5. Needs of the cognitively disabled in the community setting with special training and staffing considerations.

  • Care Of Clients With Mental Illness/Mental Retardations.

            2.1. Effective communication.
    Care of Clients with Mental Illness/Mental Retardations.

            How to care for residents with mental illness and mental retardation? The clients in your home care agency come from a variety of backgrounds, have different life experiences and have unique personalities. Some are easy-going and cheerful. Some may like to argue. Some are very active. Others are relaxed and content. In addition to the basic differences, many may also have impaired mental abilities, whether it has been a condition all of their life or a more recent onset. As a direct care staff person, it is important to have a good understanding of each resident with whom you will be working, including those who have mental deficits or impairments.

            In this session we will look at the three main causes of cognitive impairment. You will be able to identify the symptoms, describe some of the behaviors common to these conditions and identify methods of interaction that are most effective in dealing with challenging behaviors.

            Every person is different, and everyone has good days and bad days. It will be important to get to know each resident and develop your skills in working with each resident as an individual.

    Mental retardation:

            What is mental retardation? A person with mental retardation has lower intellectual functioning – meaning his/her IQ is significantly below average. He/She may need help with the daily living skills needed to live, work and play in the community. These include communication, self-care, social, leisure and work skills. Mental retardation can be caused by any condition that impairs development of the brain. Some common causes of mental retardation include genetic conditions, problems during birth, alcohol and drug use by the mother, some childhood illness and exposure to toxic materials.

            The abilities of people with mental retardation vary. Most people with mental retardation are mildly affected and are able to learn new skills. With appropriate supports all individuals with mental retardation can live satisfying lives in the community.

            Clients with mental retardation have social interests and needs that match their age. Keep this in mind as you consider the music they like, the clothes they want to wear and the activities they enjoy. It is important to get to know the abilities of each person and allow as much independent decision-making as possible. It is also important not to talk to or treat a person with mental retardation like a child. She/he is an adult who likes adult activities and has adult interests.

    Mental illness:

            What is mental illness? A mental illness is a disturbance in behavior, mood, thought process, social skills or interpersonal relationships. There are many different types of mental illnesses and different levels of severity.

            A client with a mental illness may be younger and in the home due to his/her care needs, or the client may be elderly with a mental illness. These will be important issues to know about each individual. A client with a mental illness may feel deep sadness, may hear voices, may be very suspicious of others, may change moods quickly or may have emotional highs and lows. These are symptoms of mental illness and not a person’s choices or bad behaviors.

            Many people with mental illness are treated with medication under the care of a doctor. These medications can greatly reduce the symptoms of the illness, but many often have unpleasant side effects. It will be helpful to you and the client if you take the time to learn what medication is being taken, and the side effects. You may also notice that there is frequently a cycle that occurs with some mental illnesses. A person can be doing quite well for a period of time, and then start to slip into some of the symptoms of their illness. This can be a challenging time for everyone. There needs to be a re-evaluation by the doctor and possibly an adjustment in medication or in the person’s program or environment. As a direct care staff person, you are part of the team that observes behavior. If you are noticing changes in behaviors, be sure to follow the home’s system for reporting and documenting. This will be very helpful to others in considering treatment options.

  • Behavior management skills for working with clients with cognitive impairment.

            2.1. Effective communication.

            Now that we have a basic understanding of three of the most frequent reasons for cognitive impairment, we will look at some basic behavior management skills.

            As stated throughout this training, you are likely to be faced with challenging behaviors on a regular basis. If you develop strong skills in managing these behaviors and in communicating effectively with clients, this will help you in dealing with difficult situations and provide better care for the clients in all aspects of your job, from helping with ADLs, to encouraging clients to take part in social activities in the home or in the community.

            “Behavior management” involves using certain techniques and ways of interacting in order to increase or decrease certain behaviors. It can be very effective, but it is not a quick fix, and it must be used consistently.

            Think of your behavior management skills as tools in a toolbox. In this toolbox you have many different and effective ways of dealing with people and behaviors. Depending on the behavior, the person and the situation, you will affect the decision about which tool to use. Sometimes it may take a few tries to figure out what will work best, and some days it will be harder than others, but we will begin by placing some tools in our toolbox.

            Remember, we are just touching on these basic principles. There is much to be gained by learning more about positive behavior techniques, and you are encouraged to seek out additional training, observe people who use these techniques effectively and take notice of your own interactions and how you can improve upon them. In addition to the basic ideas we will discuss here, residents in your care will have specific support plans developed by the care team. It is important to become familiar with these plans and use your skills to follow them.

    Tool # 1 – Ask questions to figure out the reason for the behavior.

            There are many causes of behavior. If you notice a change in a client’s behavior, talk with other members of the care team to find out what might be going on. If it is an ongoing problem, first look to see what the cause might be. You may need to observe for a while to see what might be happening.

            If a client is in pain, for example, it is important to take note of things such as whether he/she had a recent fall or whether they have recently been ill. If a client is not eating enough at mealtime, this may be a problem with his/her dentures fitting okay, it may be a problem with chewing and swallowing or it may be that he/she does not like the food. Watch to see when and how much the resident eats. Watch the client’s facial expressions. Watch the resident’s reactions to the people sitting at the table. What has changed recently?

    Tool # 2 – Use positive reinforcement/rewards.

            If you see a good behavior by a client, praise the good behavior. Behavior that is rewarded will be repeated.

    Tool # 3 – Listen with understanding.

            When we show a person that we are interested and want to understand their feelings we are showing that we care about them as a person. We connect with them on a more personal level which can help them feel less lonely. We show this by listening to the resident and talking with the resident. Try to understand the client’s feelings.

    Tool #4 – Smile and keep it positive!

            Believe it or not, a smile can go a long way when working with people. The times you feel least like smiling are when it will be the most important that you make your best effort. Take a deep breath, go into the room with a smile and be positive.

    General Guidelines

            The following are some simple guidelines that should help you in dealing with care recipients who have cognitive impairments:

    • Speak slowly.
    • Keep conversations short and simple.
    • Do NOT argue or reason with the care recipient.
    • Write down instructions, keeping them simple and step-by-step.
    • Do tasks one-step at a time?
    • Provide objects that make things easier, such as slip-on shoes, finger foods, etc.
    • Maintain a routine. Change of routine adds confusion.
    • Use the memory loss to your advantage to distract the care recipient.
    • Provide a safe living environment.
    • Label drawers, cupboards, and doors.
    • Encourage as much independence as possible.
    • Approach the care recipient slowly from the front.
    • Limit the choices the care recipient has to decide among.
    • Play music since it is therapeutic. Make tapes.
    • Use validation therapy. (Explained below).
    Validation therapy.

            Accept and acknowledge when they are feeling paranoid, afraid, etc. and talk about those feelings. Don’t try to convince them their feelings are wrong.

            Look for hidden messages:

    • If the care recipient makes baby crying sounds, it could mean they feel like a baby in a crib when in a bed with the side rails up.
    • Looking for parents could mean they feel lonely or scared.
    • Wanting to go to work could mean a feeling of uselessness.
    • The care recipient cannot express any of these feeling in the usual way. You have to search for them and interpret them.
    Nonverbal Communication Techniques

            Care recipient with cognitive impairment will have difficulty communicating with you and understanding your communication to them. Use the following techniques to help you:

    • Use low-pitched voice.
    • Use gentle touch.
    • Give more time for a response.
    • Approach care recipient slowly and calmly. Never display any frustrations you may feel.
    • Get rid of as many other noises as possible.
    • Have care recipient point to an object.
    • Label drawers, etc.
    • Have recognizable pictures in view.
    • Cue care recipient to begin task by pointing, touching, or beginning the task for them.
    • Observe non-verbal behavior for clues.
    Wandering Behavior

            Your care recipient may display the behavior of wandering. This can be the result of restlessness, of a search for something, or of unexpressed feelings. Here are some techniques to help you with this behavior:

    • Surround the care recipient with familiar objects.
    • Remove trigger objects, such as coats or suitcases.
    • Check care recipient often for hunger, thirst, or need to void.
    • Keep the care recipient occupied with a task.
    • Put up stop signs or barriers at exits. Cover knobs.
    • Use the care recipient’s memory loss to your advantage by distracting them with something more appropriate.
    • Give the care recipient something active to do.

            Repetitive and/or Inappropriate Behavior As in every other situation, remember that the care recipient does not know that what he/she is doing is repetitive or inappropriate. The part of the brain that would know this is no longer working properly. Do NOT scold or yell at them. Instead, try some of the following suggestions:

    • Be non-judgmental.
    • Calmly suggest a new task that is more appropriate.
    •  Look for antecedents – something that always happens before the behavior.
    • Plan activities to keep the care recipient occupied.
    • Offer reassurance.
    • Praise the care recipient when the behavior is appropriate.

            Use positive statements. Tell the care recipient what you want him/her to do, NOT what you don’t want.

  • Guidelines for communicating with the physically and verbally aggressive client.

            2.1. Effective communication.

            Most of us are able to sit back and assess a new situation. We can decide if we like what we see, whether or not it is safe, and if we are not comfortable, we can simply avoid it. And as we gain experience in the world, this process becomes easier because we have encountered similar situations before: the learning process has become more efficient. But for the client with cognitive impairment this is not the case. Because of their impairment, many situations – even ones they have encountered many times before – can seem new. Like everyone else, this can make them anxious, but unlike most people, they cannot draw on their past experiences to interpret what is happening now. And they cannot quickly assess what is happening because of their impairment. Not surprisingly, they feel vulnerable and afraid. And many people, in those situations, will feel they need to defend themselves and become aggressive. It can be very difficult to work with someone who is confused and aggressive. You need to keep that person safe, but you must also protect yourself and others. Fortunately, with some common sense and a little planning, you can accomplish these goals. · Do not indiscriminately use force: Using force can often backfire. Certainly, there are times when you need to physically restrain someone. But when and how to do so should be clearly outlined in the policies of the institution in which you are working. Make sure you familiarize yourself with them before these incidents happen. · Stay calm: It is natural to become excited when someone is acting aggressively. But many times, if you allow that person to express the anger, the possibility of physical violence can be avoided. Most people have a natural aversion to harming another person, so give the person who is angry the opportunity to be verbal rather than physical. · Use reason: Try and remember that the person who is acting aggressively is not doing so to harm you. That person believes that he/she is trying to protect themselves. Don’t give them another reason to feel threatened. Be quiet, rational, and calm.

            Behavior may disguise a client’s need for comfort and understanding.

            How do I communicate in difficult situations? If care recipients are angry, try not to take it personally. Often, they are upset about the situation and don’t know how to handle it. Give them some space and listen to their concerns. Do not raise your voice or get defensive, this will only add to their anger. Sometimes the best thing to do is not to respond but just to listen.

            Recognizing the link between actions and needs helps build good relationships. Keep in mind that residents in long-term care are adjusting to changes in their lifestyles that affect them physically, emotionally, and socially.

            Difficult behavior may signal a need for comfort and understanding. Or it may be an attempt to be in control when a person feels powerless. For example, rather than being annoyed when a resident continua uses the call light, stop by often to offer reassurance.

            Basic psychological needs are the root of most conflict. Following are four basic needs identified by Dr. William Glasser for motivating behavior.


    • Loving, sharing, and cooperating.


    • Achieving, accomplishing, being recognized and respected.


    • Making choices


    • Laughing and enjoying

            Difficult behavior is a symptom of a problem (e.g., anger, fear, boredom, loneliness). Look beyond the behavior for possible unmet needs. Try to recall any incidents that might have triggered an outburst in order to avoid future problems.

            In difficult situations, stay calm and reassuring. Pay particular attention to your voice (tone and volume), your posture, facial expression, and other nonverbal signals. Be willing to listen to concerns, and assure clients that you care about them.

            Coping with changes can be difficult for anyone. The elderly face significant changes that can bring a sense of loss, loneliness, frustration, fear, depression, lack of self-confidence, and many other unpleasant feelings. If a client seems upset, ask how you can help, and take time to listen.

            Consider some of the concerns that affect the elderly, and show compassion (sympathy for another’s suffering):

    • Change in lifestyle, loss of independence health problems, pain, unable to sleep;
    • Unmet physical and social needs;
    • Longing for the “good old days”;
    • Confusion;
    • Loneliness;
    • Lack of control;
    • Financial concerns;
    • Family problems;
    • Facing mortality (death).

            Individuals cope with problems and frustrations in different ways. Some people take out their anger on everyone; others may be quiet and withdrawn. Some people blame everyone else for their problems; others blame themselves for everything. Some deny there is a problem; others try to find a reason or excuse for everything.

            Sometimes residents are uncooperative, demanding, threatening, rude, stubborn, or unpleasant. Do not argue or feel hurt. Be calm and supportive. Try to look beyond the behavior to the underlying need for comfort and understanding. Identify and encourage coping ·skills that help the client (and you) deal with difficult situations.

  • Dealing With Emotional Barriers.

            2.1. Effective communication.
    Controlling Your Feelings

            Being a Personal Care Worker can be stressful and demanding, both physically and emotionally. To stay motivated and to provide quality care, keep a positive attitude and take good care of yourself.

            When you feel overwhelmed, ask for help and be open to suggestions. Consider ways to work smarter (not harder), and use your time wisely. Balance work and your personal life. Leave personal problems at home, and leave work-related issues at work.

            Being a Personal Care Worker requires a sincere desire to help others and a genuine interest in the sick and aged. You must be able to treat all people with dignity, including people with physical, mental, or emotional problems.

            Your attitude affects the behavior and well-being of the clients. Whenever you feel frustrated, try to understand why you feel that way. Do not take out your anger or irritation on others.

            If your feelings are out of control, do whatever is necessary to secure the area, explain that you are up-set, and excuse yourself at the earliest opportunity.

            Never express anger toward the clients. Find a quiet place until you are in control of your feelings. If you are unable to cope, ask your supervisor for advice.

            Always treat clients with patience, caring, empathy (sharing another’s emotions), concern, and kind­ ness. The clients’ well being is your primary concern. If you have a problem coping with difficult behavior, ask your supervisor for help.

    Set your feelings aside, and always provide the best possible care.

            Good interaction with the clients is vital. Emotional barriers can block communication and prevent positive interaction. As a PCW, it is important not to let your feelings interfere with providing the best possible care for each client.

            Everyone has the same basic needs, but each person is different than anyone else. Differences in the way people look, think, or behave sometimes cause misunderstandings, fear, or frustration. You may have negative feelings about certain beliefs, religions, races, cultures, backgrounds, or experiences. Regard­ less of your personal feelings, each client has the right to quality care.

            Listen to clients with an open mind. Respond to problems or complaints in a caring and courteous manner. Supportive feedback strengthens self-esteem and builds good relationships. Following are examples of caring responses to problems and concerns.

    • Tell me more about the problem.”
    • “How can I help?”
    • “You seem upset, and I want to help you.”

            Avoid being defensive. People tend to lash out whenever anything threatens their self-esteem. Defensive behavior can destroy relationships and affect work performance. Respond to hurtful comments in a calm and controlled manner. Try to resolve issues without feeling angry or hurt. If you make a mistake, admit it, learn from it, and move on.

            If your supervisor offers suggestions, accept the comments without feeling defensive or making excuses. Constructive feedback is an opportunity to improve your work performance.

            Make clients feel good about themselves, and avoid situations that make them feel defensive. Create an atmosphere in which clients feel accepted and confident to talk freely about their thoughts and feelings.

            Consider your attitude toward illness and health care. As a PCW, you will interact regularly with people who depend on you for physical and emotional care. If you enjoy helping people, being a PCW is very satisfying. If not, you should consider another career for your own sake as well as the clients’ well-being.

            Avoid the following behaviors that are emotional barriers to communication:

    • Acting impatient, irritated, or annoyed;
    • Ignoring, acting bored;
    • Threatening, shouting, or using harsh language;
    • Judging or giving advice;
    • Arguing;
    • Interrupting;
    • Changing the subject;
    • Belittling;
    • Being defensive.
  • Meeting the Care Needs of Clients in a Culturally Diverse Environment.

            2.1. Effective communication.

             You may be thinking: Why do I need to know about the different cultural backgrounds of clients? By becoming more aware and appreciative of the cultural differences among the clients, you will be better able to show respect for individual clients, provide assistance in ways that are culturally familiar to clients and develop positive relationships with clients.

            Throughout our history, many people from many different backgrounds have come to live in the United States. Historically, a number of people have come from other parts of the world to make their home in the United States. There are people of different races. There are people practicing in many different religions. Some speak a language other than English. Many have different beliefs, values, ways of communicating and ways of thinking based on their cultural background. In order to provide the best quality care and give everyone the respect they deserve, it is important to understand how culture affects the way we live our lives every day.

    What is culture?

            First, let’s take a closer look at the meaning of culture. Culture is a set of values, beliefs, and behaviors. Culture is the “truths” that are accepted by members of the group. Most cultural rules are not written down. We learn from other members of the group. Culture is like the air that we breathe. It is something that we do not think about directly. We take it for granted.

            For example, in some cultures, older people are the most respected age group in society. Older people are valued for the experience and wisdom they have gained during their long lifetime. The place of honor in the family goes to the oldest person. Members of the family seek the advice of the older persons. Older people are proud of their age. This cultural belief is true in many Asian cultures like Chinese or Japanese cultures. Yet, in other cultures, youthfulness is valued more than older age. People try to stay young as long as they can. Hair coloring and plastic surgery may be used to maintain a youthful appearance. Older people are thought to be “out of touch.” Children hold a special place in the family. This belief is strongly held by many in the United States.

            We also see some differences between cultures in terms of attitudes and behaviors related to caring for older adult members of families. In some Asian and Latino cultures, for example, when parents get older they typically move in with one of their children, who are expected to care for them. Such expectations are less common in the U.S.

            Culture is very important because we tend to interpret other people’s behaviors through our own culture. We expect others to think and act the way people in our culture think and act. We even interpret their behavior through our own expectations. When people from a different culture act differently than people in our own culture, we may consider their behavior to be strange, inappropriate or even wrong. The important thing to remember is that differences in cultures are not good or bad; differences in cultures are not right or wrong. They are just different ways of doing and thinking. Direct care staff persons need to understand and be respectful of cultural differences.

    Examples of cultural differences

            What are some cultural differences you might experience with personal home care clients? Many cultural differences are related to how we talk and listen. You have learned about the importance of good communication skills in earlier modules. Now we will learn about communication skills as they relate to cultural differences.

    Eye contact:

            One area is eye contact. Research has shown that when Americans talk to one another, they tend to look at each other directly in the eye. This sends the message that the other person is listening to you and is interested in what you have to say. It is a sign of respect. Yet, in some cultures looking directly in the eyes of another person may be a sign of disrespect. This is particularly true when the person is speaking to someone in a position of authority, such as a doctor, a nurse or a caregiver. Direct eye contact may be interpreted as being a challenge to one’s authority. Looking down or at the floor may be a way of showing respect for the person in authority. People from Latino cultures, such as Mexico and South America, may practice this cultural behavior. Therefore, when you are giving them instructions, they may not look you in the eye while you are talking. This may be a sign of respect for your authority.

            In some Middle Eastern cultures, direct eye contact between a man and a woman is considered a sexual invitation. In general, direct eye contact should be avoided with Middle Easterners of the opposite sex.

    Direct and indirect styles of communication:

            The use of directversus indirect styles of communication is another difference in cultures. Many Americans tend to use a directstyle of communication. They tend to be open, honest, direct and precise. Assertiveness is respected. If you have a problem with someone or something, it is okay to speak directly about the problem and try to get it worked out. The belief is that trusting relationships are built on openness and honesty.

            However, people in many cultures use an indirect style of communication. In these cultures, it is very important to avoid embarrassment for oneself and for the other person. Therefore, one may use a roundabout way to let the other person know there is a problem. This can be true for many people from Asian and Latino cultures. Rather than saying directly that there is a problem, the resident may hint at the problem. It will be important for you as a direct care staff person to pick up on the hint. If you are uncertain, it is best to ask questions to try to understand the message the resident is really trying to convey.

    Use of the word “yes”:

            Use of the word “yes” as an answer to a question can sometimes be tricky. In some cultures, particularly Asian cultures, people may try to avoid saying “no.” The use of “no” may cause embarrassment for the other person. Therefore, a person may simply say “yes.” In this case, “yes” may not mean that the person agrees or even understands. It may simply mean that the person acknowledges your statement. To find out if the person really understands or agrees, you may need to ask more specific questions to test their understanding or agreement.

    Use of first names:

            Another area in which we see cultural differences is in the use of first names. Many Americans tend to use a direct and informal style of communication. This is true even when they first meet someone or have known them only for a short time. One of the reasons for doing this is to show friendliness. Yet, in some cultures, calling someone by their first name is a sign of disrespect. Many people from Latino, Arab and African American cultures prefer the use of a title, such as Mr., Mrs. or Miss, when they are addressed. Using the title helps the person maintain a sense of dignity. A title should be used until a resident asks you to use his/her first name.


            Another area of cultural differences is in the way we touch one another. Most Americans do not mind having someone touch their shoulder or arm as a gesture of friendliness. However, the amount of touching that is considered appropriate varies among cultures. In many Asian cultures, casual touching may be uncomfortable and should be avoided, especially in public. Yet, people from Latino backgrounds may be much more comfortable with casual touching and hugging. In fact, a Latino may offer a hug instead of a handshake as a greeting.

            Touching may also be restricted by religious rules. For example, members of the Orthodox Jewish religion are prohibited from touching members of the opposite sex in public. This rule is similar for Muslims. This rule even extends to shaking hands when meeting and greeting. Therefore, if a female direct care staff person extends her hand to greet an Orthodox Jewish or Muslim male and he does not extend his hand in return to shake hers, she should not be offended. It does not mean he has any ill feelings toward her. He may simply be practicing the rules of his religion.


            Every culture has its own unwritten standards about how much personal space feels right and comfortable. Many Americans feel comfortable when standing about an arm’s length away from the next person. In some cultures, such as the Japanese culture, an even greater amount of distance between people is desired. Yet, in other cultures, such as Latino and Arab cultures, people are very comfortable standing very close to one another.

    Review of some key points about cultural differences:

            There are many differences in cultural practices. Few, if any, people will know everything about every culture. What is important is being aware that a client’s behaviors and beliefs may be different than your own. This may help you to be more sensitive. Try not to jump to conclusions and label behaviors that are different from your own as wrong or bad.

            It is important to recognize when different cultural behaviors and practices come into conflict. When you interact with other people, be aware that cultural differences may be coming into play when you experience such feelings as confusion, frustration, misunderstanding, tension or impatience. Ask questions to make sure that you understand the meaning of behavior that seems out of place. Seek additional information about the culture to gain a better understanding of the behavior.


            One thing that can stand in the way of our being respectful to others is stereotyping. Stereotypes are fixed assumptions made about all members of a certain group. Stereotypes are a rigid way of thinking that does not take into account the differences among people in a group. For example, “All older people are frail and sickly” is a stereotype. While some older people are frail and sickly, many older people are strong, active and in good health. Some other examples: “You cannot teach an old dog new tricks.” “All homeless people are drug addicts.” “All boys who live in the inner city are members of gangs.” “All females gossip.”

            We have so much information coming at us that our brains can only pay attention to a small percentage of it. Stereotypes help us sort large amounts of information into a smaller number of categories. The unfortunate part, however, is that they tend to discourage considering people as individuals rather than as faceless members of the group being stereotyped. We mistakenly begin to assume that everyone in the group has the same characteristics.

            Of course, if we stopped to think about it, we would have to admit to ourselves that stereotypes are not true descriptions of every person in a group. Even the good stereotypes are not true of everyone in a group. The stereotypes that we hold about people play an important part in how we communicate with and treat people. If you do not stop to consider the real possibility that the resident you are working with may not fit the stereotype category, you may not treat him/her in a respectful and appropriate manner. It is important to remember that there are always differences between individuals. It is always a mistake to stereotype people based on appearance.

    Communicating with non-English speakers:

            The number of people in this country who speak a language other than English is growing. Communicating with people whose first language is not English can take special effort. The following guidelines can be helpful.

    • Speak clearly and a little more slowly than you usually do. Sometimes we tend to speak quickly. For people who speak English well, the fast speed may not be a problem. But a slower pace will give non-English speakers more time to process your message.
    • Do not shout. Raising your voice or shouting will not increase understanding. Speak in a normal tone of voice.
    • Pronounce your words clearly. Avoid running words together.
    • Avoid slang or jargon. Americans have many expressions that are understood by those in our culture. However, they may make little sense to those from other cultures. Examples include: “Completing that job was a piece of cake.” “Thanks a million.” “The birthday celebration was a real blast.” Expressions like these may only confuse a person who is just learning English.
    • Use the written word, draw pictures or show with demonstrations. These techniques may help to increase understanding.
    • Pay attention to body language. Notice the facial expression or use of arms or gestures of the person with whom you are speaking. These may help you to determine if the person understands what you are saying.
    • Take time to consider how your words might be understood by someone who is not completely familiar with your language.