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Emily Silverman: This is The Nocturnists Conversations. I'm Emily Silverman. Today, we're sharing a very special conversation that was originally recorded for the Talking Dementia with Remo Health podcast. Remo Health is an innovative telehealth company providing whole-person care to people living with dementia and their caregivers, and we're thrilled to be cross-posting this episode. Our guest is Dr. Anne Basting, a scholar, writer, MacArthur Fellow, and founder of TimeSlips, a storytelling method that invites people with memory loss to flex their imagination.

For over 25 years, Anne has been using techniques like this to transform the way we think about dementia and use creativity and improvisation to foster joy, connection, and dignity. In my conversation with Anne, we explore how she discovered the power of improvisation and storytelling in dementia care, the principles of the TimeSlips methodology, including "the beautiful question", "yes, and", and "proof of listening," and practical ways that caregivers and families can weave creativity and curiosity into everyday moments of care.

It's an inspiring conversation about reimagining what care can look like, and I hope you enjoy it as much as I did, but first, take a listen to Anne reading an excerpt from her book, Creative Care, through the Penn Memory Center. Here's Anne.

Dr. Anne Basting: Chapter One. In Which Ruth Teaches Me What Joy Looks Like. It was opening day. Spirits were incredibly high. I had walked into Morgantown Care and Rehabilitation in Morgantown, Kentucky, that Saturday morning to a chorus of exuberant greetings, not what you'd usually expect at a nursing home. Now it was just 2:00 PM, Showtime. After two weeks of rehearsal and a year of planning, the elders, local actors, volunteers, and staff were about to perform their version of Peter Pan, one in which Wendy is in hospice care in her final phase of growing up.

The audience, rather than clapping to prove their belief in fairies, would meet the extended hand of an elder to prove that they believed in one another. There would be song and dance, there would be a giant crocodile, pirates, and of course, flying. These residents, several of whom had not been out of their rooms for months, were about to welcome an audience to see them and their nursing home in a completely new light. They were inviting the audience to see beauty and meaning in a place where most people see only overwhelming loss.

Ruth had been at every rehearsal. If I had to guess, I would say Ruth was in her late '80s with a bob of gray hair framing her face, riding a wheelchair, she was one of the dozen elders dancing in the finale to Frank Sinatra singing, Fly Me To The Moon, as Shirley, a resident who had been the activity director in this very nursing home for 40 years, offered a blessing on the performance, and the stage manager called out places. Ruth's care partner wheeled her out onto the home's front patio for the pre-show.

The wind carried a chill, but every elder in the dance chorus insisted on going outside to greet the audience and to listen to the live music. I looked around at the faces. Every one of them was wide-eyed and wonder-filled, except Ruth. She was crying. Her eyes were bright, but tears rolled down her cheeks. Her mouth was twisted into a half smile, half grimace. I went to her straight away, kneeling down in front of her and taking her hands. "Ruth," I whispered, "Are you okay?" She nodded eagerly. "Are they happy tears?" I asked. "Oh yes," she said, with a laugh, "happy, happy tears."

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Emily Silverman: I'm Dr. Emily Silverman, and welcome to Talking Dementia with Remo Health. Join us as we explore the latest advances, insights, and strategies that help empower those living with dementia and the families that support them. Each episode, we sit down with leading experts, from physicians and researchers to policy makers and clinicians, to provide you with the resources needed to navigate this complex disease.

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Today, we're speaking with Anne Basting. Anne Basting, PhD, is a scholar, writer, and advocate for creative aging. She is a professor emeritus of theater at the University of Wisconsin, Milwaukee, and the founder of TimeSlips, a nonprofit organization that promotes creative storytelling as a means of engaging people with dementia. In her book, Creative Care, she challenges traditional dementia care by shifting the focus from memory loss to imagination and meaningful connection. A MacArthur Fellow, Basting's innovative approach has transformed how we engage with aging and promoted the fostering of dignity and joy through the arts. Anne, thank you so much for being with us today.

Dr. Anne Basting: It's great to be here.

Emily Silverman: Anne, you have over 25 years of experience doing this work, working with elders, working with people who have dementia, using the arts and storytelling and creativity and improvisation to help bring joy and care to this group of people. Before we get to some of the lessons or takeaways of your work, let's rewind to the beginning. Tell us about, 25 years ago, what initially drew you to this work, and specifically working with older people and people with dementia.

Dr. Anne Basting: I like to start, when I answer that question, by saying it's perfectly normal for a 25-year-old to want to do a PhD about theatrical and everyday life representations of aging? Because why wouldn't you want to focus on what's ahead and 50 years of the life course? There's always something behind that question that's a little bit like it's not normal for people to be interested in this. What is that explanation? Then there is always an interesting story. I would say that I was one of those kids growing up that did not understand my peers as well as I understood people older than me. I often found myself in the company of people much older.

When I was in seventh grade, my mother put me in art classes. I think I was 12, and everyone else was in their 40s and 50s. I was just super comfortable making art with older people. I did have a good relationship with my grandmother. I didn't see her all that often, but I was a fiction writer and wrote older characters, and that was powerful for me, until I started writing plays, and then suddenly it was a problem. I would have a play reading, and people would say, "We love this play, but there's no actors for a play about four women in their 90s in a nursing home in their friendship." I'm like, "Really?"

That really compelled my research on the theatrical representations. I did a master's in theater and then a PhD in theater, and followed around senior theater groups around the country, which have blossomed. I mean, there are so many now, you can't count them. Then I think when I was turning the dissertation into a book, I just wanted to see if all of this powerful theater games and the essence of creating theater playing a new role could be as transformative with people with profound disabilities as it was for these healthy older adults that I saw in senior theater, and then I just started volunteering in a nursing home on an Alzheimer's unit.

That was 1996, and really has just compelled my work ever since, really stumbling into the miracle of improvisation and its power to relieve the pressure or the expectation of memory and invite the expression of imagination, just completely transform the dynamics in the relationship and what was possible. Once you feel that, you really can't stop doing it, it's not really possible.

Emily Silverman: I think a lot of people, when they think about times they have visited nursing homes, the images that they have in their head are stuffy rooms, people sitting in chairs, maybe some of them are nodding off. Maybe there's games that are happening, but the games are passive, like maybe it's bingo or something. A lot of the people sit and watch TV and zone out in front of the TV, and these are the activities that we think of in the garden variety, ordinary nursing home. Talk to us about why that's so limiting, and the difference between your approach and that approach, and why you think we are where we are, and where we could go.

Dr. Anne Basting: It's a big question, and it encapsulates 30 years of work, because that first nursing home that I went to as a volunteer, just practicing these theater techniques was exactly that. I vividly remember having to force myself over the threshold through the smells. It was not a very good place, not a place that invited you in to experience meaningful connection with people. I think that "activities," quote, unquote, have really been framed as something to do onto another person, rather than as something to create meaningful engagement and connection between people.

Our healthcare system is really about treatment on the person and not really about the relational dynamics. In a situation like dementia, where one's identity is, let me just say, always relational. In situations of dementia and cognitive challenges, and profound physical disabilities, that relationality is more pronounced, it's present. So much of what we need to do in care with people experiencing dementia is activate that relationality. I think that's where we go wrong. If you look at the arc of what I've done, I started just with that improvisational technique and then figuring out how to teach it to anyone. [chukles] Any-- watch out, I'll try to teach you, right? Any human being can learn this technique. Then trying to teach it to people in different care settings.

Then trying to accumulate the approach inside of a care setting, to transform that setting into a place that feels like people are literally just waiting to die, and activities are just disrupting that overarching feeling into a place where meaning and beauty can be made and experienced every day. That, to me, is the transformative potential of "activities". Those activities are successful if they are infused into the whole care system so that it becomes the way of being with each other, rather than, "Now, we're going to go out and do this thing and then come back in and you're going to sit in your room in front of the television for hours." It has to be poured into the water.

Emily Silverman: There's a scene in your book I'd love for you to dig into for a moment, for the audience, because they may not be familiar with your work. The scene is you go to a group where there's a bunch of elders, and you embark on this process of constructing a character, like, "Who should this person be? Is it a man? Is it a woman? What's their name? What's their job?" Everybody's shouting things out. It reminded me of going to an improv show where they say "shout out a word," and then everyone-

Dr. Anne Basting: Is exactly what it is.

Emily Silverman: -builds on it. Tell us about that exercise, and help us understand why that's generative and why that gets people participating and exciting in a way that's just so different from bingo or watching TV.

Dr. Anne Basting: Sure. You're referencing the core of what's been called the TimeSlips methodology. That's that thing that I fell into, and that felt like a miracle, and then I've spent so much time trying to hone it as a process, to be able to explain it to other people. I'll give it my best shot. There's basically a three-part communication loop. It starts with what I've come to call "a beautiful question," which is a question that just opens up discovery. There's no right or wrong answer. It just opens up discovery. Some people call it an "open-ended question." It's not yes or no. There's no right or wrong. It also invites, I think, a little bit of wonder about the world around you.

People are so used to certain kinds of questions. I like to say that the "beautiful question" helps you jump the track of what's expected from you and makes you reconsider. Then it's followed by "Yes, and," which is the core of improvisation. It's only two, three-letter words, but it's so radically transformative, particularly in a health setting. It means that you're accepting everything that's given to you in the moment, which can be profound disability from a person that you love deeply, and are trying to protect, and put back together through a process that can feel like they're dissolving in front of you.

It's hard to accept where that person is in the moment, observing everything that they're using to communicate with you, and then adding something to it that's positive. I like to say yes and not yes, but you're not correcting. You're really just building on what's given to you. Then the third one is what I've come to call "proof-of-listening," which is a way to show the person that they've been heard. Sometimes, especially in dementia, when you're having cognitive intake challenges, I'll put it that way, you have to do it in multiple ways. You can write down the person's words or echo them back and be open to being corrected, so that the person knows that you're really understanding what they're saying.

You can use your face to echo the emotion. Whatever tools you have to echo and show the person that they've been heard. It's, "beautiful question" "yes, and" "proof-of-listening." To give an example of "What does that look like in practice?" The story, it was such a miracle, I just tell it over-and-over. Is really the first one that you were talking about. You start with a prompt, which is really anything in those first sessions. I just tore a picture out of a magazine that was iconic. I happened to pull the Marlboro Man, iconic cowboy hat, profile, and I just said, "What do you want to call him?"

That is an example of an open, beautiful question. It's giving the creative control to the other person and reminding them, in the question, that they have that creative control. "What do you want to call him?" Someone said, "Fred." I said, "Fred. Is that right?" "Yes. That's right." "Fred who?" "Fred Astaire." We had a cowboy named Fred Astaire. "Where do you want to say this takes place?" Someone said, "Oklahoma." Then someone started to sing, "Oklahoma, where the wind goes sweeping down the plain," and we all did it together. We all laughed, and I said, "Okay."

Then you start the repetition. There's little waves of story that gets built, and the magic is that you're always repeating it so that the person feels like they have the whole story. Because wherever they are in the short-term memory loss, if you don't repeat the story, they might not remember what they've built so far, so you just repeat it. We had Fred Astaire, who lived in Oklahoma. "Oklahoma, where the wind goes sweeping down the plain."

What does Oklahoma look like? "There are a lot of skinny rivers and skinny trees," which I just loved. "Does he have a family?" "Yes, he does. He has a family. He's married to Gina Autry. They both ride the rodeo. She's better than he is, so they do different events. He does the calf roping, and she did the barrel riding." It went on for 45 minutes. I would just repeat it every now and then to get them back to the moment of creativity, where we would add to it. Then you feel like, "I think we're done. We've explored all past, present, future of this moment and the characters."

"Should we finish it?" "Yes." "What do you want to call it?" Then we're done. It's a beautiful thing that you have that is filled with joy and laughter, and sometimes sorrow, and sometimes regret, and sometimes dreams, and they're just beautiful.

Emily Silverman: There was a story in your book. Maybe it wasn't a story, maybe it was a hypothetical, but it was something along these lines, where, let's say there's an older man with dementia, and his wife died 10 years ago, and he doesn't remember that she died, and he's with his daughter, and he says to his daughter, "When's my wife coming home?" The daughter freezes. She doesn't know what to say. One option is the daughter can lie. She can say, "Oh, mom will be home in five minutes," which is not true. Another option is she can repeat again and again, "Daddy, mom's dead. Daddy, Mommy died," and that doesn't feel good either.

Then there's a third way, which is more generative, which is something along the lines of, "Well, if mom were here, what would we do together?" More of that beautiful question. I was just wondering if you could talk about beautiful questions and improv. The first example that you shared was more coming into a space and doing it as an activity, but weaving it into these moments in life.

Dr. Anne Basting: Sure. There is actually at TimeSlips.org, and also now at Dementia Friendly America, TimeSlips has a free 45-minute, really beautifully designed training that's designed for family and friends, and shares exactly this, the core principles, and then how to integrate it into specific moments of care. I think also Dr. Jason Karlawish, who is at the Penn Memory Center, actually wrote an article. I can't remember if it was in Stat or Lancet that he calls it the "creative option." That you don't have to use "therapeutic lying" or the white lie, the cold truth, the white lie, or the third approach of the creative care approach, which is to follow the feeling and the curiosity, to turn it into wonder.

An example would be exactly what you said. "Tell me what you miss about Mom." "When you think of Mom, what do you think of? Let's write a little poem about her." I like to say, get in touch with your inner terrible drawer. I've been doing it a lot, now I have a sub stack, and I'm illustrating my own essays, and I'm just bad. It doesn't matter because it captures the emotion of the moment. You can create a little story. You can supply your favorite memory. Memories should always be offered as gifts and not tests. It's not, "Do you remember?" It's, "I remember," and it's a gift. It really unlocks that third approach.

I'd say another really clear micro moment is when someone gets frustrated because they can't think of a word. We pulled this, actually, from a real-life story that came to us when a woman with dementia wanted the ketchup and was really frustrated, and instead of supplying the word, the daughter said, "What do you want to call it? We'll just call it whatever you want to call it." She said, "Red sauce." That's perfectly logical. Don't fret about not being able to get the word. Let us call it red sauce until the next time, and you decide it's ketchup again. It just relieves the pressure on the moment in a world that is ruled by the expectation of rational language and chronology. It just loosens the edges that make those moments a little more connective.

Emily Silverman: I don't want to romanticize dementia in any way, and we had a beautiful story on the podcast several months ago. It was a woman describing going for a walk with her husband, and he was the one living with dementia, and she was very sad that day. She was in a sad mood, and they're walking together, and at one point, he turns to her, and he says, "Why are you raining?" As she was telling us that story, she started tearing up. You could tell that she thought there was something beautiful there, something obviously metaphorical there about the question.

I'm not sure why he said it that way. I'm not sure if there was a word that he was reaching for that he couldn't find. Instead, he opted for, "Why are you raining?" I'm wondering if you have any thoughts about brains that are sick with dementia, and what they offer creatively that a healthy brain may not be able to offer.

Dr. Anne Basting: The simplest way to describe it is that people with cognitive challenges like dementia are living in poetry. Poetry is metaphoric language. If you can't come up with one word or a concept, you have to reach for another one. Already, that's metaphor or simile. They open up our understanding of the world by communicating in poetry. That example you gave is a really beautiful example of that, but it's my pretty common experience, and sometimes they won't be words at all. They'll be sounds or gestures, depending on if the person is beyond language, either in that moment or in that phase of wherever they are.

It's teaching us to open how we think about communication and how we interpret the world. I'll add a little story to that, which is, I don't know if people have seen the movie Away From Her, it's based on an Alice Munro story, The Bear Went Over the Mountain. It's a story of a woman experiencing dementia, and before she moves into supportive care environment, she is taking a walk with her husband, and her face is just filled with wonder and light. He says, "What is it?" She said, "I look away, and I look back, and yellow is new again." She's looking at a flower that's yellow.

You don't want to romanticize it because it is hard. It is really hard, but it also is filled with these little openings that can deepen our understanding of what it means to be alive and to perceive.

Emily Silverman: You talked earlier about relationality and just now about communication. You also spoke earlier about how using this more improvisational approach can de-escalate situations in a way. It blunts the edges, it removes the expectation. "Do you remember?" That becomes a test. Memories should be gifts. They shouldn't be tests. I was just wondering if you could open up that a little bit more for us, and talk about how this approach can affect the relationships between the person living with dementia and their loved one, or their caregiver and their family.

There's so much pain and so much difficulty with communication. There's behavioral issues that come up. Things get lost in translation. Have you found that this approach does help de-escalate some of that pain or tension, or difficulty inside the home or inside the relationship?

Dr. Anne Basting: I do think it eases some of the pain of it, and it's because when you're engaging in the process of shared co-creation, of making the moment into something, you're basically creating a new experience or a little piece of art, whether it's theater, which is ephemeral and you don't capture it in any way, or you're making a poem or a piece of art together, the creative process reduces stress in and of itself. You enter into what Mihaly Csikszentmihalyi called the flow state, which boosts your immune system, we know from research, and also reduces stress, and it gives you a way to stop fighting the changes and embrace the moment.

I also think that there are large organizations that try to teach you how to be in the moment, and when you really fully enter it, this experience of care, and this framework of care is really being in the moment and treasuring what's right in front of you. Caregivers are also battling-- My mother has dementia now, so I'm fully in it as well, and you're experiencing what they call anticipatory grief, where the person is in front of you. They aren't gone yet, but you're holding the memory of what the person was like. In some ways, it's almost overwhelming, the impulse to try to repair and fill in the gap between who they were and who they are, or protect it.

I've seen that, especially with children or spouses of men who were very powerful and dignified. I don't want them dancing in the care home. It's just not what they ever would have done. You're denying a person an expression in the moment that is just transformative. Is it that you're protecting who they were, but you're also then losing the opportunity to really connect with them in the moment and to share in an emotional experience?

I think figuring out how to understand anticipatory loss and understand that that temptation to protect and rebuild, the way I describe it, is, if you keep building up these blocks of who they were, you end up with a nice brick wall between you and the person, and it really blocks off any current emotional connection. To release that temptation and to get curious, "Who is the person right in front of me today?"

I have this thing where I walk into my mom's room and I say, "Hoo hoo." If she answers, "Hoo hoo," I'll know something about her presence that day, if she's having a hard day or not. There might be music that you can share and just listen to and sway together in the moment. Really, the research on music and dementia is probably the strongest of any of the arts, but just sharing the present moment, experiencing those things, can relieve a lot of the sorrow. What you're really grieving is the connection. I think finding a way toward the deep connection is the best way to heal that sorrow.

Emily Silverman: What about the stigma against dementia? It's a word, I think, that people sometimes struggle to even say. They don't want people to know. It's different from cancer. How might this work? Or is it already, do you think, helping reduce the stigma of dementia in society?

Dr. Anne Basting: I have done a lot of thinking about what I call the iatrogenic effects, because sometimes I would go into care settings and I'm like, "I can't tell if this is a symptom of the drugs that they're using to treat the person or to deaden the person's awareness of their environment, unstimulating environment, or is it a symptom of dementia? Is it a symptom of we don't have enough care workers?" You can't tell, and if you enliven the environment, you can see a dramatic transformation.

Another part of my way into this as a college professor for many, many years, was teaching service learning students across shocking number of disciplines, from the arts and English to psychology and theology, and nursing, and social work to the improvisational engagement technique, and to go into the care homes or one on one settings and just be in company, guide a storytelling session in a group or one on one. There aren't enough geriatric social workers. There aren't enough geriatricians. There aren't enough nurses that are trained in geriatrics because of the stigma of "I want to help kids."

The presumed joyfulness of helping kids, which honestly is not always just joyful, it can also bring its own challenges. My mission was really to create a framework and tools that would bring these volunteers and these service learning students into these settings that they really were scared of because of the stigma and the presumed stereotypes, and just being gobsmacked by how joyful and fun it was. One of my favorite stories of that was a student in one of my classes who came up to me and said, "You know, this morning, I was really down. I have tests coming up, and I'm just not prepared, and I have to work, and I don't have enough time."

Then I thought, "Oh, I get to be with people with dementia today." She was so happy. She was like, "That's just going to reset my mood." I thought, "Well, that is what we need for people to realize that this can be joyful and connective. It doesn't have to be depressing." It's not that it's easy, people are at the end of their lives, but that's the human experience. Because someone's near the end of their lives, are we going to abandon them? That's what the stigma is leading us to. I think we really do need to invest in messaging that this can be really powerful and joyful.

Some of the work I'm doing with Memory Cafes is really getting to that right now. We're in the midst of a public awareness campaign to grow Memory Cafes tenfold in 10 years, because we should always be really ambitious. Memory Cafes are just social gatherings where people with dementia and a care partner, or if they want to go alone, they can go alone. It's designed for respite together, is a good way to say it. You can find friendship and joy and meaningful social programming, and everyone should have a Memory Cafe within driving distance. We're getting there, but we're trying to spread it. The video that we have is just full of dancing and laughter. Those sessions are just euphoric, because people are just happy to be together.

Emily Silverman: Looking ahead at the next 10, 20 years, what do you see, or what would you like to see? How should dementia care evolve?

Dr. Anne Basting: It's a big question, and it's fraught in the moment that we're recording this with a lot of instability about the infrastructures that have done somewhat of a good job propping up care, but with a lot of room for improvement, and now even that system is in jeopardy, which is really scary. I think the Memory Cafe movement is a big answer. I think there should be 10,000 Memory Cafes across the United States, every library, every congregation, every arts and culture organization, any place where people gather. YMCAs, if you think of it, akin to the homeschool movement, when kids were starting to get homeschooled, and then they invented a whole social network for kids who were being homeschooled to come together.

If you think about the 85% of people with dementia and a caregiver who are living at home, not in residential care settings, they need that same infrastructure for gathering and friendship, and shared experience. I really would imagine a vibrant network, and we have a directory now capturing all the existing ones called Memory Cafe directory.com I think too, that the way in it is very difficult to, in residential care settings or even home care, to find and train staff. I think those care workers should get health care. I think that is just a human right at this point, that if you're relationally protecting the care of another human being, you should have health care coverage.

I also think that because we don't have enough people to provide care that we should really be boosting the volunteer and service learning components from high school and colleges, and also from retirees to be part of the solution for meaningful engagement in residential care settings and home care settings. TimeSlips is switching to a train-the-trainer program, so that we can really get these approaches out there, and then figuring out which systems to run these frameworks and trainings through, so that they can really just start expanding and offering it as part of the solution.

Emily Silverman: That feels very concrete and doable, actually, [crosstalk] like Memory Cafes, training the trainer. That leaves me feeling hopeful and inspired. I'm wondering, as we draw this to a close, if there's anything else you'd like to share with the Remo audience.

Dr. Anne Basting: I often tell people to have confidence in their own creativity, that every human being is creative, feeling that creativity is really powerful for everyone, and then you can't invite another person into creativity until you feel that yourself. It's also really good to challenge your own brain, and the shift toward brain health is really powerful as well now, and in 10 years. I've also started following my own advice, and I have a sub stack where I've been creating little videos and creating prompts and short essays, and then illustrating those essays as a way to say, "Look, everybody can do this."

Grow a little bit yourself. Try it. Just try some form of expression. I'm trying to model opening up moments into wonder in that way. I think I just leave it with, try it, experiment. Turn toward the curious, turn toward the moment of wonder, and think about how you could connect in the moment. People have instrumental tasks they have to get done, but try to do them playfully and make them into creativity instead, so that you're doing them together.

Emily Silverman: I have been speaking with the wonderful Anne Basting. Anne is a scholar, writer, an advocate for creative aging, and we're just so thrilled to have had you on the show today. This has been really, really wonderful. Anne, thanks again for coming on.

Dr. Anne Basting: It's been my pleasure.

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Emily Silverman: Thank you for listening. For more information about this episode, check out the links and resources listed in the show notes. If you're interested in learning more from Remo, visit us at www.remo.health. Take care.

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Emily Silverman: This episode of The Nocturnists was originally produced by Remo Health as part of their Talking Dementia podcast. Remo is a virtual dementia care company that provides comprehensive and personalized care plans for people with dementia and their caregivers. To learn more about Remo, visit remo.health, and special thanks to Molly Rose-Williams for assembling this episode for our audience here at The Nocturnists.

Our executive producer is Ali Block, and Ashley Pettit is our program director. Original theme music was composed by Yosef Munro, and additional music comes from Blue Dot Sessions. The Nocturnists is made possible by the California Medical Association, a physician-led organization that works to ensure the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org. This episode of The Nocturnists conversations is sponsored by the Physicians Foundation, which supports physician well-being, practice sustainability and leadership in delivering high-quality, cost-efficient care.

The Nocturnists is also made possible by donations from listeners like you. In fact, we recently moved over to Substack, which makes it easier than ever to support our work directly. By joining us with a donation of $2, $5, or $10 a month, you'll become an essential part of our creative community. I'm your host, Emily Silverman. See you next week.