First Do No Harm

Turn The Megaphone Around

An AudienceWorks White Paper – Jon Hardie   

Would you like a pdf of this document? Click: Download Turn the Megaphone Around

Alan Brown, of WolfBrown, in “What’s Real Value”, raised a series of interesting issues on value, evaluation, & accountability in their “On Our Minds” E-newsletter.

Woven deeply into our years of NPO management & consulting at AudienceWorks; it is our view, that sound, shared, evaluative data, is the nectar of good decisions, innovation, creativity, and transformation.

Good Data: defined as: timely, accurate, relevant, accessible, and complete, vs. fragmented databases and staff in multiple isolated silos, provides a foundation that will sustain broad institutional alignment, inform transparency, as well as nimble and agile responsiveness. It also sustains critical “institutional intentionality” - by building a shared core awareness, understanding, agreement, buy-in and ownership of your dynamic vision & mission.

So, we ask, why is this perspective so antithetical to the perception of many NPO’s and performing arts managers; who view evaluative data as “penance for getting a grant”; something you “glom onto” your grant app - after the fact - because you have to.

Our hunch is that many Arts & NPO Managers really don’t understand how to leverage evaluative data as a powerful asset; and consequently - don’t see its value. In much the same way that a patron doesn’t see value in the typical take-it-or-leave-it, fixed schedule subscription offer, from a push monologue, script driven, telemarketer - who interrupts dinner.

Take-it-or-leave-it value propositions, “If you want your series from a telemarketer or a grant from the foundation, then you must do “X”, are experienced as being shoved down recipient’s throats. Sadly, most of these propositions do not emerge from a conversation or relationship, they are not negotiable; and are very often passively-aggressively - and reluctantly - accepted. We find that they have less buy-in & ownership than the classic Attila the Hun proposition; “The beatings will continue until morale improves!”

A recent classic example of this failed take-it-or-leave-it value proposition, is reflected in the outraged and aghast online e-book customers of the Amazon Kindle, when they discovered that Amazon had actually remotely deleted books by, (of all people), George Orwell - that they thought they had legitimately purchased on their Kindle devices.

When we do get it right, accountability, evaluation, relationships - and value - are all seamlessly woven into the fabric of a customer-centered engagement; that is built on a dialog of trust and transparency; and not, the “act now, in-your face, opaque, product-centered, push-marketed, one way monologue, begging for $$$ to put butts in seats”…

We also suspect that the conspicuous absence of sustained, trusting, customer-centered relationships, built on value & loyalty - other than with major donors - is often a direct result of the endemic, product-centered, gladiator-culture, of both arts ticketing, and the funding marketplace; where 9 out of 10, equally qualified, proposals are often rejected.

C’mon, we’re not getting married here, we’re just doing - and saying - what we have to, to get the money, put butts in seats, and make it through the season – it’s no big deal!

So, given that perception, why waste time and money building sustained value? Why do we need to build relationships … (e.g., shared trust, awareness, understanding, agreement, buy-in and ownership)? Why do we need to build institutional alignment, internally, within our stakeholder facing organizations, and relationships with our patrons, about what our value propositions need to look like?

Here’s what we found, it is a big deal! In a struggle for mindshare environment, we often get stuck push-selling our take-it-or-leave-it value propositions; rather than listening to needs, and being responsive. When we stop pushing our monologues, we can be open to spending more time listening, being transparent, building trust, while adding real value in our conversations with clients and patrons - as Jeff Bezos, CEO of Amazon, has painfully acknowledged.

As a result, at AudienceWorks, we find that we are spending much more time facilitating & coaching organizations that are planning, seamlessly integrating, and implementing social media strategies; precisely because they have begun to discover that there is sustained value in turning the megaphone around.

It’s No Surprise then, that there is a growing body of evidence that making the institutional decision to turn the megaphone around; does in fact, build and sustain relationships, real value and loyalty. Some Results: incrementally changed perceptions, enlightened leveraging of data; and, OMG, pick-it-yourself subscriptions. We note that Institutions who do invest in customer listening-centered relationships, drive good results, and often get the grants, while their newly valued & appreciated Patrons OMG, have a choice of performances, or seats, and offers.

See Pete Bradshaw’s excellent Zappos Article in Ad Age: “Brand Turns (their heroic customer service) Cost Center into an Unassailable Asset …”

Let’s take a look at the process of implementing a social media strategy as an intriguing and metaphor for how we might want to pragmatically approach this transformative, value, evaluative, and accountability conundrum.

The Social Media Thingy  Many of our clients (Museums, Arts & Dance Companies, Presenting Organizations, Symphonies, to Regional Cultural Councils) have been asking for help navigating and seamlessly integrating, “This Web 2.0 / Social Media Thingy”, into their institutional strategic planning.

Social Media Rule #1: Spend lots of time listening. We ask what they have been doing. What’s working and what isn’t ... and how do they know that? “What do you know about social media? Invariably, the answer is: “My Son or Daughter told me we really ought to have a FaceBook page – So, We want one!”

Then we ask, “Ok, let’s say that you do that, “What do you want for outcomes?” “How”, we ask, “are you going know when you get there?” and “How will you define success- upfront?”

The Drill: Folks want to have a FaceBook page, because it’s THE social media place to be du jour; without wrapping their mind around the necessary core relationship building implications - for every stakeholder facing person in their institution.

This is no different than putting a bumper sticker on your forehead that says “Nirvana”- and instantly believing that you found it; absent only the need to be free of your institutions monkey-minded, reactive, impulsive, push-marketing-monologue, about what, when, and how much to do next, because – “OMG! – OMG! The numbers are down!”

Sadly, in this product & seat centered vs. customer centered institutional environment, we only seem to know how to turn up the volume on the megaphone and drive up collective noise of our push marketing monologues; with more print, more email lists, more big bucks out the door … and more poor results.

If the conversion rate on these push monologue marketing efforts is 2-4%, then we are wrong in guessing what our customers or patrons need, want - and value - 98% of the time. While we observe that, the conversionrate of free, value-based, personal referrals in your networked relationships … is a whopping 75%!

A walking-the-talk caveat: these free referrals from friends to friends, on your behalf, are not to be taken for granted; they are only made based on their ongoing relationships of trust and their direct experience of transparency, and sustained value with you - over time. And explicitly, not because you said so!

All customers are from Missouri! They detect very quickly, the difference between real “Street Cred” e.g., your genuine customer-centered institutional alignment & intentionality; incorporating a real dialog of trust, transparency, and value; AND, your hyped, push product-centered monolog of “just give me your money - wrapped in smoke and mirrors”.

p.s. BS doesn’t cut it. Your impassioned patrons won’t hesitate to instantly twitter their pleasant - or not so pleasant - experiences - X 10; to their network of 600 friends of friends, with delightful - or devastating - effect.

In relationships and Social Media, Truth telling counts!

So don’t go there! Customers are not disposable; churn & burn is a negative sum game - times 10. “If you mess up - fess up”; just like Jeff Bezos of Amazon, or David Neelman of Jet Blue, after Jet Blue left passengers on the NYC runway for 11 hours.

Time to give it up, and not make it up! Turn the megaphone around! Forget the foundation grant - for now.

Do This! Go through these 4 steps, twice.

1. Internally, together: What do you all agree that you want for outcomes? Now, prioritize them - together

2. Now, how would you define success - together, in the same room, same place and same time?

3. Now, Make these outcomes SMART. Make each of those incremental steps that will get you from (Here = point A) to (Success=point B): Specific, Measurable, Achievable, Realistic & Time-based.

4. Why Measurable? So everyone knows where you are; you all know where you’re going, and how you’re doing at each step. So that, en route together, you’re all in the same boat, rowing in the same direction; agile, nimble, creative, adaptive, responsive … and voila, successful!

And, sigh, not at the end of the grant, where one delegates responsibility and assigns blame; and you turn in the evaluation; only to discover, belatedly, that it’s too late, to use your en route data, to fix it.

If you want real value; deliver customer centered outcomes … by turning the megaphone around.

Now go through this internal process, 1-4 (above), again, but this time turn the megaphone around, and listen, from your clients, customers and patron’s perspective – and see what you come up with.

If those two process outcomes: (1) internal-product centered, (2) external customer-centered, are not very, very, closely aligned; then it’s time to pay more attention, and do more thoughtful listening.

p.s. Resist the temptation to fudge the data, and minimize the differences. They are what they are.

How are you going to bring these two process outcomes into seamless alignment, with your staff & patrons?

Here’s great slideshare by Kelsey Ruger, given at Net Squared, Houston 2009, on reorienting NPO Sales Approaches and focus on real listening and relationships, Sales Eye for the Non Profit Guy.

Social Media, calls this incremental and iterative process of getting it right: Wash Rinse and Repeat. First, you turn the megaphone around: then really listen, then join the conversation - adding value, then share your learning, adjust, and jump back in: WR&R

The Ah-Ha moment: As you finally begin to turn the institutional megaphone around (often described as turning a large oil tanker around in an estuary), evaluation becomes an intrinsic part of an exciting, dynamic, value creating, trust building, relationship-building process. Your accountability is personal, and relationship based, and is not externally imposed.

Visualize shared goal setting, jointly defining success, jumping in together, returning to
share your experiences - and your data; then together, as a team, nimbly re-imagining, responding, adapting, and continuing on toward your shared, realistic, achievable, and measurable objectives … WR & R.

The real payoff lies in the subtle and powerful institutional transformation inherent in this listening. It’s often exhilarating for both the institution - and the customers - silos disappear; informal work groups emerge; what was once a struggle for both the institution - and the patron - now becomes a series of iterative opportunities to get it right, together.

p.s. No one is giving up artistic excellence; they are expecting it; relationships plus emotions - all that is woven into the fabric of your engagement.

If you passionately believe that your institution - and your customers - need and deserve way better outcomes - and real value - ask, listen & have at it!

Turn the Megaphone Around - Together. (Don’t ask permission, ask for forgiveness) as you build real value, real ownership, and real accountability - that is customer relationship centered, and grounded in awareness, understanding, agreement and buy-in.

Just do it!

So, What do you think? Can you imagine what your customer-centered & focused, institutionally-aligned, arts or funding organization will look and act like, in this complex economic environment; of swirling, conversational rich, social media opportunities for networks of trust and value based relationships?

Tune into the next episode of: Ok, We Turned the Megaphone Around, Now What?
OMG, Look at that, LOL they went viral!

25 Words of Social Media Wisdom

"First, build institutional alignment and intentionality; then turn the megaphone around, really listen, add value, and review your learning together ... then wash rinse and repeat!"

And, big thanks to Liz Strauss, great blog, terrific wisdom seeking initiative, and walking the talk of turning the megaphone around ... and really listening!

Elderspeak and Emergency Rooms

This blog's focus is First Do No Harm. Seems reasonable enough. Yet, in the past several weeks, the tsunami of harm impacting elders living at home is simply mind boggling.  The financial environment this past year is having an horrific impact on the elderly, cost of food doubled, cost of gas and oil and propane doubled, health care premiums,  for those borrowing from retirement accounts to pay for current living expenses, many of these accounts have values that have fallen below levels that will recover in their remain lifetime, falling into bankruptcy up almost 500% for elderly.

Many elderly in the past several years, took out equity loans to pay for health and living expenses, and refinanced their homes ... on balloon mortgages.poof - foreclosure looms large for many ... with their children, in the same boat, unable to rescue them

If that isn't enough, when folks do seek help - they often find it demeaning, frustrating,  depressing and simply give up. We have two recent studies that confirm several concerns reported here on this blog :ElderSpeak & Emergency Rooms -Not surprisingly they are closely related.

It's all about elder caregivers (family and professional alike) intention, actions & investment in relationships - a frequent topic here. In the case of ElderSpeak, which is adult to elderly conversation that is patronizing condescending, blaming, dismissive - and ultimately abusive; and which only serves to engender fear, shame, and push-back isolation.

There are now measurable negative impacts on outcomes and mortality when we treat elderly like children, in our intention, control and conversations - when we talk with fake familiarity to elderly as baby, honey, sweetie, and dearie ... while not engaging active supportive and safe listening -for them.

Which leads us to Emergency Rooms. Recent data suggests that a huge majority of elderly to not follow through with their home care orders and medications after discharge from the emergency room visits. Why is that not surprising? Elderly Patients in ER's are under terrific stress, often sitting passively for hours (worried about how to pay, will they hospitalize me, will they send me to a nursing home? We print discharge orders too small for poorly sighted elderly to read, We fail to engage or retain a caregiver (family, home health aide or VNA to assist in proper follow-through).

And we talk to elderly patients and parents like children - forgetting short term memory loss, and processing them -matriculating them back back into their homes rather than graduating them with appropriate with the tools and knowledge they need to manage their care ... because we don't engage then in the conversation -

instead, we talk in the third person to the family member who drove then to the hospital and the patient is presumed to be deaf. (Daily followup phone callbacks with simple discharge orders in large print are very helpful.

What is the outcome? You know the answer, depression, suicide, reduced mortality, reduced cooperation, compliance and increased isolation.

Look at the 90 year old woman who shot herself as they were foreclosing on her house. After all of the publicity, the bank forgave her mortgage... How Sweet of Them.

Yea Right!  How scummy can you get. You only do the right thing when the searchlight is on you and you look really stupid.  Yet this pattern, of "I'll do what I want - until I'm caught" (like the CNA who verbally abused a patient beside me - at 2:30 in the morning) is endemic is elder care.

Why not engage in a real conversation with real respect, real active listening, and turn caregiving into a dynamic partnership ... and not a cattle processing center.

The excuse that there is no time to do it right - is nonsense. If we took the time ... the data says - our elder caregiving costs would drop, lives would be lived, and care givers and elderly wuold have a lot more joy in their engagement ... in the quality of their lives.

So why don't more banks forgive elder mortgages or renegotiate terms ... it would be cheaper than a 700 billion dollar bailout. Perhaps we are approaching a new vision of elderly care and civility - in which we don't blame and punish the victim.

Strong message to follow...

Coping with the specter of financial ruin

This is not a pretty picture - the Queen of De'Nial is having a hard time keeping the lid on.

From McKinsey Quarterly: "By 2015, the United States will have more than 45 million households with people from 51 to 70 years old, compared with about 25 million for the “silent” generation, born from 1925 to 1945. Their real disposable income and consumption will be roughly 40 percent higher, and they will control nearly 60 percent of US net wealth."

That's the good news. But tough stuff happens quickly, while you make other plans. In this case, the recent crash of financial markets dramatically reduced  the value of their portfolios (and that of their adult children who are drawing on them to care for their aging and not so well off parents) ... For many older adults, this is a real tragedy. Traditionally one would just "wait out the market", it would recover, and financial instruments would regain their value. This time there is a new twist - for many, because of the profound structural changes in the financial markets and bank failures, it appears that there may not be enough time to recover the value of their assets ... before they die.

In an article in the NY Times: More to Fear..., and recent "Surveys by AARP; the Transamerica Center for Retirement Studies and the Employee Benefit Research Institute have found that more workers nearing retirement age are putting off their plans to retire, curtailing contributions to their 401(k) accounts, and borrowing from their accounts to pay for living expenses, including credit card and mortgage debt." (and that was before the crash)

"The collapse of the housing market has hit older homeowners. According to the Center for Retirement Research, Americans over age 63 pulled $300 billion out of their home equity through refinancing from 2001 to 2006, lowering their net worth."

And now, if you have a reverse mortgage and depend upon the income for living expenses; if the the rapidly declining value of your home falls below the basis value of your mortgage ... you have a major problem.

Which brings us to the point of paying for in home or nursing home care - with these reduced assets. The average nursing home cost is $60,000 a year /$1150 a week. If you have any assets left, you can expect to consume them rapidly, beyond the limited coverage of medicare for rehabilitation - unless you have preplanned trusts that transfer the value of your assets to your children, with the right to live at home.

Speaking of Nursing Home Care: In Florida, 8500 nursing home patients are suing the state in a class action suit, for the failure to provide patient appropriate, much cheaper, and more cost effective in-home care services ... with patients claiming what amounts to false imprisonment in institutional settings by the nursing home industry, that they claim has taken over a large percentage of the available medicare and medicaid funding.

We should pay very close attention to this battle. Transitional nursing home rehabilitative care is often a critical part of an effective plan of care. However, the problem arises when the need for skilled and expensive nursing home care decreases, and these services can be delivered more appropriately, more cost effectively, (and are psychologically more appropriate) at home, in the community, or in an assisted living facility.

This pitched political battle is about the allocation of state and federal resources, to often competing components in the elder health care delivery system, (home health, nursing home, assisted living, hospice, etc) - and what role patient needs driven, "patient appropriate", and positive outcomes play in making these decision ... sounds like the current banking and real estate mortgage industry situation,  doesn't it?

It is increasingly clear, once again ... as we found in the early 70's ... that warehousing mental patients for 10's of years; institutionalizing the vast majority of these patients - at 3-10 times the cost of providing community based services - was not only an outrage, but fundamentally the wrong plan of care - IF WHAT YOU WANTED WAS POSITIVE OUTCOMES AND QUALITY OF LIFE ... FOR THE PATIENT.

We need to urge our legislators to get it right - turn off the lobbyists campaign funding faucet PACs - and focus on patient needs and quality of life outcomes.  What a concept? Again.

What were they thinking?

What were they thinking? I listen as folks express their "world view" of aging. Invariably they are missing a couple key pieces. Often they have substantial difficulty putting themselves in their aging patients shoes ... essentially into their parents or patients cognitive mind map.

This was brought home by Dr Stanly Falkow of Stanford Univ, one of five researchers recently honored with The Lasker Medical Prize. "Dr. Falkow, 74, was honored for his discoveries that grew out of an extraordinary ability to imagine himself as a bacterium so he could view the world from the microbial perspective."

Now, fast forward an order of magnitude, (from micro to macro), and explore the work of RD Laing. This brilliant Scottish psychiatrist turned psychiatry on its ear, insisting that he (and we) need to really get into the minds of our patients. His classic 90 page book Knots, is essentially a verbatim transcription of his amazing conversations with schizophrenic patients.

So, what happens when we take the time to be there - present and accounted for - with our parents, our patients, or our microbial friends - in their cognitive mind space, not ours ... not in our projections, our misperceptions, our assumptions, not watching the clock?  Just Be There With Them.

The answer, the experience for Stanley Falkow, R D Laing, and for us ... is breathtaking. It is transformative of outcomes for us ... and for the parent or patient. However, to experience that, we need to give ourselves permission to let go, roll up the shades, open up the view, and change our perspective from viewfinder to subject, free of judgment, criticism or pretense - WITH our parent, WITH the patient.Not, colloquially, "them and us".

A caveat: In R D Laing's case, it was important to have a large rock and a strong climbing rope, to find ones way back from spelunking in the dark caves of depression, paranoia and schizophrenia. But, that should not preclude the journey - for either of you.Together, you can take it easy, take your time, take it in bite sized pieces - reflect, appreciate, and return for more ... insight after insight.

What were they thinking? Just ask (and be open to the answer)

Informed Consent, Tenderness & Nonviolent Communication

A strange and wonderful tapestry this. Pierre Teilhard de Chardin spoke of a noosphere of consciousness that connects us all across the planet. Some would call the pragmatic version of that, the Internet ... but at a conscious, interpersonal level; Lilly Tomlin, Marcelle Pick, and Marshall Rosenberg, (below) are all singing the same riff.

The message: in the face of a daily tsunami of an often dismissive, disappearing, dehumanizing health care delivery system ... It is up to each of us; it is both an opportunity and our responsibility, to make our way in the world with each other, to engage each other with kindness, respect, dignity, empathy, and informed sensibility. Because, as the Native American Peoples would say ... we are all Human Beings. We are all in it together.

When we say "First Do No Harm" - at the very core of this - is our individual intentionality, about how we choose to engage with each other .. and, in this specific context what do we want for outcomes .. how do we choose to engage with our aging parents, patients and the health care system. We can throw up or hands in exasperation. We can abdicate our responsibility to become informed participants. Or, we can learn how to engage in a process - a dialog - that is more inclusive and responsive: and delivers awareness, understanding, agreement and ultimately - ownership ... and (for all the parties) more positive outcomes.

Lilly Tomlin is quoted as saying,"The sensibility in this culture can be so hard-edged, so brutal, so ridiculing and so dismissive that I think the most radical thing you can do now is to be tender".      Which I read as - in the face of impersonality - choosing to be authentically present, open, gentle, caring, compassionate, nourishing, empathic, and supportive.

Marcelle Pick an OB/GYN/NP at Women to Women up in Maine,in her article, The truth about modern health care - it's in your hands. "I think it’s time to remind women who is steering the ship when it comes their health care. I know that health issues can instill a lot of fear in women, especially today, but making fear-based decisions is never as safe or effective as making informed ones."     To make safe informed decisions - we have to make it safe to ask those questions ... and make it safe to have those conversations.

Marshall Rosenberg MD, is a psychiatrist whose work is focused on NonViolent Communication in the medical profession. "NVC language strengthens our ability to inspire compassion from others and respond compassionately to others and ourselves. NVC guides us to reframe how we express ourselves, how we hear others and resolve conflicts by focusing our consciousness on what we are observing, feeling, needing, and requesting."

This is powerful stuff ... perhaps we could learn to hum a couple bars together.
   

The Golden Years ... and then Bankruptcy

The fastest growing segment of our population is 75-85 and older, and so is the rate of their personal bankruptcy. According to the National Consumer Bankruptcy Project at Harvard, in 1991, those who were 55 or older accounted for about 8 percent of bankruptcy filers. In 2007, they accounted for 22 percent. The filing rate of those between the ages of 65 and 74 rose by 125 percent. However, for those between 75 and 84, The bankruptcy rate rose by 433 percent. Illness and injury now contribute to more than 55% of all bankruptcy filings (as illness increases with age so do bankruptcy filings).

Another Lawyer, Sandra Freeburger, an Evansville Illinois bankruptcy attorney, said she sees seniors citizens who are also hurt by adjusted interest rate mortgages on their houses. Also common are those who cannot afford prescription drugs at the same time as car loans and other debt. Or a person’s spouse may die, cutting in half the fixed household income.

Young folks seem less likely to think of declaring bankruptcy as dishonorable thing to do. Yet a reluctance to seek protection from the courts can be particularly harmful to an elderly person, especially if they use savings placed in a 401k account to pay off debt. If they had declared bankruptcy, that money would have been protected from creditors.An aversion to bankruptcy can be a “detriment to their financial future,” Freeburger said.

What to do: Once again relationships are critical to opening the door to talking about finances. The shame and embarrassment of bankruptcy and perceived financial ruin, among those who are 75 and older, contributes dramatically to depression and suicide. It is important to see how their financial situation impacts their daily lives, mobility and health - such as checking on food in the refrigerator, automobile insurance, gas, shopping, prescriptions ... by taking time to talk about "the hard stuff" with them.

The most common description of elderly responses to the converging perfect storm of financial ruin that is triggered by out of control medical costs, variable rate mortgages, credit card debt, heating and cooling costs, masked by shame and embarrassment; is that instead of taking action, they often "freeze" and do nothing, feeling powerless, and alone.

Making the time - taking the time for safe conversation, negotiation, mediation, exploring options, and unloading the emotional baggage and confusion surrounding this rapidly rising financial crisis, is critical. At a very personal level, this experience transcends for many the idea of recession. Once again it is reliving the desperate times of the Depression.

Postscript: When we rewrote the bankruptcy rules, it became a punitive response to those, who we were lead to believe, were using bankruptcy to avoid bill payment. This is a familiar pattern of blaming the victim to justify protecting the predatory lender. For example; more than 60% of women on welfare are victims of domestic violence, where he controls the purse string. Here's the choice: Stay home and be beaten, or escape - at the risk of your life - onto the street, destitute and homeless with your children.

In fact, the new bankruptcy laws protect the very banking and credit card institutions who saw an unregulated gold mine in usurious credit card interest payments, and balloon & variable rate mortgages issued to millions of unqualified recipients. Of course when energy costs skyrocketed, along with their interest, mortgage payments and layoffs - the outcome was predictable.

Now, with billions in losses; magically, the treasury and congress are finding billions to bail out these same financial institutions .... while leaving in their wake,  hundreds of thousands of at risk women, and now destitute elderly. Only a small fraction of those experiencing foreclosure are eligible for bailout.

None of these new bailout provisions restructure the existing bankruptcy laws, as strongly urged by the report from the National Consumer Bankruptcy Project.  This is a powerful report and well worth the read.

This is a rapidly ballooning epidemic, and it is an outrage of horrific proportions.

Depression ... the great abyss for elders

Anguish, uncontrollable sense of loss, deep sadness, powerlessness, profound emptiness, regret and feeling overwhelmed ... all contribute to elders checking out.  If this is compounded with social isolation, and being treated in ways that are dismissive and abusive, it is a recipe for disaster.

Is this the quality of life ... at the end of life, that we wish for our aging population? Is that what you would want for your spouse or aging parents? Of course not! So how can we respond effectively in our communities, in our networks of caregiving?

Relationships, Relationships Relationships.

The most powerful antidote to the slippery slope of depression - from the moment of retirement -  is building a network of safe supportive relationships. These are places where it is safe for folks to talk about what is real for them. Ram Das speaks of the conversations that elders have, that feel more like "Organ Recitals" ....My knee, my hip, my eyes, my hearing, my heart, my joints etc. Younger adults often check out when older folks start in with the litany of broken stuff. But that is what is going on - and like water behind a beaver dam - you have to drain out all the dark murky stuff - before the stream runs clear. Be patient and be rewarded with the rich fabric of a life fully lived.

Older men, whose person-hood or identity has been defined as "What they did - is who they were". Veterans, machinists, salesmen, teachers, engineers etc., are quick to fall into the depression trap, on retirement. The average life expectancy for men, after an unplanned retirement, is about 18 months.

For women, who invariably outlive their spouses by many years; their connection to other women in social networks of community, churches, senior centers, children and grand children is a critical part of healthy aging. For those couples with a long term personal relationships of 40 - 50 or 60 years, the loss of a spouse can be profoundly traumatic.

For both, actively investing, inviting and building a network of social relationships BEFORE retirement is an important part of healthy aging. One of the most productive of these networks is volunteering: in schools, hospitals, non-profits, literacy programs & multi-generational groups. Often, the key ingredient here is arranging transportation. The loss of ones license or car is often one of the first steps into the abyss of social isolation.

Paying close attention to symptoms of depression and responding with engagement, dignity and respect, so that it safe to talk about loss and loneliness, is critical - and the prescription of socialization is both helpful and critical.

Relationships, Relationships, Relationships ...

Intentions and outcomes... continued

I have often been treated better: more warmly, more kindly, more humorously, more respectfully, more affirmatively - and acknowledged as a real person - by the man or woman who is mopping the floor in the hospital room. 

And so have the elderly patients with whom I have shared a hospital room.  Many of whom carry on delightful, animated conversations in response to  gentle entreaties and lighthearted banter. They are laid back, easy and real ...  until the technician, or clinician, or caregiver arrives with their blinders on and their singular focus...

What is the "quality of life" experience there.. in that moment, that is so comforting, relaxed, and reassuring - and often, sadly, is not present in more uptight caregiving or clinical encounters? I think there are two issues. First, there is no pretense - no mask. Folks are acknowledged; taken and offered as they are;  Second, there are no aloof walls of assumptions presumptions, minds full of charts and schedules - no hidden agendas.

There are no clear signals of let down your guard discomfort - not among the patients ...  who have little guard and urinary privacy left to let down - but among the caregivers and clinicians.

My hunch is, having had wonderful encounters with family members, technicians, nurses, nurse practitioners, and physicians; that it has to do with how comfortable these folks are with themselves. Yet, in conversations, many have said that it was not always that way.

So here is the good news. It's apparently all learned behavior. It's not about manipulating the patient or putting on false fronts. It's about taking the opportunity to learn to be present, real, and deeply in touch with yourself ... who you are... who the patient is (not a nagging mother, or a remote father, or a diagnosis, or a procedure). 

And in that existential moment, one chooses to be there, fully present and accounted for - that's where the phrase - attending physician, really comes from.

Maybe it should really be "the paying attention caregiver"; the relaxed, being herself/himself care giver. By doing that, the caregiver also gives permission for the patient to be herself or himself ... to be relaxed, appreciated, acknowledged, to let go and be an intrinsic part of the conversation. In both boxing and Tai Chi, they call it telegraphing your punches.

What you get when you do this, is a present and accounted for dialog like the attendant - not a monologue. Patients can instantly tell the difference. A recent study of animal behavior shows that most animals from mice to fish can detect pheromones of fear, anger, anxiety, and even impending death. Just like the cat at a New England nursing home - whom the staff has learned to trust when calling the family - who only visits patients who are about to die.

Maybe there is a hurried caregiving or clinical equivalent. Perhaps we are sensitive the the pheromones of hastily applied hand sanitizer or makeup, or a quick trip from the office, which fails to mask the anxiety of too many demands, too many patients, and too little time before office hours, as they rush from room to room, or house to office to hospital and home again.

Perhaps they could take a lesson from Barbara, the second wife of Miles Standish, the uptight Puritanical leader of the Plymouth Colony, who said to him, "Don't be so standoffish, Miles!"

Intentions - Our role in what we get for outcomes

I am always surprised at the disconnect between our stated intentions in elder care, and what we actually get for outcomes. I am particularly intrigued by the "It wasn't me officer" approach of folks, who are often the loudest critics of outcomes ... and the worst offenders.

Lets start with treating aging, elderly, older, frail, persons as deaf children.  I see it every day.  Doctor, Adult child  or spouse accompanying Elderly Parent - all in the doctors office or hospital room. The adult child is having a conversation about the elderly parent, referring to them in the third person. The older person is mute. Are they really mute. NO WAY! They are actually disappeared, outraged and withdrawn and feeling powerless, then they are shouted at - as if they were deaf,  and spoken to in patronizing, condescending baby talk.

I know the feeling. I have recently been on the receiving end of that kind of conversation between a nurse and a doctor in a hospital room or in an emergency room where it is assumed that because I am almost 66, that I am retired, deaf, stupid and inarticulate .. and my name is always "Honey". It's excruciating - like being trapped in a $64,000 Question isolation booth.  Except that  I know the answer, understand the question, and could be an active  participant/partner in the  plan of care ... if asked  But no one asks, invites or considered me a participant. Until I ask a very focused core question? My, what an interesting response....

This is the same problem Kubler-Ross discovered when terminally ill patients - whose minds were working just fine, but several major organs were caught up in metastasized cancer.
HELLO, I'm here, brain is working just fine ... and so is the isolation booth Same excruciating problem was discovered by Dr Jill Bolte Taylor, who had a stroke, and could not speak - but could certainly hear perfectly. trapped in an isolation booth and treated like fertilizer.

We must look at our own assumptions and intentions when we engage our parents or patients, and look at our unconscious behaviors driven by our own discomfort, our own anxiety, our need to control, our need to take control (even when no one has actually given up control - and if asked might reasonably - and rationally be able to respond - even with an eye movement or blink).

Our (misdirected and misinformed) good intentions (the road to hell is paved with them) absolutely drive our parents and our patients outcomes. If we want better outcomes, better compliance and responsiveness - then we ought to treat folks like real people - with dignity and respect.

If the tables were turned - "Would  he like to be treated like that", said the Adult family member to the Doctor?"As you sat there screaming silently no...

"Why don't you ask me ...I'm sitting right here."

NOW WOULD YOU! ...Honey?