This week, we’d like to welcome Melanie P. Merriman, PhD to the blog. Melanie is a research scientist turned hospice quality consultant. Her professional and personal lives converged when she became a caregiver for her aging mother, which is the subject of her award-winning new book, Holding the Net: Caring For My Mother on the Tightrope of Aging (Green Writers Press, 2017) — a Caring.com choice for 2017’s Best Books on Caregiving.
1. Tell us about your role in helping your aging mom find solutions when she began needing care.
My mother and I were always close. After my father died, I traveled 300 miles — from Miami to New Port Richey — to visit her four or five times a year. Given those frequent visits, it was both shocking and embarrassing that her best friend had to write to me, not once but twice, to convince me that Mom, in her late eighties by then, was declining both mentally and physically to the point of needing assistance. Mom hid her weakness and mental frailty from me, and the truth is that I did not want to see it. Once I realized that the time had come to make some changes, I needed to help my reluctant mother to realize it.
My sister and I researched several different options for Mom’s care, and in the end decided that she needed to move closer to one of us. Although she could have done well with supportive care in her condominium, we would not have been able to get to her quickly, or stay with her should there be some kind of crisis. Mom decided that “if” she decided to move, it would be to North Carolina to live near my sister. My first goal was to change Mom’s “if” into “when”—to get her to commit to the move.
2. What was it like trying to communicate with your mom during this time? What did you learn about trying to communicate?
Picture me with my elbows on my desk and my face in my hands—that’s what it was like—frustrating, confusing, deflating. The mistake I made over and over again was thinking that I could talk with the smart, logical mother who raised me; that she would be able to weigh all the pros and cons, and see clearly that the only viable option was the move to North Carolina. Mom was on what I call the “tightrope of aging.” She was less steady on her feet, her reflexes were slowing, and while she still had all her faculties, her reasoning ability was declining. These normal effects of aging made her cling to the familiar. She felt safe in her condominium, her home for thirty-five years, and the thought of any kind of change was frightening. I realized that if we were to be able to have a rational discussion, I needed to create a conversation plan in much the same way that I did in giving presentations to my clients.
3. What is a conversation plan?
I think of a conversation plan as a written, step-by-step guide designed to generate a meaningful discussion and achieve a specific goal. Writing out the key points that you want to cover is critical because it forces you to think about the entire arc of the conversation and then place the discussion points in a logical sequence. The goal for a conversation plan depends on the topic under discussion.Once the goal is clear, you can create a list of questions and/or statements and place them in a logical order that will drive the discussion toward your goal.
4. What did the conversation plan for talking with your mom look like?
When my sister and I planned a conference call so that the three of us could discuss Mom’s possible move from her condo in Florida to the apartment in North Carolina, our goal was to get Mom to agree to move. Our conversation plan included the following points:
- Ask Mom how she is feeling about the move. Is she leaning toward or against it?
- If she is leaning toward the move, talk to her about getting the paperwork signed and the deposit sent. Volunteer to visit her and help with the paperwork if needed.
- If she is leaning against the move, remind her about how nice the new place is: the activities, the proximity to my sister, etc.
- Volunteer to take care of the entire move: packing, logistics, selling condo, etc.
- Ask if she has questions or concerns.
5. When you put the plan into action, how did the conversation go?
The conversation went pretty well. Mom was leaning against the move at the beginning of the conversation, but by the end, she was willing to reconsider and wanted to go see the apartment in North Carolina one more time before making her decision. Of course, we jumped on that and set a date for a return trip. Unfortunately, it was only a short-term success. We had to have this conversation approximately three more times. Mom would decide to make the move, and then back out a few days or weeks later.
6. What improvements, if any, would you have made to your plan?
Looking back on this conversation plan now, I see the flaws. The biggest one is that we failed to ask, “Why?” When Mom said she was leaning against making the move, we went straight to our arguments in favor. We did not ask her to explain why she did not want to move. I guess I thought I knew her reasons—that she liked where she was, that she did not want to leave her friends, that any kind of change was frightening. But we should have asked. A good conversation plan includes opportunities for participants to clarify their concerns. Another change I would make is that I would ask about her questions and concerns first, rather than last. Again, this would have allowed us to address the things she cared most about right up front.
7. For professionals who might need a conversation plan to use with clients, how would you recommend creating one?
Here is the step-by-step process I suggest:
- Think about the desired outcome for the conversation. Do you hope your client will contact a geriatric care manager to talk about their aging parents? Would you like to see your elderly client seek medical advice about symptoms they have been complaining about? Are you assisting the family with shared decision-making about next steps in aging care? Are you sharing information about concerns expressed by the elderly person or family members? Spend as much time as needed articulating this goal.
- Carefully consider how much you can accomplish with one conversation. Often, several conversations are needed. It’s better to scale back the scope of the discussion and create a series of smaller, intermediary goals than to get ahead of your client’s capacity to absorb and process difficult information. If the first conversation goes well, you can follow-up with a conversation about a small second goal at another time.
- Use scenario testing to help your client express preferences. If your goal is to encourage your client to express their preferences about health care options or plans for the future, use scenario testing, asking “What if. . .” questions, or outlining what has happened with other clients (anonymously, of course). Often people are more comfortable giving advice about others, rather than addressing their own situation. For example, describe a client who became too weak to climb the stairs to his second floor (or some other scenario relevant to the current client) and ask what might be good options for him. When the client provides some ideas, ask which one would work best if he/she were in that same situation.
8. What insights can you offer professionals on having a conversation once the plan is formulated?
Most professionals will be good at the basics—choosing the right time and place to have the conversation based on the client’s comfort and state of mind, gearing the conversation to the client’s cognitive level, and establishing the right power dynamic, that is, making sure the client feels respected and valued. Then, I think it is essential to get agreement about the topic of conversation, for example “I’d like for us to talk about ways to make you/your dad safer at home.” If the client is not quite ready, be prepared to backtrack, possibly returning to and reviewing a previous conversation. It can be difficult to accurately assess the client’s ability to understand his or her situation and this can take time.
Another challenge is striking a balance between keeping the conversation on track (sticking to the plan) versus changing direction based on what the client says. The whole purpose of the conversation plan is to guide the discussion toward the specific goal.
If the discussion starts to veer in another direction, there are at least two good options:
- Acknowledge that what is being said is important and that you will make a note to talk about it later, then bring the discussion back in line with the plan.
- Let the conversation move in a new, unplanned direction.
Obviously, you will feel less prepared if you choose the latter, and should do so only if, in your professional judgment, it will serve the client better than the original planned conversation. It’s important to remember that a conversation like this may need to happen multiple times in order to make headway. Don’t feel discouraged if the talk veers or the results aren’t neat and tidy. Make note of what worked and didn’t, and use it to prepare for the next talk.
9. Is there anything else you’ve learned that you’d like to share?
In my experience with my mother, I learned how valuable it is to have a professional involved in family conversations. Once I involved my mother’s physician, and once I involved an Aging Life Care™ expert. Both times, the dynamic of the conversation changed. The expert’s opinion held weight with my mother, and the expert could help her hear and accept bad news while I could take on the role of the supportive daughter.
Both of these professionals showed my mother that they had her best interests uppermost in their minds. I was reminded of a quote I once saw on the wall of a hospital: They don’t care what you know, until they know that you care. When it comes to a conversation plan, I think that says it all.