Navigating The Challenges Of Caregiving: Selected Resources

This list features some of the resources families I work with have found useful. It is no means meant to be comprehensive, but should provide a good starting point for Virginia families who are taking on the role as caregivers for one or both of their parents.

Virginia Caregiver Coalition –

The premier grassroots advocacy group for family caregivers in Virginia. Membership provides education, access to resources and a voice in legislation to support your care-giving efforts. Membership is free.

No Wrong Door –

Network of resources of long-term supports and services for seniors and people with disabilities. One phone call connects you with a “concierge” who listens to your needs and directs you to services that can help.

Senior Navigator –

A must-see website that includes good information on a variety of aging issues. The sections of “Family Conversations” and “Family Dynamics” can be particularly helpful as your journey caring for your parents begins.

Department of Aging and Rehabilitative Services –

The Office for Aging Services of the Division for Community Living helps older Virginians live as independently as possible by coordinating and providing services to help them maintain their dignity and security. Our website provides information that aging Virginians, caregivers and their families can use in making important decisions about their lives and the lives of their loved ones.

Leading Age – Virginia –

An association of not-for-profit aging services organizations serving residents and clients through life plan/continuing care retirement communities, senior housing, assisted living, nursing homes, adult day centers and home and community based services

Department of Social Services –

The Virginia Department of Social Services develops and administers programs that provide timely and accurate income support benefits and employment services to families and individuals in the Commonwealth. Look under “Assistance” for adult programs.

Area Agency on Aging –

25 local area agencies on aging (AAA’s) are spread across Virginia to bring support and resources closer to home. Find yours and connect with them today.

Family Caregiver Alliance –

Based in California with Chapters nationwide. FCA’s work intersects three key areas: caregiver services, policy, and research.

Benefit Finder | – is an online resource to help you find federal benefits you may be eligible for in the United States.

Virginia Insurance Counseling & Assistance Program (VICAP)

Part of a national network of programs that offers FREE, unbiased, confidential counseling and assistance for people with Medicare

Virginia Health Information –

Useful resource with information on health insurance, hospitals and physicians.

Everything Aging from news and lifestyle to advice and discounts.

National Council On Aging –
Helps people aged 60+ meet the challenges of aging. They partner with nonprofit organizations, government, and business to provide innovative community programs and services, online help, and advocacy.

Good Article from US News & World Report on Parenting Parents –

How To Rewrite The Bad Stories You Tell Yourself

Chris Nufer, a late-life depression therapist and family counselor in Virgina, discusses how an increasingly popular form of therapy takes special advantage of our natural tendency to organize how we live using stories.

When people have problems, Narrative Therapy simply asks you to tell a story about your problem. Sounds easy. Stories are how we live. They pour out of us almost without thinking. Just listen to someone who has been pulled over by the police or a student who was late for an exam.

The narrative therapist’s job is to listen to a client’s story, explore what the client has said and in the process help find the internal or external resources necessary to overcome the obstacles they face.

One way to do this is to help clients externalize their problems. This occurs when the therapist helps the clients describe a problem as though it were a character or event in their lives. Once this story has been told, the therapist and client take the opportunity to question certain plot twists, options and outcomes. In the process, the therapist helps clients work with their story lines to rewrite the causes and the outcomes of their problems.

When I’m with a client, I’m listening to the story but, because of my REBT training, I’m listening for clues about how rigid or resilient they are. I’m asking them to flesh out their thinking about a problem in a way they wouldn’t normally. I’m actively challenging them to imagine possibilities and not to think the stories they are telling themselves are written in stone.

The final component of the narrative therapy engagement is the story the therapist writes back to the clients. This is the part I love about this approach. Michael White and David Epston, the fathers of the current person-centered approach to narrative therapy, established the need to document the engagement—much the way a story documents or at least represents events, emotions or personal actions in our lives. For White and Epston, documentation takes the form of a letter. It is in these letters that the real magic of this therapeutic approach takes place.

The final letter may be the story of the mistakes they discovered together and also about the progress they made. It may tell the story of decisions the client may be thinking about making or things they feel are missing in their lives. Whatever the plot twists, the letter is a story about them. And, more than that, it is also a story about them finding the tools and the confidence to get their story straight.

The 90 Second Rule

When you are working with clients who have anger issues, you may want to consider teaching him or her “The 90-Second Rule.” Our emotions come into our body and are interpreted in the brain. We think we feel them in the brain, but the emotions are actually feelings in the body. When an intense emotion such as anger comes into the body, it will be funneled straight to the adrenal glands. Then adrenaline is sent to the brain through vagus nerve. It goes to the amygdala which is the switching station in the lymbic system. The amygdala interprets the message as anger. This message is sent to the hypothalamus (the hypothalamus is the emotional regulator) which then floods the brain with cortisol. When the brain is flooded with the anger message we received from the body, we experience the anger. This is the course of anger that allows us to say sometimes, “I’m so angry I could burst.”   No matter what the cause of that anger, the process between the adrenalin gland, the spinal cord, the amygdala and the hypothalamus and then the constant anger surging through the body, will only last 90 seconds unless you continue to feed the anger.
So what does that mean? The amazing thing is that if you stop this chemical process, the anger will stop. The key is, don’t feed the anger. An example would be when one is driving and somebody cuts him or her off. Our driver had the right of way but almost hit the other car. Just barely missing it. The other driver drove on probably not even knowing that he almost hit the person in our example. But for the next half an hour our driver is saying to him/herself, “That stupid so and so, I wish he were here so I could give him a piece of my mind.”   As long as the driver keeps this message going, it keeps the anger going. It feeds the emotion. The cortisol keeps flooding the brain and repeatedly triggering more anger and stress. The other guy is down the road oblivious to what almost happened. Our driver is ruining his/her day over something the other driver probably didn’t know anything about.

Get your clients to learn a new behavior which is to say to him/herself, “That was a stupid thing he did and it pissed me off but there’s nothing I can do about it now.” Then the person in our example isn’t feeding the anger and in 90 seconds it will naturally dissipate. In time the client will learn to catch themselves before they feed the anger beyond its original 90 second life

The 90-Second Rule is a very interesting piece of neurology that is important to the work that we do treating DID. Almost all people with DID have angry “parts”. With this understanding, you can teach the angry parts to wait ninety seconds and they will generally stabilize. If you don’t feed the anger, then the chemical reaction that’s been kicked off in the brain will simply peter out and you will no longer be experiencing angry. I teach this technique to clients with angry parts and it is extremely effective in stabilizing them. Of course, most of the time, we are all inclined feed the chemical reaction over and over again. But the thing to remember is — you don’t have to.

Late-Life Depression: Triggered By Age…Or Ageism?

No one knows for certain what causes depression or what role it is meant to play in the evolution of humankind. Most current theories propose it is the result of the interaction of factors as varied as epigenetics, trauma, illness, stress, loss, guilt, regret, isolation, side effects from medications, and even hearing problems. We do know that many times depression is the result of external events, but just as often it is believed to be the result of internal factors such as negative self-talk or a generally pessimistic worldview.

It’s normal to feel sad when bad things happen. But when you can’t bounce back and the feelings of sadness, lethargy or anger begin to affect how you get along with friends and family, it becomes a real problem.

One tell-tale sign that you are depressed is that when time passes and the situation improves, you don’t feel better.

According to a 2015 study by the National Institute of Mental Health, 6.7 percent of American adults 18+ annually experience at least one episode of symptoms sufficient to warrant a diagnosis of Major Depressive Disorder. That figure is projected to be more than doubled for older adults. The founder of the Weill Cornell Institute of Geriatric Psychiatry, Dr. George Alexopoulos, predicts that 15 percent of the population over sixty-five will develop clinical depression and that more than two-thirds of those will remain undiagnosed and untreated. The thing to remember is that depression is one form of mental illness that can be fatal because it may lead to suicide, especially among seniors. According to the New York Times (8/7/13), elderly white men have the highest rate of suicide with 29 per 100,000 over all, and more than 47 per 100,000 among those over age 85. Dr. Martha Bruce, PhD, also of Weill Cornell, says this alarming figure is “partly a result of so much stigma about mental illness and partly a result of ageism.”

Ageism is only now being recognized as a significant contributing factor in late-life depression. One reason for this new awareness of age discrimination may be that the Baby Boomers who created our youth-obsessed culture are now entering their sixties and surprised to find traditional assumptions about old age at odds with their values and lifestyles.  Ageism remains the last socially accepted form of prejudice. Older adults continue to be portrayed as frail, inflexible, and a burden on society. These attitudes are instilled in us when we are young and are further reinforced by the media and society as we grow. What’s even worse is that we tend to internalize these socially constructed biases without questioning them.

Studies have shown a definite link between age discrimination and depression.  If you believe the stereotypes, the instant you turn 65 you are suddenly “old and in the way.” These unfounded characterizations have a corrosive effect on our self-esteem and tend to make us withdraw from activities that are not “age-appropriate.” If you add this sense of marginalization to the loss of identity, loss of youth, loss of career, loss of independence, and loss of friends or loved ones you experience as you age, you have a surefire recipe for depression. In fact, loneliness, and the depression it causes, have been cited in a recent study by the Alzheimer’s Association (2015) as a major factor in cognitive decline.

There are several reasons why depression in older adults often goes untreated. The state of the medical profession is one. There is a severe shortage of doctors trained in geriatric medicine, especially in psychiatry. General practitioners rarely take the time to screen for depression or anxiety during routine check-ups. If an older person complains of feeling down or not enjoying life, the doctor is likely to say something like, “Well at your age, what do you expect?”  If your doctors pass off your symptoms as a function of age, call them on it. Depression is not a normal part of aging. And hopefully in the near future ageism won’t be either.

This article originally appeared in the Charlottesville Daily Progress on September 14, 2017

Mindfulness Training: A Proven Brain Changer

As I was researching material for an upcoming workshop, I came across an article by Dr. Frank Sommers who is the author of “Lose Weight, Stop Stress and Make Better Love” ( / Caversham Booksellers). The article appears in The Sexual and Relationship Therapy Journal’s special edition on Mindfulness (ed. By L. Brotto and M. Barker).  In the abstract for the piece, Dr. Sommers says, “Increasing evidence is accumulating on the real benefits of mindfulness training. It is also emerging as a core, effective component of modern sex therapy practice.” He notes that neuro-endocrine and neuro-imagery studies he’s observed provide evidence that a treatment called Visually Enhanced Psycho-Sexual Therapy is effective in treating sexual dysfunctions in a number of cases. He discusses applying two basic mindfulness principles, which he terms, “Present Centered” and “Process Absorbed,” as a way of “training the autonomic nervous system, and the integrative and sensory components of the central nervous system.”  He sums up by saying that the “graduates” of his 10–15 session practice program “learn to become mindful not only in their loving and love-making behavior, but also generalize this way of being in the world in their daily lives.”

Dr. Sommers’ findings echo what many therapists I talk to are discovering: that using mindfulness techniques in tandem with evidence-based therapies such as CBT and REBT in treating sexual dysfunction not only changes behavior but actually alters brain structure and chemistry in a way that makes those changes more lasting. When you become more mindful about the sources of your pleasure, it encourages the brain to set up a positive feedback mechanism that motivates us to recreate that pleasure we’re feeling now in the future. As a result of becoming more mindful of where our pleasures come from, we can almost assure a consistent increase in the amount of pleasure we will experience.  This pleasure, according to Dr. Sommers, will encourage our nervous systems to become more tuned to pleasant experiences and (one hopes) make us more resilient and resistant to negative thoughts and mood disorders.

How Resilient Are We?

A therapist working with older adults looks at how people react to loss and realizes that in the end most of us do a pretty good job of coping.

While providing crisis counseling to people who suffered significant losses in the aftermath of Hurricane Sandy, I began to wonder what the natural response is to losing someone (or something) we hold dear, especially among the older adults I work with.

First off, it’s well known that all of us face a mounting number of losses as we get older– Parents and friends pass away, careers end, bodies wear down, and our minds sometimes aren’t as sharp as they once were. How we respond to those losses varies depending on a number of factors.  A socially (and clinically) accepted response to a significant loss is profound sadness.  But how long that sadness lasts and how it affects the way we function on a daily basis reveals a lot.  First a few quick definitions: Bereavement is the state of having suffered a loss. Grief refers to how a person deals with loss. Mourning has to do with society’s rituals surrounding the loss, such as funerals and burial rites.

The Handbook of Assessment in Clinical Gerontology edited by Peter A. Lichtenberg, cites a longitudinal study by Zisook, Paulus, Shuchter and Judd of how prevalent depressive disorders are after the loss of a loved one.  The results showed that 20 percent of the participants met the criteria for major depressive disorder two months after the loss.  After 13 months, that figure fell to 12 percent. After 25 months, it dropped even further to only 6 percent.  At the same time, during all three periods, the study showed that nearly half the participants displayed no symptoms of depression, major or otherwise. These people coped.  They may have been very sad, but they processed the loss and moved on.

How did they do it?  My guess is that they had positive social supports that gave them a time to grieve and at the same time signaled them when it was proper to stop grieving.  Furthermore, since having depressive symptoms or other problems prior to a traumatic loss is a prime indicator of whether or not a person will become depressed when a loss occurs, it’s safe to assume the resilient ones were not prone to rumination, negative self-talk, or delusions that God was somehow punishing them. Studies have shown that in most cases half of us will bounce back from a significant loss after about two months, about a third of us will have trouble adjusting but eventually let the loss go, and the remaining 20 percent will continue to suffer for a while.  In the end, the number of people who have the most difficulty getting better is approximately equal to the number of people in the general population who are already at risk for mood disorders.

Bereavement is a normal reaction to loss.  Depression is not. Statistics show that in most cases paying attention to others, maintaining a healthy lifestyle, staying mentally active and keeping a positive outlook will provide the resiliency we need when we lose someone or something we hold dear.

In Defense Of Pleasure

As a therapist in New York working with older adults, it seems that just about every psychological issue has its roots in a lack of feeling safe, included or trusted. Generally people develop severe mental illness when accidents of heredity or persistent trauma are added to that equation. Sexual abuse can be the most crippling. Parental abandonment is right up there, too. Healing in traumatic situations like these requires much more than the “pain relief” pills provide. Instead, I believe it requires the proactive introduction of pleasure into the individual’s life. This pleasure is not just for fun. It is to attempt to see if pleasure can be learned and applied to the affairs of daily living. It is also an attempt to see if the endocrine system can reverse the physical damage caused by long-term stress or trauma.

What would happen if a program of treatment included increased human touch, along with social engagement, personal validation, and group activities instead of pharmacological interventions? Of course, there will always be those who require medication, but we should only provide pharmaceuticals when a caring environment and efforts of a healing community have failed. I want to see if having masseuses, therapists, sex surrogates, nutritionists and personal trainers working as something of a “personal crisis team” can help older adults improve their sense of well-being.

The reason I mention all this is that, too often, as people get older, their opportunities for pleasure diminish. Older adults deserve to feel good and that includes having physical intimacy with others or themselves. The fact that people who are uncomfortable with sexual activity–whether adult children, institutional caregivers or administrators–restrict older adults’ opportunity for privacy, intimacy and pleasurable activity is both ageist and contemptible.

As you can probably guess by now, I’m a big believer in talk therapy in general and the therapeutic value of human touch in particular. I won’t go into the research comparing the act of hugging favorably with drugs for reported relief from distress. But I believe we should treat pain and distress by finding ways to increase the amount of pleasure a person is experiencing rather than simply trying to reduce their pain.

Motivational Interviewing: It’s All About Creating Change

Motivational Interviewing is a directive counseling style that is all about creating change. It works on modifying clients’ behavior by helping them explore and resolve their ambivalence. Using empathy, encouraging self-motivation, and diffusing resistance, the counselor helps clients develop their coping skills. The goal is to enable people to realize the discrepancy between behavior that helps them meet their personal goals and behavior that doesn’t.  Motivation for change occurs “when people see the gap between where they are and where they want to be.”

The technique has become the therapy of choice for many addiction counselors and, when combined with education, harm-reduction approaches, social support and (occasionally) Cognitive Behavioral Therapy, it has been proven effective in many cases, especially in the area of relapse prevention.

Motivational Interviewing is based on Abraham Maslow’s Hierarchy of Needs and his concepts of “self-actualization” and “self-transcendence.” Maslow’s theory is that at the most basic level we need food, water, sex, sleep and oxygen.  After taking care of those needs, we turn our attention to finding shelter and safety.  When those needs are satisfied, we look to meet our social needs—things like love, belonging, friendship, and intimacy. After that, we are driven to satisfy our need to think well of ourselves and strive to build self-esteem, achieve things, gain courage and confidence, and obtain the respect of others.

Once you have secured these needs in your life, then you are in position to begin to think about reaching the “apex” which is self-actualization. Self Actualization is the state where your needs for order, creativity, problem solving, are met and you realize your fullest potential. Self-Actualization was the apex of the hierarchy. At least until Maslow added the need for “Self-Transcendence.” In the Self Transcendence area, your spiritual needs are met. These needs are beyond and outside the self and are usually concerned with feeling a part of you will live on after you’re gone. People in this stage are concerned with issues such as success of their offspring and leaving a legacy.

Maslow believed that society’s full focus should not be on creating people who can work and fight, but instead on creating people who are self-actualized.  If people have their needs met at that level, he reasoned, then everything else would take care of itself.

With Maslow’s theory in mind and Motivational Interviewing techniques in hand, the therapeutic possibilities outside addiction counseling are interesting. It helped one member of a couple I worked with recently understand why she was upset with her partner and how to create change when she was certain it was impossible.

For teenagers who feel forced into therapy by their parents, it is an effective tool for building a therapeutic alliance under difficult circumstances. I have also seen MI break therapeutic logjams in cognitive-behavioral treatment for depression and anxiety. I also encourage parents to acquaint themselves with Motivational Interviewing. It can come in handy when your teenager begins acting out or shutting you down.

For those who want more information,  “Eight Stages In Learning Motivational Interviewing,” an article by Miller and Moyers in the Journal of Teaching in the Addictions is a good resource. Also Monty Roberts’ instruction manual, “OASAS Training of New Trainers and Supervisors.”