Welcome all. We are very excited here at the E4 Center in partnership with SMI Advisor and the Illinois Department on Aging to welcome you to this learning community event on valued social roles in older adults with serious mental illness. It is a particular honor and joy for me because the speakers today are one of my dearest friends and colleagues from graduate school and one of my favorite professors from graduate school coming together to talk about such an important topic. And as we move forward today, just a couple of housekeeping topics. Let you all know it is being recorded. None of your voices are on the recording, so not such a big deal for you all. But as we are recording, you will all get a copy of the slides for today along with a link to this recording. As we go along, please drop your questions into the Q&A and we will make sure to get them answered at the end of the presentation. We really want to hear from all of you, so please do actively participate in the chat and in the Q&A and at the end of the slide presentation, Dr. Sun and Stein will answer all of your questions. Just a reminder for those of you who are not familiar with the E4 Center, we are based here in Chicago, which are the ancestral lands of the Council of the Three Fires comprised of the Ojibwe, Odawa, and Potawatomi Nations, as well as Miami, Ho-Chunk, Menominee, Sac, Fox, Kickapoo, and Illinois Nations. The E4 Center is focused on three key areas of depression and suicide, substance use disorders, and serious mental illness, which we are highlighting today, and where they overlap to create or exacerbate physical health disorders. For some, this is layered on top of low socioeconomic status and minority status that creates the most vulnerable population of older adults. To address these needs, the E4 Center is focused on building knowledge, skills, and attitudes in the mental health workforce, very broadly defined, this is what we're here to do today, as well as working with health systems and the aging network to build partnerships to prevent older adults from falling through the cracks, which is also in part why we are partnering today with the Illinois Department on Aging for this presentation. We are also providing training and technical assistance on evidence-based programs for older adult mental health and substance use, so if any of you are looking to learn more, please don't hesitate to reach out to us at e4center at rush.edu. Although we don't train older adults and families directly with E4, we do provide resources to equip all of you to meet the needs of the older adults that you work for or work with. Part of that is evident in some of our upcoming programs. Next week, May 11th, is the sixth annual Older Adult Mental Health Awareness Day Symposium. There are some phenomenal presentations. I've been on the planning committee for that event, and there are some amazing presentations that are going to be shared. Free continuing education for that event all day, courtesy of the E4 Center, and would love to have you join us for that event. We are also honored to be hosting Dr. Robin Stone from LeadingAge, who will be talking about the direct care workforce as part of our Shaman Senior Voices Inaugural Thought Leader Lectureship on Wednesday, May 31st. Greasy E for that one as well. And you've heard us talk about this before, but just in case you've missed it, we have a phenomenal online program for foundational competencies in older adult mental health. There is a small fee for continuing education for that program, but if you've got a group of folks, reach out to us. Happy to give you a discount. Would love to have as many groups of folks get trained in working with older adults as possible. And then next month, for our learning community, we are really excited to have Dr. Patrick Rao from the University of Washington talking about depression in older adults, and he has developed this peer-led program that he's running through senior centers that is amazing and having some really great outcomes. So particularly, y'all from the Illinois Department on Aging who are joining us today, come and join us again next month for that presentation. So, also, we are very excited to be co-sponsoring this with SMI Advisor, Amy. Thank you so much. Oh, my voice. I'm sorry. What a pleasure it is to be here today. I just wanted to let you know the Clinical Support System for Serious Mental Illness, also known as SMI Advisor, is a SAMHSA-funded initiative to help clinicians like you care for your patients with serious mental illness. And again, I apologize for my voice, but I wouldn't miss this webinar for the world today. So I wanted to be here. Thank you so much for helping, for joining and partnering with us today. Been a longtime fan of the E4 Center. Thank you so much. Such a wonderful partnership with the many SAMHSA-funded centers. So, without further ado, we are honored today to have Dr. Marcia Hunt, who is a licensed psychologist serving as a Senior Health Services Researcher at the E4 Center of Excellence right here at Rush, and an Adjunct Associate Professor in the Department of Psychiatry at Yale University Medical School. In the last 15 years, Dr. Hunt has worked in the Office of Mental Health and Suicide Prevention at the Veterans Health Administration. Her work includes teaching, research, and the improvement of mental health systems of care and care provision, focused on older adults and people with a diagnosis of serious mental illness. Dr. Catherine Stein is a Professor and Clinical Community Psychologist in the Department of Psychology at Bowling Green State University, which is why I had the great opportunity to learn from her. Dr. Stein's research focuses on the role of social environment in the individual well-being for older adults coping with serious mental illness and their families, older and younger adults both. Her work with older adults with mental illness is focused on understanding pathways and barriers to community integration. So it is my great honor to turn it over to Marcy and Kathy for this presentation. Thanks so much, Erin. It's really great to be here with you all today. This is our disclosure slide. And just so you know, we have nothing to disclose, no conflicts of interest. You can also find information about the accreditation on this slide as well. And these are our learning objectives. As you know, we'll be talking about valued social roles in the lives of older adults with serious mental illness. And we do hope that you take away a number of things from this presentation that will help you think more about valued social roles in your work with older adults with SMI. And that's what's described here. So to set the stage, what we'll be doing first is defining what we mean by social roles, what we mean by the value that's attached to any given role. So specifically, that value is tied to levels of opportunity, power, and respect that are associated with someone holding a particular role. We'll also talk about ageism, bias and stereotypes that impact older adults with serious mental illness, and how those things can limit opportunities to access and hold any or even enact any given valued social role. Since the social roles available to people change over the lifespan, we'll discuss those changes and how different personal characteristics can influence or impact the changes. And then our last objective is about tying the information we discuss about valued social roles in the lives of older adults with SMI to the work that you do, and how thinking about valued social roles can help shape that work. So before we get started, we'd love to get a sense of your thoughts about valued social roles with older adults, particularly older adults with serious mental illness. So we have a poll question here. If you could take a look at this and provide your best answer. So in your work with an older adult with serious mental illness in the past month, how often have you considered their ability to enact valued social roles? Desired roles, and how might that impact the quality of life or attainment of those? We've got a lot of comments coming in. Oh goodness, this is awesome. We're seeing a lot of people who do this, at least sometimes or very often, and very often it's our biggest category right now. A lot of people responding. Okay. Let's keep coming in. It's very heartening. So I think that's, you know, it's sometimes it's hard for people to actually consider a valued social roles because they're not thinking about it that way. So it's really wonderful to hear that we are thinking about that. It looks like responses have slowed down. And is there a way to show that, Selina, or? We stopped the video. Selina, or? We stopped the poll. So, yeah. Okay, so then I'll just flip this over. I don't know if you can see it. It's kind of small. But we have most folks in the very often area or the sometimes area. So that's terrific to see. Really wonderful. Okay. So our next slide is just a thought slide. So we're going to take a second before we dive in, and this is going to require you to do a little typing too, to get your different take on your thoughts about valued social roles. So warm up those fingers and get ready to type in the chat. If you could just put in a few words about how you think about social roles, about their importance, and kind of what you're thinking as we're starting this discussion today. So just go ahead and type right into the chat. Advocacy. Wonderful. Belongingness. Family member or friend roles. Absolutely. Mentor. Social roles can help. Yes. These are going so fast, it's hard to even read. This is wonderful. Lots about connections, lots about resiliency, and being, and purpose, and meaning, and connections. Absolutely. Support and value. A sense of belonging. Being family, friend, and educator, a volunteer. Empowerment also, yes, and connection. Absolutely. Feel free to keep putting those in as we go on. But what I want you to do is kind of keep in mind as we proceed to see if any of that shifts or changes for you or expands as we go along. OK. We're going to start off now with a definition of social roles, a broad definition that has a number of parts. So first, you can think of social roles as a set or a group of attitudes, behaviors, or expectations. We probably understand what we mean by behaviors and expectations, but what do we mean by attitudes exactly? Well, let's take an example. If you hold a role as a leader of a group, we would expect you as the leader to think and feel in such a way that you're able to behave like one, like a leader, to take charge of a meeting or a group, let's say. And if you're described as a leader, then others will have expectations of you, expectations of you, expectations that you will take charge as opposed to waiting for someone else to enact those behaviors in the group or the meeting. So social roles also reflect values and norms of behavior in a society, and they differ in importance and status. This ties to the valued part of valued social roles. So we'll talk more in depth about that later. But to make sure that we're on the same page about how values impact roles, let's say that you were in a society that has a core value of money. So having lots of money or seeming to would give you importance and raise your status. That society would then likely value social roles that paid a lot of money or were associated with money, like lawyers or physicians or investment bankers, for example, and would place less value on roles that were not associated with money or being paid a lot of money. So, for example, teachers or bus drivers or mechanics in the society that values money, people seen as poor or poorly paid would also then be associated with less status or less importance overall. And that leads to the next part, differing levels of opportunity, power and respect afforded to somebody based on that role. So let's go back to that society that valued money. In that society, those lawyers, physicians or bankers might have lots of opportunities, maybe being on boards of businesses, being invited to join groups or clubs that can help them with connections and making more money and getting more power, lending more respect to them and their roles. On the flip side, those boards or groups might not ask a bus driver or an unemployed person to join, limiting their opportunity, power and respect. In short, holding socially valued roles can bring more things and give that person holding the role more opportunity, power and respect. Holding roles with little value to a society seldom brings opportunities for that person to have an increase in the value through other opportunities and all that comes with them. And it's important to note that in most societies, I would actually say all, but I don't think there's data on that specifically. But in most societies, access to valued roles at any time of life is not equal among all members of that society. So now I'll turn it over to Kathy to talk a little more about another aspect of social roles, reciprocity. Thank you, Marcy. You're probably familiar with the fact that social roles are reciprocal. They come in pairs. So for example, it would be difficult for me to call myself a presenter if it weren't for you in the role of audience members. We can think about any number of reciprocal roles, parents and children, employer, employee, as well as the social role of helper, helping. We don't usually use those terms. We name roles like social worker, client, psychiatrist, patient, but obviously it's hard to call yourself a helper if there wasn't someone there to help. Communities and other social systems create roles that are linked to that system. So for example, the role of retiree implies that a person was linked to a job. There's lots of research evidence to suggest that adults, particularly older adults, have strong attachment to place. They identify as a community member linked to a specific location. I bet we've all met at least one proud New Yorker. We can also talk about the social role of citizen, which by definition is linked to a country. Our social roles shape societal definitions of who we are and who we are not, and as importantly, shape how we see ourselves. Enacting our roles, that is fulfilling those activities and expectations of the roles that we hold, help to shape our social identities. We think about social identities as internalized meanings and self-definitions connected with enacting social roles. It's not surprising that our identities are shaped by our roles, as sometimes we enact these roles over the course of many years, decades, or even our whole lives. So I am a mother, I am a teacher, I am a daughter. The meaning that I give to my life is connected primarily to the social roles that I hold. For the purposes of our discussion, we want to emphasize the importance of valued social roles. So as Marcy described, not all roles are created equal. Some social roles are valued by the dominant culture, and some roles are not as valued. For example, researchers asked a sample of 15-year-olds in the United States what they wanted to be when they grew up. Adolescents from both economically advantaged and disadvantaged families generally reported that they aspired to high status roles, and they wanted to become doctors, engineers, business managers, and lawyers. In describing their career aspirations, they wanted jobs where they could have powerful, important, and valued roles in society. They aspired to these roles regardless of their perceived talents and abilities to actually achieve them. In enacting a social role, your behaviors and interactions are supposed to align with the expectations of the role. So in your role as a medical doctor, you're expected to act the part in the way that you look and dress and speak and interact with others. In a medical setting, for example, the role expectation for the valued social role of doctor are different from the less valued social role of janitorial worker. Back to you, Marcy. Thanks. So, so far, we've talked about the definition of social roles, how they relate to society's values, how they're reciprocal, how they're linked or embedded in a system, and how the value that's embedded with any given social role impacts the person holding that role. That's the landscape of social roles and the values aspect. Now we're going to switch gears a little bit to the level of the individual. We're going to talk about changes in social roles across the lifespan. So social roles are linked to time in our lives, the trajectory of our lives. So if you think about social roles that you might hold as a child, for example, the role of student comes to mind, as do other developmentally appropriate roles like budding musician or school athlete. Later in life, in early adulthood, let's say you might hold the role of married person or college student or early career person. Later yet, perhaps parent or senior worker or manager. Events that happen along that life trajectory change anyone's role expectations and opportunities. So maybe you expect or want to be a parent and can't, for whatever reason, have a child. The parent role would then be lost to you. When you have other endings in life, loss of a job or loss of functionality due to accident or disease or divorce, your roles change. So all of this mainly speaks to role loss, but you also often have gains associated with those losses. For example, an older adult might stop working and lose the worker role and then gain the retiree role. Or your child grows up and your parent role changes or subsides, but you may gain a grandparent role. The passage of time changes the availability of social roles as well. Importantly, other events also take you off the life trajectory. One major event that can do this is illness, particularly one that impacts functioning. For example, take schizophrenia. Most people develop schizophrenia, which is arguably the hallmark disorder of the group of disorders that comprise serious mental illness category. They develop this in early adulthood, young adulthood typically. So this disease and its symptoms can mean that someone's role expectations, let's say of being a college student or a partner or spouse or a worker or a parent are changed. These may be harder to achieve or maybe they come later than expected or even be a milestone in a typical life trajectory that an individual is not able to achieve. We think of this as being off time. So when something prevents you from achieving a typically socially valued milestone at a particular time in life. And the takeaway here is that life events, including the passage of time, change social role expectations and hopes. Social roles and the value tied to them influence our personal identity. So one way to think about this is thinking about how you describe yourself. Like Kathy's example earlier, do you say, this is who I am. I'm a spouse, a mother, a sister, someone who lives in an apartment, a caregiver, a dog owner, an employee of XYZ Hospital. These are all social roles with really some significant value. Most of us do describe ourselves and more importantly, think of ourselves in terms of our social roles. We describe ourselves in this way and the roles themselves describe our identity. Now, keep in mind that our awareness of how these roles shape our identity and our feelings about ourselves may not be something that we are conscious of at that particular level. But most people could and do describe themselves by their roles and that's embedded in our society. Think about it for a minute. If you're meeting somebody for the first time to orient yourself, you're likely to ask them what they do or if they're partnered or if they have a child or a pet or where they live, or if they like to garden. This is information, but it's also information about their social roles. But what happens when our roles change? We just talked about how life events, including the passage of time, can change social role expectations. Well, what happens to our sense of identity when those roles change? Do we still feel like ourself if our partner dies and we're no longer a spouse? What if an illness or other thing happens and we can't live independently anymore? Do we feel like ourselves? What if you're retired and you're no longer able to work at a job or you're no longer able to work at a job? What does that do to your sense of self or sense of your value to yourself or to other ones or to society? So the takeaway here is that changes in social roles can impact how people see themselves and how they view their own value. Given that changes in social roles can shift people's understanding of their own identities and how they see their value to themselves and to others in their world, even society, it's really no surprise that our mental health and sense of wellbeing can be impacted by social role losses and gains. When we think about social roles in general, the more valued social roles that you hold, the more positive the impact on your mental health. Value is key here. The roles need to be of value to the person. Holding devalued roles doesn't have a positive impact on mental health particularly. And this is the theory of role accumulation. So if you gain valued roles or if you lose devalued roles, this is likely to have a positive impact on your emotional wellbeing, including feelings of depression and anxiety. Similarly, gaining devalued roles or losing valued ones is likely to have a negative impact on our wellbeing. This plays out pretty clearly day to day. Let's say somebody loses their job, losing the valued role of worker. We may be concerned about them beyond loss of income. We may be concerned about their feelings and how they feel about themselves. On the other side, if somebody gains a job after being unemployed or never employed, losing the devalued role of unemployed person, we're expecting them to feel happy and good about themselves. We just don't typically think of this as losing and gaining valued or devalued roles necessarily, but that's what we're talking about in these everyday situations. Keep in mind though, that the definition of a job, I'm talking about work and job, that's really very broad when we think about valued social roles. A job may or may not be paid, a job may be a volunteer. The value of the role in this case, thinking about a job, is in contributing regardless of remuneration. Kathy, back to you. Let's talk for a few minutes about social roles, ageism, and stigma. None of us are free of stereotypes and biases. And people like us in helping professions try hard to recognize those stereotypes and bias. And how they can impact our work. When we think about older adults living with mental illness, we begin to understand how negative stereotypes about aging and about mental illness often serve to limit the opportunities that these individuals have to hold valued social roles. These negative stereotypes are in addition to biases that they may already encounter based on gender, ethnicity, education level, SES, and so on. One thing that negative stereotypes about aging and having a mental illness have in common, these are can't do stereotypes. There's usually a long parade of things that people think that older adults or adults with mental illness can't do. In other words, stereotypes about aging and mental illness focus on individual deficits rather than their strengths. You can see where this is going. Unfortunately, our society usually affords older adults few opportunities to hold valued social roles. No matter what roles they occupied when they were younger, being an older person is a can't do stereotype. And thanks largely to social stigma and fear, our society also affords adults with mental illness relatively few opportunities to hold valued social roles. So the combination of being an older adult and having a serious mental illness typically provides a person with very few, if any, opportunities to hold valued social roles. In other words, aging plus serious mental illness equals double marginalization. If you are an older person living with serious mental illness, you are likely to be marginalized by social systems. Your opportunities to hold valued social roles decrease while opportunities to hold non-valued or stigmatized social roles increase. You go from being seen as a mother who takes care of your children to being seen as an old woman who needs constant care. You go from being a helper to someone who needs help. You are limited in how you can relate to others through your roles in society. People focus on what you can't do and stop seeing your strengths. And you too can define yourself in terms of these marginalized roles. We talk about this concept as self stigma. So for example, I am a person with serious mental illness. That's all I am. I can only occupy the sick role. So we now recognize the power of social roles to define the attitudes, behaviors, and expectations that others have for us and that we hold for ourselves. We now understand how intersecting marginalized identities can severely limit access to valued social roles. Then how can we as helping professionals find and create valued social roles for our clients? Well, we can start by thinking about systems over symptoms. You are already aware of your client's limitations and symptoms, but a shift in thinking about systems, the systems in which your client is embedded can help us to identify valued social roles. So these can be family systems or systems in settings like nursing homes or assisted living facilities. And we can begin to ask questions about the social roles currently available in these systems and the social roles that we have the power to create for our clients. You can consider social roles, role losses and gains and the value of specific roles that you encounter in your work. You can then try to understand how these roles can apply to your client. You can start analyzing how settings impact clients' abilities to enact social roles. Now, Marcy's gonna fill in the details for us in a practical way. Marcy. Thanks. So let's dig a little bit deeper to find out how to think about or create valued social roles when you're working with an older adult with serious mental illness. So the first step would be to assess their roles as you go through your typical getting to know them process. So as you ask them about their lives, think in terms of social roles. What roles do they play that they're proud of or happy with? What role losses do they describe? What hopes do they have that link to social roles? What do they spend their time doing? So let me give you an example. Let's say that you're working with Bruce. Bruce is an older adult with schizophrenia. You know that he lives in a nursing home, so he doesn't hold the role of independent person, which is valued in our society over that of a dependent person. He tells you that he used to have a job selling newspapers, but hasn't worked since sometime before he moved into the nursing home. He also said he didn't really like the newspaper job, but he was not afraid of working. In talking about being not afraid of working, he describes how he used to help his neighbor with his garden, saying how much his neighbor needed him and how he enjoyed that work. He just keeps repeating how he's not afraid of working. So Bruce's description of jobs, the newspaper and helping his neighbor with the garden are both valued social roles. It's clear that he values one much more than the other, and that's important information. Bruce also describes himself as sitting around a lot and doing nothing when you ask about his time. So all of these things might make you think about the real need for some sort of valued role in his current setting that involves maybe helping or showing others in some way how he isn't afraid of working. It's also important to listen to Bruce, not only about the roles that he held in life, but how that might impact his sense of self. This is likely to be most clear when he talks about role losses. Let's see, are we there? Looks like that moved, okay. When he talks about role losses. So let's keep thinking about Bruce's story in terms of social roles. Bruce also tells you that he used to have a pet cat, Smokey, when he lived in a group home. He describes how much Smokey meant to him and how they used to play together. He talks about how others in the group home were jealous of his cat, who was fun and pretty and really loved him. That's describing the very valued role of pet owner. But he goes further, talks about taking care of Smokey, of being responsible and envied by others. And those are powerful things that elevate that role of pet owner. Bruce then talks about Smokey's death and his deep sadness around that. How he felt like he lost the one being who loved him no matter what, and no longer felt like a special person with Smokey gone. That's describing a profound loss of role and relationship as well. So, you know from the story that Bruce and Smokey had a reciprocal relationship. Bruce cared for and loved Smokey, and Smokey played with him and loved him back. That's more important information. And Bruce also describes how he's not allowed to have a pet in his nursing home now, and he's frustrated about not having an animal in his life. So one of the first things you probably know thinking about Bruce, is how much his relationship with Smokey meant to him. As a pet owner, a valued role, he had a reciprocal relationship, he was responsible, he was seen to have status, people envied him. Also important is that in Bruce's current setting, in the nursing home, it's now impossible for him to fulfill his desire for a pet in the same way he did in the group home. So to fulfill the pet owner role and have that key reciprocal relationship can't happen in the same sort of way. Knowing these things about Bruce and the social roles he values, and the ones he doesn't, really lets you think in a different way about how to help Bruce. More than needing something to fill his day, remember he talks about sitting around and not doing much, you also know that he is not afraid of working, and that's important to him. More than knowing that he likes cats from his story about Smokey, you know that he values connections and reciprocal relationships, and he values helping and being responsible. That's a really strong starting place to begin thinking about helping Bruce think about his own social role hopes for his future and how those can be enacted in the setting that he's in now. So, so far, we've talked a lot about understanding clients or patients' history around social roles and role losses in particular, when thinking about our role of helping people find and create valued social roles in their lives. In addition to understanding these past roles and their view of values and meaning, it's also important to understand how any intersecting marginalities and marginalized identities can play a role in the future of our society. I mean, might impact their hope for developing and holding future valued social roles. One question is how does their age or any mental health symptom they might be struggling with challenge their abilities to occupy roles when you're working with older adults with SMI? Well, what other things are there that marginalize their ability in life? Are they homeless? Do they have a legal history? Other physical health problems? These can add more barriers to the can't do list that Kathy was talking about for older adults with SMI. Let's think about Bruce again. We know that he's likely hoping to have valued social roles that make him feel like he's contributing to show that he's not afraid of working and that link him to others that allow him to have connections and reciprocal friendships. But while we're talking with him, we also learned that he has a number of physical health problems. He's diabetic and has neuropathy in his feet. And that really limits the amount of time he can move around. His schizophrenia symptoms are mostly negative symptoms now, but they make him want to avoid people despite the fact that he likes connecting. So due to both of these concerns, Bruce describes himself as sitting around a lot and doing nothing. So with Bruce, it would be easy to fall into thinking about a can't do list for him rather than his strengths. With his neuropathy and his avoidance of people, staff too could inadvertently isolate him further. And that would decrease his ability to occupy roles and have those relationships related to them. But since you're working with Bruce and know a bit about his past valued social roles and are thinking about those and thinking in terms of setting instead of symptoms, you can think about his hopes for the future and how that might translate in this setting. As we know with Bruce, our settings where we live and spend our time impact our role opportunities. This is something particularly important to consider when working with older adults with SMI or really with anyone. If someone lives in the community, they're gonna have very different opportunities merely due to the setting compared to someone living in a residential care home or a nursing home or any other setting with less independence or freedom over your day-to-day life. Similarly, our interactions with other people in our lives can differ based on setting. We don't really think about that much, but that can impact our role options. For example, the people around you will differ based on where you're living. If you live in a community or a nursing home, those settings will influence how the people around you are in contact with you. Whether they're friends, family, neighbors, or helpers, it'll influence how they spend their time with you and what they focus on and how often they see you. Let's think a little bit about settings in Bruce's life. So he lives in a nursing home and his desire for connections with others, his desire to work and help, those are shaped by his setting, his ability to move forward with them, that is. So your assistance to him involves thinking about what type of role he could have in a nursing home that capitalizes on his strengths, aligns with his values, might promote connections for him, and is practical. So let's say Bruce's nursing home, like many of them, might have a gardening space or be open to developing one. In that case, this would allow you to explore with Bruce what it would be like to help develop a garden or work in the existing garden, like he did with his neighbor, and perhaps to work with others that are interested in gardening, but don't know as much as he is. The garden produce could even be used for meals in the nursing home. So a value and importance to the community in multiple ways. Gardeners hold valued social roles. Another option might be, is exploring the possibility of Bruce assisting a therapist who provides pet therapy. Depending upon the therapist or the setting rules, perhaps Bruce could help the therapist identify more people who might be interested in pet therapy and use his affinity with animals to act as an ambassador for the pet, if people are uncertain about interacting with the animals. Ambassadors hold valued social roles. So thinking about valued roles within settings is really important in developing a plan. What we'd like to do now is bring you back into the conversation. We'd like to explore this practical application of using valued social roles in your work with older adults with SMI. To do this, I want to introduce you to Denise in a vignette, and then we can work together to think about our own values, assumptions, and biases, what might play into that can't-do list, and how we might take a systems-focused approach or way of thinking as opposed to a symptom-focused way of thinking to combat that can't-do list. To think about how Denise's role losses, gains, and hopes for the future might help you think about developing a plan with Denise, and ultimately, to think about how you can share the power of your professional role to help create social roles and value within those roles. You ready to meet Denise? Denise is 65 years old and was first diagnosed with schizophrenia when she was 23. As a very young woman, Denise had dreams of being an actress. She loved creating costumes and acting out plays for her friends and later on in high school, she did the same thing with the drama club. Denise went to a local community college when she was around 20 as a step towards getting into a larger school, so she could major in drama. She was admitted to a university when she was 22 and had one year of courses before she had a long hospitalization. Denise today still has a strong interest in the movies and the look of movies and movie sets. Denise talks about her younger life and love of acting and costumes, all aspects of the movie, setting a mood, talks about that a lot. Denise also tells you she's never had a long-term romantic relationship or a child that she'd hoped for. When she describes her wishes for romance in a family, she talks most and most longingly about watching movies as a family and her dreams of helping the child that she always wanted by saying she'd hoped to teach them songs she knows, teach them how to dance, and appreciate all of that look of movies and movie costumes and sets. Denise has struggled with her positive symptoms of schizophrenia most of her adult life and still occasionally responds to voices that she hears. She also has a significant facial tick that is much more apparent when she's emotionally upset. Denise right now lives in a group home for adults over age 40. She moved in about three months ago and that's after living for 10 years in another group home. Denise talks to you about staying in her room a lot and saying that she's not sure how to meet people when she comes to new places. Her tick is worse because she's very anxious. She was upset about not feeling like she fits in and just keeps struggling with that tick. Your work with Denise is to help her in this new situation and if possible work with valued social roles to improve the quality of her life. Here we go. Now that you've met Denise, let's use the chat to think together. The first thing is think for a second and then type in the chat, what might be on her can't do list? What assumptions, what biases or stereotype beliefs might we or even other people at the group home have about Denise? Too old for romance, can't maintain relationships, not in control of her life, can't make friends easily, can't have children. Denise might hurt others. Mental deficits, can't work, can't be consistent, limited, can't have independence, socializing, lives in a dream world, lack of relationships, standoffish, unable to work, limited, dreams not met. Options are limited due to where she lives. She looks weird. The tick will limit engagements. Unrealistic expectations, antisocial, yeah. Can't fit in, unrealistic. Oh my goodness, I don't know about you, but after reading these things, I'm starting to feel like I can't do anything and I'm not even Denise. You can imagine, you guys have done a great job coming up with can't do's and look how they flow, right? That's how our mind works, I think. Let's take a minute. We'll kind of get rid of some of the can't do's and shift from a systems approach, I mean, from a symptom approach to a systems approach in thinking about Denise. All of those things that you so quickly listed on the can't do list, how can we think about them and more as a system barrier, more about what is not right in the system, what that doesn't let her fit in as it stands. So what kind of things are you thinking about with her tick, with her relationships, with her dreams, that might actually be a system barrier than a problem or an issue with Denise? So much negativity for Denise, that's right. More activities at the home, art therapy, group therapy, lack of funding, that's certainly something at a group home that might happen. Social biases, physical space in the home might make it difficult for her, not a supportive environment. Staff turnover, yeah, sure. Lack of belief in herself, right? But flipping that on its head to a systems thing might be a lack of support in the system to realize her dreams, right? Lack of information and chances to learn, encouragement, lack of encouragement, right, funding, funding, funding. Yeah, I agree, Jane. Okay, great. We're doing a great job of thinking about what are the things in the system rather than Denise herself that the system is not letting her fit in. Maybe no phone or computer, exactly, right. Okay, that's terrific. All right, so we thought about her can't-do list. We flipped that a little bit to what is it really about when we think about systems, not about our symptoms, lack of strength-based approach. You've said it in a nutshell, right? Let's shift over then to the roles. What types of role losses or role gains has Denise had? Not a wife or a mother, there's a loss, a student loss, right, loss of mother and spouse role, loss of an opportunity to become a mother, being an actress, friendships, loss of confidence, loss of independent adult. Yeah, lots of losses. What has she gained? Remember, you can lose or gain valued or low-valued roles. Role of a patient, exactly, she's gained that, right. Role of community, dwelling in a residential community, right. Right, member of a different kind of community, mm-hmm, exactly. So those are some of the role losses and gains. She's lost the role that we've said about being a mother or being a partner so far or student so far, she lost those. She gained being a group home member, she's gained a patient role. Loss of status, that's right. I mean, there's status changes in all of that, definitely, that's right. So thinking about the gained ageism, that's right, she's older now, so she gets to deal with that, absolutely. And it's a great question, we'll get back to that about culture too as well. Easier access to care potentially is something she gained, not really a role, but it goes along with her role as patient, absolutely. Okay, then let's move to the last piece of this. We've talked about those biases and everything that plays into the can't do list. We've talked about the systems piece that actually is a better consideration than the big list of the things she can't do. We've talked about her roles, losses, and gains and the things that she values. So taking her setting into account and the system approach of looking at that instead of the can't dos, living this residential community, what comes to mind using your role, right, in this drama, if you will, what types of valued social roles might you help her explore, develop, or enact? Put together a one-act play in the home, there you go. Help decorate the facility she lives in, like for the holidays, entertaining others, care planning activities. So we have a hostess piece, a movie night piece, oh my goodness, you guys are full of so much, so many ideas. Role of teacher, she can teach people in the movies and arts. Right, volunteer to help children be in plays, there's the mother piece attached with the children piece, exactly. Increase those social opportunities, maybe those are some ways to do that. Sewing costumes, exactly. Terrific, facilitate a movie night on a regular basis, a writer's group, teaching songs, right, teaching classes, decorating the group home. Wonderful ideas. Mending clothes of her community members, yeah, if she's not like me who likes costumes but would not sew. Getting involved in other groups online that share that interest, peer supports in acting, drama, singing, absolutely, absolutely. So these are great ideas and wonderful ways to think about those valued social roles that she told you about that she loves. Everything from out of the box things like decorating for holidays because she loves that setting the scene to all of those different other things that have to do with her primary thing that she's talked about as movies and costuming and dance and singing and performing, terrific. And I would say too, when you think about sharing the power of your professional role to help create those, you may have to help the other people in the home understand the importance of this and see, you know, lend your weight behind Denise in asking for these things. Because if you think back on that list of can't do, one thing that really stuck out to me was impractical goals, right. She had impractical goals. Somebody said that, I can't remember the exact phrase you used, but that really stuck out to me. And that could be one of the barriers that you find with her. So if you go back to, I'm going to read this one. If you go back to the identity piece, feeling valued for her dreams lost or otherwise, acknowledging that that loss and ways to gain things back in a different manner. Yeah, that could certainly help Denise. And it might also very well help the staff in the home to understand why you would be thinking with them about changing what they do to incorporate those movie nights or other things. Okay. So the takeaways here, and thank you all for playing. This is terrific. The takeaways here is that you can think of it as small as the new big. Consider what matters to the individual and what they value when you're thinking about valued social roles. Helping people explore, develop and enact valued roles in their setting is not easy though. And I think that's important to say. And it's seldom straightforward because typically we are not working in systems that are constructed and encouraged to develop valued roles for individuals. As a matter of fact, I would even say that a lot of settings and a lot of times, even professionals really don't have the faith that older people with serious mental illness can enact valued roles in the work that they do. But that said, we know that holding valued roles for older adults with SMI is as important in their lives as it is within anyone else's. And we know that when an opportunity to hold a role is available, older adults with SMI have a can-do list if we shift our point of view. And we know people with SMI often hold valued roles that are under the radar, which doesn't help when people are, the under the radar piece doesn't help when people are trying to think about older adults with SMI. So I want to just briefly describe a couple of studies that I think really underscores this piece of under the radar roles, and it has to do with caregiving of all things, right? So we're talking about people's lives. We don't understand that oftentimes adults with SMI in the community provide things like even caregiving assistance. One study had over 570 adults with a relative with SMI. So they were interviewed, the adults who had the relative, and they said that 67% of them received help from their relative with SMI for ADLs, and 37% received help with financial assistance. Another study had 1,800 people with psychosis. They were interviewed about providing care, help, or support to other people. And again, that's what a lot of valued roles are, those connections with other people. Over 14% of them provided care to others. And those that didn't provide care reported, those that did provide care reported better social connection and functioning than those didn't. So in other words, people with serious mental illness and older adults with serious mental illness can occupy those roles. And older adults can also be cared for by people with serious mental illness, as we see by the family members that are providing those care. So it really is about providing the role. So that's what we have for you today. I'll turn it back over to Erin. Wonderful. Thank you so much for such a fantastic presentation. And if you want to go ahead and take the slides down so folks can see your faces as you address some of the questions. And we'll invite folks to drop questions into the Q&A. There have been a couple of questions that have come in back channel. You know, you talk a lot about trying to think about valued social roles for older adults. And as Mariana pointed out in the chat, that this is sort of a standard process for OTs. So occupational therapists are used to doing this. That's just what they do. But many of the rest of us in helping professions are not. Are there helpful ways to assess for that or tools that we should use or ways to incorporate that into a standard interview? Well, I think for me, and I'd love to hear what you think too as well, Kathy. When I think about this, a lot of it has to do with rethinking the information that you get from the normal process that you go through with your clients. So I'm a clinical psychologist, so I approach things in a particular way. But I probably get the same kind of information that a social worker does that a lot of other people do. So it's really more about shifting your point of view in your head to hear things in a different way, right? Like we were talking about with Bruce. Yeah, you can encode Bruce likes cats because he had a cat's monkey. Or you could encode that Bruce had a valued social role as pet owner that gave him certain opportunities to do things that gave him certain value and status. And so recreating a role, maybe it has to do with pets if possible, maybe not. But you know that he really likes the undergirding of that role, right? He likes having a reciprocal relationship, being supported, helping others, and having status. So that's what I would think. Kathy? I think that that's a really good point, Marcy. I also think that the more we know, understand, assess systems that our clients are in can really help us to be creative. And so if I'm seeing older adults with SMI in a nursing care facility, then what connections have I made to staff at the facility? What do I know about their recreational activities that they typically do? Some of this I can find out from my clients who perhaps don't go to X, Y, or Z group, all right? But I feel that I'm more knowledgeable and able to think creatively when I do know more about the setting in which our clients are embedded. And so I just really want to emphasize that finding and creating valued social roles for our clients in the setting just captures our creativity. Like, oh, we're listening, like you say, with a system's ear to our clients, what is behind, you know, Bruce's love for Smokey. But we're also connected to settings in some ways to say, well, gosh, do they already have pet therapy? How can Bruce get involved? Oh, who do I talk to about us getting pets in? You know, that notion that we are thinking about systems and learning about them. Thank you for that. And I think, you know, as you've mentioned the system so many times, and there are several questions that have come up about the rigidity of systems and systems that may not be as supportive of those kinds of role creations. Can you talk a little bit about that and how to get creative with rigid systems? Marcy, you want to start? Sure. So I think it has to do with a carrot and a stick benefit piece, right? So when I'm in a rigid system, and I've been in a few, I think that it's important to understand what the gatekeepers, because there's always gatekeepers, typically the staff that have the most interaction with people, what are they hoping for, right? So typically they're hoping for easier days. You can pretty much apply that, I think, across the board. So what's going to make their day easier? And how would the creativity that I'm trying to generate in working with this client, how would that help them? So I would say if you've got a bunch of people, you think about Bruce sitting in his room doing nothing, you've got other people that are frustrated, what we know from the research that being active, having something to do, having something to keep your mind occupied, moving around, all of those things help all of us. But most importantly, in those settings that tend to be more rigid, which are those ones that tend to, you don't have much autonomy in as a patient or a client. So making it a win-win for staff and the people that you're trying to work at is kind of the way that I try to approach it, knowing, I mean, you have to be forthright, it's not like tomorrow it's going to be a win-win for everybody, there's a path to go down, but I think that that's the main way I've been most successful. Kathy? Yeah, I think that those are really excellent points, Marcy. And in terms of rigid systems, sometimes I find that there are, I don't know, secret advocates, okay, so that there are staff members who recognize the rigidity of the system. And you say, oh, well, they don't have power, but when you talk to them, they often have really good ideas about who does have the power, and, you know, and how things can be navigated, you know, and again, it goes back to what you said, that there's a benefit for the system itself. But oftentimes, there are really lovely, dedicated staff members who would like to see some of the same changes that you would like to see, and the ability to create alliances, and, you know, and work on, you know, perhaps Bruce's behalf, but just to open that little space that it may be Bruce and his next door neighbor, Sally Sue and Jerry, I think that it can really be a bit of a snowballing effect. I think, though, that you have to be prepared for two of my favorite things, which is, one, we tried that before and it didn't work, okay, and two, some other greater mysterious entity doesn't let us do that. We'd love to, but we can't. And, you know, sometimes I often expect that, like I'm listening for that. And then it really becomes a chance to understand more, well, what happened in ought six that it didn't work, and what, you know, and who is it that says, you know, no, we must do it this way for insurance purposes. I always like that one. You know, that a priori, if you expect these systems resistances, you can think a priori about ways to help navigate them, as opposed to being shut down by them. And again, easy for me to say, I'm sitting here, but it often happens when we are trying to move the system just a little bit one way or the other. Yeah. And I do just think that that question, what do you do when you work in a rigid system, may be at the core of all of this, because what we're doing is talking about that kind of change. And the way, one of the main reasons I have faith that this works is an early experience that I had in graduate school, when we were working in a supportive housing organization for adults with serious mental illness. And it was an absolutely no pets rule, no pets, no, no, no, about 80% of people had pets. And those secret advocates were the case managers. So I know those people exist as well. And, and of course, they talked about, we tried pets before it didn't work at all of those system barriers. It was classic, right, ultimately ended up getting a pet policy in place, because we were able to anticipate that, oh, no, no, no, no, we can't make this change. So I think that, you know, Kathy couldn't be more right, that will be the very first thing that you run into. And so thinking about how can you make it a win win what has happened in the past, and what are you most afraid of you being the system? What are you most afraid of happening? So thank you for that. And you know, you're highlighting the people within the system, right, because the people create a system. And one of the people in that system is the older adult themselves. And there have been several questions about, you know, when the older adult themselves is has has either internalized that ageism, or internalized that bias, that they don't, they can't hold these kinds of roles, or, as Chris points out, you know, somebody who has chronic pain and thus can't do list is extremely long. How would you suggest engaging that older adult in shifting from the can't do to potentially the valued roles? That's a great question. And I think that's where we have to be, it's kind of a reminder to be careful around thinking about doing as being a role. It's easiest to talk about jobs and things we do, right, and which involve movement and things like that, as opposed to things that involve thinking, or imagining or talking or other things like that, right. So that's why I think although OTs have a leg up on helping people to do, it does go beyond that. And let's say if you have a lot of pain, what's one of the best things to do to help with your pain that doesn't involve medication and stuff is a distraction, right? So focusing on other things, and how what's the best way to do that? Sometimes it's teaching, it's often thinking and trying to talk with someone about something interacting. So it could be that you don't talk about this as a role or things that you do, but a way to help in other ways so that the social role piece can be in your head totally, you don't have to say, we need to think of a valued social role for you. You can say, we need to figure out the best way to help you with your pain right now, or you're fill in the blank right now. And your ear is listening for that and knowing all of the things that go with social roles, because we all want to feel valued. And we want to give value typically, because that's part of that reciprocity to give and take with it. So I think if you can listen with that ear, whether or not you say the words valued social role, or things that you do, you're really thinking about how that way of thinking can address the problem that they have, as opposed to, because if you anticipate that barrier, right, just like with the system, if you anticipate this person has a lot of pain, there's a lot of stuff that or physically, it's going to be a problem, then you're going to shift your thinking to begin with and kind of scoot around that barrier with them. You've got it. So thank you for that. I think, you know, there, I think, as is reflected in the chat, this way of thinking is new to a lot of people. And so, you know, you're kind of giving some some wonderful ways of thinking about this. And there are a couple of folks who've asked about any additional resources or tools I you know, I'm thinking about like the older adult pleasant event schedule is wonderful when you're trying to engage an older adult in pleasant events or behavioral activation, and they just can't come up with anything that they like, well, here's a list of things you can consider. Are there any additional resources that exist for folks to use when they're just kind of getting their feet wet and thinking about this with older adults? So I don't know of any because people don't tend to think social roles first, they think lots of other things first, and it kind of leads to social roles. But what I would say is it does have to do with a shift in thinking if you have favorite tools, like that pleasant activity tool, anything like that, that will help you sort of help them think about what they like to do what they want to do what brings value into their life. Right. But if you ask somebody that what brings value into your life, well, that's quite a head scratcher as opposed to what do you like to do on every Saturday? That you can answer more easily. So you may have to make those linkages using the tools that you like already. So I think it really is, at least for me, it's a shift in my head. And I can use, I don't care what it is, you know, if the PHQ-9, you turn your question on its head and then ask it the other direction, something that leads you to help them explore that value. I also think that when we're thinking about the value of older adults, that one of the things that always comes to my mind is that they've been around for a long time, okay? That they know things. And we did a study not long ago for older adults with serious mental illness who were in psychosocial rehabilitation clubhouses. And we did a photovoice study where they went around and took pictures of their neighborhood and focused on issues of integration and barriers to integration. And one of the things that really came out of the study is the notion of history. That people in their pictures could tell you, look, this is the way it was now, but, you know, 10 years ago, it was really different. And it worked better 10 years ago because they had X, Y, and Z. And I guess that that seems obvious, particularly to many of you out there who work with older adults, that they have this time perspective. But oftentimes we talk about this as kind of reminiscing and helping older adults to reminisce, and this is good for the older adults. But if you think about it in a systems perspective, it's also good for our understanding of the system and how things were and how things are now. And, you know, to be able to take the passage of time and turn it into a valued social role. You know, the role of historian is more than just all of the benefits for the individual of reminiscence. It's ready to grab. It's right there. Because when you're dealing with older adults and older adults with SMI, they were young. Or people with SMI have been in the system for years and years, decades, and they know how the system has changed. So again, it's not necessarily a tangible resource, you know, use this inventory, but it's something that we know about older adults and adults with SMI. Well, and as I'm listening to you talk about sort of, you know, weaving those stories and listening to those stories, one of the things that would come out in those stories may be culture or religious background. And I'm wondering if you can comment a little bit on that as it relates to valued social roles. Go ahead, Kathy. Bring more of yours. That's only fair. Gosh, I think that we recognize that many, many people are part of faith communities that they have religion as a or spirituality as a primary aspect of their lives. And I think that even though many helping professions are secular in nature, that we appreciate what those religious or cultural underpinnings mean in people's lives. And it may be that others in the setting can share some of those, you know, faith-based beliefs. It may be just trying to understand what it means in the role of, you know, being a Christian, being a Jew, you know, what is in what encompasses that role for the clients with whom we work and to see how that is valued and how it can be valued in the setting that our clients find ourselves in. Yeah. And as you're talking to Kathy, I'm thinking a lot about some stories that I've been hearing about culture recently and how various groups of people when they move to new countries are mourning the loss, what they feel like is a loss of their culture because they're kind of embedding themselves into a larger culture. And I think that when you talk to people about their stories and whether it's, you know, religious traditions or other cultures, helping people keep them alive, right? And it really does kind of go back to that historian piece. So who do you, and this is the connection part too, if you're the speaker, who's your audience, how can you connect people to someone or some group of people that allows you to keep that culture alive, allows you to keep that religious tradition alive. And that is certainly a very valued social role. You think about way, way, way back in time, everything was an oral tradition, right? So is there a way to recreate that oral tradition that allows people to participate in that way? Also sharing those stories are about forming community. When you have a sangha, when you have a group that you are with that shares your values, that can be really powerful. And so whether it's spiritual or not, maybe you get together for Friday night dinner, right? Maybe you get together for whatever. And that sort of sharing might be another way to do it, particularly when you think about older adults with SMI and meaning making. And as I listened to that, I'm sort of envisioning this group home where the Lebanese person and the Irish person and the Jewish person are getting together for dinner and they're taught tonight is Jewish night. So we're having whatever, and I'm going to talk about my, so they don't necessarily have to be the same culture if they're sharing, this is who I am as a valued social role. Right. You don't have to preach to your choir. It's about getting that together and let's start that home. I like that idea. Let's do that. Great. So, you know, the other piece about that, and, you know, Cathy, as you mentioned, the idea of religious traditions in particular, and there are folks who may have delusions about their role in a particular religious tradition. And there are some questions about, you know, working with clients to achieve certain valued social roles, but what if somebody thinks they're not realistic or, you know, do you work to achieve somebody's valued social role of Messiah? You know, how do you address those elements that may be a piece of the psychosis or, you know, maybe not, we may not know. You can speak to that. It's your turn to start, Nelson. I think, again, it's about digging deeper. So, I mean, Messiah is a tough one. Maybe people would want to be a Messiah. I don't know. But when you think about aspects of that, just like you think about aspects of any other valued social role, what does that mean? You have stories to tell. You have people to lead. That's what Messiahs do, right? They tell you the way things are. They tell you their points of view. So, I kind of go back to that storytelling piece. Can we talk about how do you see life, the universe, and everything? How do I see life, the universe, and everything? And a lot of it is really putting this sort of symptom aside, right? I mean, everybody's been around somebody who has some sort of a tick. Maybe you clear your throat all the time. I scratch my head all the time. People do stuff, right? So, if you can set those pieces aside and look what's behind them, then sometimes that allows you to move to a different level. So, if you are thinking about that particular person, how do you help them get into a leadership role in some way? So that if they're preaching as a Messiah might, then maybe it's seen in a different context and is more tolerable by others. That sort of thing is the thing that I think has worked for me particularly around that part. But it does require you to think about a system because the person doesn't exist in isolation. So, maybe this is an opportunity to talk about what we all do. Scratch our noses or clear your throat or talk about being a Messiah. We all do these things. Can we move to the next step then? What's next? Right. And again, I think that when we talk about systems over symptoms, that folks might get a really Pollyannish view that, no, we're ignoring people's symptoms and that that's dangerous. I don't think that's what we're saying. We're saying that people are more than their symptoms. And yes, of course, we're talking about, you know, we're both clinical psychologists. We understand the individual level limitations that particular conditions put on people. And so we're not saying, no, no, be blind to symptoms. We're saying that people who have symptoms are more than that. They have values. They have dreams. They have aspirations. And if we only take, you know, the symptom view, then we can't see beyond the symptoms. And so I just want to make that clear that we're not trying to be Pollyannish. Well, I think that idea of looking beyond the symptoms is exactly the right take-home message to wrap up on. And wanted to just say thank you so much, Marcy and Kathy, for this wonderful presentation. The gratitude has been pouring into the chat since you finished your formal presentation and so many wonderful resources. There was also just one question about adaptive equipment for folks who are challenged to engage in their valued social roles, to which I would let you all know that coming this fall, we're going to have an occupational therapy presentation coming up that are going to be able to talk about all kinds of options, because as we've already discussed, occupational therapists are wonderful in this space, both equipment-wise and social role-wise. So keep an eye out for announcements about that and for our many other upcoming presentations. Thank you all so much for being here. Thank you, Kathy and Marcy. Thank you, SMI Advisor, for co-sponsoring. Thank you, Illinois Department on Aging, for co-sponsoring. So excited to have so many people. This is one of our biggest events that we've ever had, and so many people invested in this space is a joy to my heart and hope that you all go out and help the older adults who you work with to live their best lives by identifying their most valued social roles. Thank you. Thanks all so much. Have a great day.

learning community event

valued social roles

older adults

serious mental illness

systems approach

symptoms

clients

practical strategies

creating social roles

supporting social roles

mental health workforce

partnerships