision not to take care of her husband by saying, “I’m sick and tired of you not thinking of me. You promised to take care of him, and I’m going to hold you to that promise whether you like it or not!”

“In summary, aggressive communication can involve:

Standing up for yourself and expressing thoughts in an unhelpful way.

Getting angry or verbally attacking.

Ignoring other peoples’ point of view.

Trying to force the other person to agree with you.”

Session 5 2nd Edition 8

Assertive communication leads to problem solving and working together. It

can send the message:

How is this different from the previous examples?

What might the effect be on the situation?

Can you think of anything else that might have helped in this situation?

Example: assertive communication

Sabrina responds to Daniel’s statement that he doesn’t want to take care of her husband by saying, “It’s important that I get a break. I know you’re busy, but can you find time to give me a break even if it’s not today.”

“In summary, assertive communication can involve:

Expressing your own opinions whilst respecting the views of others.

Expressing your thoughts directly and honestly.

Problem solving and negotiation.

Making your requests more clear to others.” “What do you think is the most useful style of communication?”

“This is what I think, this is what I feel. This is

how I see the situation. Your thoughts and

feelings are also important”.

Session 5 2nd Edition 9

How do you communicate?

1. How do you communicate with doctors and health care professionals?

2. What about in situations with family members or friends? Or

when asking for help? 3. What about with the person you care for with Dementia? 4. How would you like to change your communication pattern in any of

these situations?

“Now we are going to think together about the different ways that you communicate, this will be different depending on who you are talking to, when you are talking to them and what you are talking about”

“For example with with family, friends, health care professionals, or the person you look after with Dementia”.

Session 5 2nd Edition 10

Now we are going to talk about asking for help. Think of a recent situation

where you asked for help with your relative and things didn’t go as you hoped.

Tips for assertive communication

1. Think about what you want or need

2. Briefly work out exactly what the problem is

3. Try to describe your thoughts and feelings clearly

4. Give detailed information about what you need. Be specific! E.g. Taking care of Mum for two hours involves feeding her a snack, turning the radio to her favourite station, and taking her to the toilet

5. Be persistent and flexible: Maybe you won’t get exactly what you asked for, but you will get something that will be helpful

6. Break it down into smaller parts or ask for things one at a time – it’s usually easier for people to say yes to a small request than to a big one!

7. If you feel stuck – agree to think about it and talk again

8. Recognise that sometimes there isn’t a solution

9. Remember that what you want and what the person you care for wants might not always be the same

DON’T GIVE UP! It may take many attempts before things change

“Try to be aware of how to be effective and assertive in your approach. Here are some tips to consider before we practice together” Talk through the tips ”

“Now let’s practice these skills. Tell me about a specific situation related to getting support for your relative, be specific”. Follow instructions for role play on the next page.

Session 5 2nd Edition 11

How did you find practicing assertive communication? What went well and what

techniques would you use again?

Role play exercise:

Before this session, think of an example the carer has told you about that would be a good example for this exercise.

Ask the carer to think of a specific situation relating to getting support for their relative and get them to simply describe the scene. Be very specific!

Explain that you will take the role of the person the carer is negotiating with.

Encourage them to be assertive. Try prompting e.g. “If you were to ask ‘x’ for help, what would you say?”

If carers do not have an example, use this alternative role play:

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

After practicing the role play, encourage them to reflect on

how it went.

Discuss whether they found it difficult to communicate

assertively? What are the barriers to this in real life?

Session 5 2nd Edition 12

Communicating with a person with memory problems

Communicating with someone with memory problems can be challenging. You may now or in the future, feel as if you have to jump over many hurdles.

When we feel frustrated or rushed it can be even harder to communicate clearly.

You may know some of the following already, or it may be new information. Memory problems can affect people’s ability to:

o Understand what they see and hear.

o Remember what they wanted to say.

o Find the right words.

o Concentrate or pay attention to what is being said.

o Understand what was said

How could Gloria have done things differently?

Because people with memory problems

often cannot overcome their difficulties in

communicating, we need to find ways to

communicate with them.

Example

Gloria wants her husband John to come outside with her. He is watching television. She shouts from another room to turn off the television so they can get ready. He ignores her. She shouts louder for him to turn off the television and get ready to go out. John continues to ignore her. Gloria is feeling so stressed she begins to cry.

Encourage them to think of possible strategies and what has worked for them in the past

Session 5 2nd Edition 13

Tips for communicating with people with memory problems

Listening to and understanding

Try to listen carefully to what your relative is saying and gently encourage them.

If they find it difficult to express themselves, allow plenty of time.

If you have had to guess what they mean, check that you have understood correctly.

If you feel yourself becoming frustrated or irritated, change the subject or talk about it later.

Remember that some people with memory problems won’t be able to answer questions but

may show you what they want by their reaction.

Getting someone’s attention

Try to catch your relative’s attention before beginning to speak to them.

Position yourself so that they can see you clearly and make eye contact.

Smiling and gently touching your relative may help you to attract their attention.

Always check that people have glasses or hearing aids available.

Reduce distractions when talking, e.g. switch off or lead them away from the TV or radio.

Making yourself understood

Sit closely, ensure that background noise is minimal and that lighting is good.

Speak clearly, slowly and calmly.

Try counting to ten in your mind after asking a question, to allow people time to answer.

Use short sentences.

Try to ask only simple questions, one at a time, allowing for yes/no answers.

If they have to make a choice eg menu, ask them to choose from two and then narrow it

further eg meat or fish – then salmon or haddock

If they do not understand: try a different way, using actions, objects, signs or pictures.

You may have to try different communication strategies and see

what works for you and your relative. You may also have to

change again over time.

“Here is a list of tips for good communication, this includes some of the suggestions you have

already and will include strategies that you are already using. This list is just a reminder which

might be useful particularly if communication with your relative is difficult”

Session 5 2nd Edition 14

What changes have you noticed in your relative’s ability to understand and express themselves?

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

Which of these tips do you already use?

Which of these tips do you think you will start using?

Communication record

Here is a way to record how you communicate with your relative or others, remember to write down what has worked well as well as any difficulties.

Situation

What I said or did?

How did it turn out?

How did I feel?

Session 5 2nd Edition 15

Managing Stress 5: Meditation

Meditation is a stress reduction technique that involves combining pleasant imagery whilst noticing various physical sensations.

Visualizing yourself in a relaxing scene (e.g. a beach, forest, etc...) helps you to become less tense and focus better.

Focusing on pleasant images will make it easier for you to notice the relaxing physical sensations that I am going to repeat to you.

The more you practice, the more useful it will be.

Stress Rating Before Exercise

First, please rate your level of stress or tension right now, before we practice the

Meditation exercise.

On a scale of 1 to 5, how would you rate your tension? _____

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

“Now I am going to talk you through the meditation exercise…”

10mins

“Now we are going to try a new stress reduction

technique, last week we learnt the guided imagery –

meadow and stream exercise. This week we will

practise meditation.

First, let’s think about the guided imagery- meadow

and stream exercise. Did you get a chance to try it

out this week?

If you gave it a go, how did you find it? When did you

use it? What effect did it have on how you felt?

If you did not get a chance to try it, what got in the

way?

Please try and carry on practicing the guided

imagery- meadow and stream exercise.”

Session 5 2nd Edition 16

Meditation: Practice Session

“Let’s begin... Settle comfortably in your chair and take in a deep, cleansing breath...

When you are ready, close your eyes and feel yourself becoming more and more relaxed with every breath...

Continue to breathe normally, as you picture yourself in a relaxing setting... You may be at the beach, or in a forest, or wherever you feel comfortable and at ease...

Take a moment to notice the details around you in this peaceful place and notice that you are becoming more and more relaxed...

Once you feel at ease in your special place, think to yourself, ‘I am at peace... My right arm is heavy... My left arm is heavy...’

Now continue on your own, noticing your calm breathing and heartbeat, and the heavy, warm sensation in your arms and legs...

‘I am at peace... My arms and legs are heavy and warm, my heartbeat is regular and calm... My breathing is calm... My breathing is calm... My abdomen is warm... I am at peace... My abdomen is warm... My abdomen is warm... I am at peace... My arms and legs are heavy and warm... my heartbeat is calm and regular... My breathing is calm... My abdomen is warm... My abdomen is warm...’

Now, continue to notice the heaviness and warmth in your legs, and your calm and regular heartbeat and breathing and the warmth of your abdomen...

‘I am at peace... My arms and legs are heavy and warm... my heartbeat is calm and regular... My breathing is calm... My breathing is calm... My abdomen is warm... My forehead is cool... My forehead is cool... I am at peace... My forehead is cool... My forehead is cool... I am at peace...’

Now, continue to notice the sensations you feel throughout your body as you relax in your peaceful place...

Now, I am going to count from 3 to 1, and as I do, you will open your eyes and become more alert and aware of your surroundings... By the time I say 1, your eyes will be completely open, and you will feel alert, refreshed, and relaxed...

Here we go... Three... two... one... Your eyes are open and you are awake, alert, relaxed and aware of your surroundings...”

Session 5 2nd Edition 17

Tension Rating After Exercise

How would you rate your tension level now, after practicing the mediation

exercise?

Q! Now, please rate your tension or stress level from 1 to 5 _____

Encourage carers to practice the meditation at least twice this week. Check that they have been able to make use of the CD or MP3 files.

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

Discuss: • Did your level of tension change? • What was this experience like for you? • Can you think of specific times when this might have helped?

Session 5 2nd Edition 18

Summary

Today, we have talked about:

Different communication styles

Passive, aggressive and assertive communication

Communicating with a person with memory problems

Stress reduction technique: Meditation

“Thinking about what we have

discussed, is there any

information from today’s

session that you would want

to share with someone else

(e.g. a family member, a

friend or a neighbour) ”.

Session 5 2nd Edition 19

FOR NEXT WEEK: Putting it into practice

Stress reduction - Meditation:

Try to practice this at least once a day and notice how it feels.

Communication record:

Try to complete the communication record on page 20 for three separate

situations over the next week, remember to notice any patterns in your

communication and what strategies work well as well as any difficulties

you face.

Planning for the future:

Please read over the material for next week. It will help you to use this

important information. Feel free to invite another family member who is

helping you care to come to the session.

Optional exercises:

Please continue to use the behaviour and thought records if this is

something that you have found useful in previous weeks.

START: Putting it into Practice

When will you have an opportunity to do this?

What might get in the way?

What might make it easier?

Provide the carer with the CHOICE leaflet.

Session 5 2nd Edition 20

Communication Record

Please use this sheet to write down how you communicate both verbally and nonverbally with your relative or others this week.

Situation

What I said or did?

How did it turn out?

How did I feel?

“Write down a specific situation, how you communicate, how it turned out and what your feelings were. Try and do this at least three times…”

Session 5 2nd Edition 21

Extra Communication Record

Situation

What I said or did?

How did it turn out?

How did I feel?

Session 5 2nd Edition 22

Thought Record

What was

happening?

What were you

thinking?

How did you feel?

An alternative

response would be…

How do you feel

now?

Session 5 2nd Edition 23

Extra Thought Record

What was

happening?

What were you

thinking?

How did you feel?

An alternative

response would be…

How do you feel

now?

Session 5 2nd Edition 24

Behaviour Record Please use these pages to write down the things your relative does (or that you do) and the strategies that you try out.

Day Morning/Afternoon/

Night

Who was

there?

Trigger Behaviour Reaction What strategy did you

try?

What happened?

Session 5 2nd Edition 25

Extra Behaviour Record

Day Morning/Afternoon/

Night

Who was

there?

Trigger Behaviour Reaction What strategy did you

try?

What happened?

Session 5 2nd Edition 26

Notes

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