to something more precise – for example, o ff ering closed questions to support manageable engagement when appropriate. Understanding the need to match the client’s pace and to allow time for people to reply when word fi nding or articulation is di ffi cult is paramount. In Contented Dementia , Oliver James acknowledged that people with dementia can move from ‘green’ to ‘red’ very rapidly in terms of emotional and behavioural change. However, he also pointed out that the swing may occur just as easily in the opposite direction. 8 Once we become fully attuned to the person’s feelings and world view we can begin to see what is uniquely distressing for that person. James advocates that ‘contented dementia’ requires not asking questions but instead learning from the client as the expert and agreeing with what is said, however di ff erent that person’s reality may seem from ours. What is suggested by James may be counter-intuitive, based on an ethical commitment to congruence, but he argues that we are being authentically present by entering the world and realities of the person with dementia. Understanding where the client is and drawing on the client’s older memories allows for connection when new information may be absent. Additionally, it may be that care works best when there is protection from having to internalise and hold new information and having to navigate new environments. Richard Behers emphasised the need for a foundation of knowledge of each of the individual conditions. 9 The most common types of dementia include Alzheimer’s disease, vascular dementia, Lewy body dementia, frontotemporal dementia, Parkinsonian dementia and mixed dementia. Behers acknowledged that a person’s diagnosis may only come after death, and for some there will be mixed dementias. However, understanding the di ff ering symptoms is important if we are to observe and learn about the nuances of anxiety and depression that may be experienced and expressed. Taking time to learn about conditions supports understanding of anticipated journeys as cognitions, behaviours and bodily functions alter in various ways that will impact the person and engagement. He also advocated a multisensory approach, emphasising the
Therapies services have felt the need for more training and support to work with people with dementia. 3 The study authors indicated that of more than 1,500 people diagnosed with dementia between 2012 and 2019 (based on data gathered from 211 NHS clinical commissioning groups), 63% reliably improved following psychological therapy and 40% reliably recovered. However, it was also found ‘that they were also more likely to deteriorate …in their symptoms following therapy’. They added that, ‘Adaptations to standard care might be required to make therapy outcomes for people living with dementia more comparable with people without dementia’ and that ‘work is needed to improve therapy outcomes for people living with dementia’. Lipinska’s work highlighted that conventional counsellor assumptions and formulation may require modi fi cation, shifting the focus to ‘ how the individual is experiencing rather than the experience itself’. 4 Pörtner more generally set out necessary ground rules for working with older people that included understanding that ‘the person is more than her current condition’ and ‘what is decisive is not what is lacking but what is present’. 6 Immersing myself in the literature helped me to recognise the need to always re fl ect on conventionally accepted theory, considering more broadly what theoretical models have to o ff er clients and what more needs to be embraced in terms of training and practice by practitioners to meet client needs. As therapists and counsellors we are challenged to acknowledge at times – as Mearns and Thorne stated – that congruence may require working with the ‘not-for-growth experience’. 4 It caused me to re fl ect too that what I, as a counsellor, may perceive as a challenge, the client may not, and that we may not be aware of the speci fi c challenges with counsellors and counselling experienced by the client.
Pre-symbolic self Working with dementia means understanding communication in manifold ways, including the ‘pre-symbolic self’, that is through ‘tone of voice, sounds, crying, gesture’. 4 This may be confusing for therapists who work with coherence; the learning for me here is to be open, to be with and to hear the person as well as the content when it emerges. Lipinska took her lead from clients, fi nding out from them how they communicated, which requires being ‘profoundly aware of the subtlety of symbolic meaning and metaphor’ 4 and understanding that by patiently being present, clients who have been labelled as non-verbal and non-communicative can still make themselves understood. Counsellors are called to hear with their ‘third ear’ and to see with their ‘third eye’, and to create an environment that allows counsellor and client to connect. 4 When memory of words fades, feelings may still remain, as may memory of colours, shapes and sensations and images. Counselling may need to move from conventionally trained enquiry, with the o ff er of choices and open-ended questions,
‘Counselling may need to move from conventionally trained enquiry to something more precise’
50 THERAPY TODAY MAY 2024
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