Download:: PSIGE newsletter no. 118

Psychology SpecialistsWorking With Older People

Faculty of Old Age Psychology

ISSN: 1360-3671

www.psige.org

PSIGENewsletter

No. 118 – January 2012

AIMS

◆ to promote opportunities for the exchange of knowledge and expertise

between members;

◆ to promote a greater appreciation of psychological factors in ageing;

◆ to advise and participate in matters of teaching and training;

◆ to stimulate research and disseminate research findings;

◆ to act in an advisory capacity on issues relating to the well-being and

provision for care for older people;

◆ to foster an exchange of information and ideas with other professional

and voluntary groups.

EDITOR

Dr Louisa Jackman

E-mail: [email protected]

Psychology SpecialistsWorking With Older People

ISSN: 1360-3671

This publication is essentially a forum for members. Articles may be reproduced for personal use unlessotherwise stated. Views expressed by the authors may not represent views by PSIGE as an organisation.

PSIGE is the Faculty for Old Age Psychology(British Psychological Society, Division of Clinical Psychology)

www.psige.org

Letter from the EditorLouisa Jackman

PSIGE Newsletter, No. 118, January 2012 1© The British Psychological Society

IAM HAPPY to introduce the Wessexedition of the Newsletter. Many thanks to itscontributors who were taken somewhat by

surprise by how quickly it crept up. I mustshoulder some responsibility for not havingbeen proactive in reminding the group aboutthe deadlines, and I would recommend thatother groups look closely at the timetablewhich appeared in the conference edition ofthe newsletter to spot their own slot.

I was finally able to attend a nationalcommittee meeting in November and catchup properly on where we are at with thevarious strands of National PSIGE work.There was interesting debate about how wepresent our function to the wider world, andthe potential acronyms that could emergefrom a change in name. As part of ourdiscussions, it became increasingly obvioushow much the Newsletter is valued by itscontributors and its readers. We know thatthe special edition on supervision andformulation and the edition on IAPT havebeen extremely helpful to PSIGE membersas a tangible means to introduce ideas tomanagers and commissioners and to show-case good practice, and we are lookingforward to producing another specialedition reflecting our other work stream ondementia. Also of relevance to the newsletterwas the discussion on the need for closerlinks between the Newsletter and websitecontent. I have had several enquiries frompeople searching for references which haveappeared in previous copies of the Newsletter.We have agreed the importance of keepingthe pdf’s of past editions up-to-date andavailable.

In this edition, Rik Cheston and hiscolleagues have developed a number ofpapers with a back drop of existentialism.Cheston initially introduces us to the threatsto self emanating from the dementiaprocess, and, in introducing ‘Terror Manage-

ment Theory’, encapsulates the experienceof dementia in a way that simply referring to‘anxiety’ or ‘uncertainty’ does not. Ashurst,Cheston, and Gleeson continue the themeby looking at how people with dementiamight use the objects around them as a wayof feeling more safe and secure in the face ofthe threat of dementia. Importantly, theysuggest that those of us working with peoplewith dementia have a role in promoting thisaspect of everyday objects to enable thisprocess to take place. Betts and Chestonpresent a paper which considers the positiveeffects of enabling people suffering fromdementia to come to terms with their condi-tion through their application of the Assimi-lation Model of Problematic Voices to theexperiences of the person with dementia.They helpfully provide case study material tobring life to their discussion and concludethat this process could be a helpful part ofthe memory assessment process.

Richardson and Marshall describe theirtrust’s efforts to address the inequity ofdementia services up-take for Black andEthnic Minority groups. The organisation israising awareness among different culturalcommunities through a national mentalhealth campaign and give a list of steps theyhave taken which would be helpful forothers considering tackling this issue. Youngand Keetch outline a project looking at staffexperience of supervision in response toconcerns about blurred patient-clinicianboundaries in their organisation. On a posi-tive note, they found that there were manygood experiences of supervision describes byrespondents, but some respondentscontinued to feel that supervision was notgiven the time or space it required to make ita useful tool for problem-solving or feed-back. Whitby provides us with an excellentreview of ‘Teach us to sit still….’ which Ithink will significantly boost the author’s

New Year sales(!), and he also summariseshis experiences of successfully applying foran award from the Winston Churchill Memo-rial Trust. Both contributions leaving methinking I must get out more… Finally, I loved Hodge’s reflections on using ACTwith an 80-year-old lady, and beginning toapply some its principles to her own outlook.

I am looking forward to presenting youwith April’s general papers edition which ispacked full of submissions received over thelast year. Thanks to the many contributorsand their patience in waiting for a slot toshowcase their work.

Best wishes for the New Year.

Louisa

PS: Could I please draw your attention to amistake in the last edition of the Newsletterwhere we should have listed Dr GemmaMurphy as the presenter of the poster ‘Thelived experience of older women withdepression….’ on the back cover of thejournal.

2 PSIGE Newsletter, No. 118, January 2012

Louisa Jackman

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PSIGE Newsletter, No. 118, January 2012 3

WELCOME to the Wessex Edition ofthe PSIGE Newsletter.

The term Wessex, originating from WestSaxony is a geographically antiquated oneand can no longer be found on a modernmap. Historically though Wessex is quintes-sentially important to the process of Englandbecoming a unified country. King Alfred theGreat ruled Wessex from 871 to 899 ADwhen the rest of England was controlled bythe Vikings and united warring tribes to fightthe Danish invaders. Alfred was a great mili-tary leader, but he was also a very learnedman, establishing a programme for trans-lating Latin documents into the vernacularof what we would now call Old English.

It could be argued then that English liter-ature was founded in Wessex and the regioncertainly has strong literary connections.Thomas Hardy is the most famous of these ashe drew sketch maps of Wessex, which givesit the loose geographical definition we relyon today. It is stretches from Berkshire,Hampshire and Isle of Wight in the east toWiltshire, Somerset, Dorset and Devon inthe west. Hardy created fictional alter-egosfor real towns and cities in his novels such asChristminster for Oxford in Jude the Obscureand Wintoncester for Winchester in Tess ofthe D’Urbervilles.

Winchester, which was the capital ofEngland under Alfred and remained so untilafter the Norman conquest, is spoilt forliterary heritage. Jane Austen lived in thenearby village of Chawton and when shebecame ill moved to a house on CollegeStreet in Winchester which is still standingtoday. She sadly died at 41 in 1817 and isburied in the north aisle of WinchesterCathedral. The romantic poet John Keats,wrote one of his most famous sonnets, To Autumn, in 1819 whilst walking besidesthe River Itchen in what is known locally atthe water-meadows and it is possible toretrace his footsteps today. Finally, the Victo-rian writer Anthony Trollope attended theboy’s public school Winchester college,founded in 1382 it is thought to have thelongest unbroken history of any school inEngland. Trollope based his Chronicles ofBarchester novels on his experiences of thecity which was later made into a televisionseries.

Wessex continued to inspire writers in tothe 20th century, especially John Fowleswhose genre defying classic The French Lieu-tenant’s Woman put Lyme Regis on the mapfor international audiences, Fowles spent thelatter part of his life in Lyme and served asthe curator of the local museum. Morerecently Ian McEwan’s 2007 novel On ChesilBeach will once more return attention to theDorset coast as a film starring CareyMulligan is currently in the making.

Paul Whitby

4 PSIGE Newsletter, No. 118, January 2012© The British Psychological Society

Guest EditorialPaul Whitby


IAM WRITING THIS balancing a laptopon my knee on a very crowded train fromLondon to the snowy hills of Shropshire

(as I finally have a seat). After a (very) earlystart to get to a meeting with the Division ofNeuropsychology about how we can makecloser links between our groups – and ameeting about IAPT and Long Term Condi-tions with the DH Lead. The last couple ofmonths have been very busy for the NationalCommittee with attendance at the NewSavoy Partnerships Conference, NationalCommittee meeting, DCP conference,Commissioning Groups, Dementia ActionAlliance and work stream meetings and tele-conferences. Not bad as most of this is doneby everyone on top of the day job! So whereto start?

This edition of the Newsletter feeds wellinto both the dementia and the IAPT workstreams, with food for thought aboutsupporting older people with dementia andin therapy, together with looking after staffand each other through a stronger processof supervision and some reflection on Mind-fulness for therapists. I look forward to morethan a quick skim read when I clear my ‘todo list ‘ and get the Christmas cards written.Who knows I might even take up Paul’ssuggestion of applying for a Churchill schol-arship and go travelling. My recent trip toZululand has reminded me that one of theaspects of many peoples’ retirement is travel!

So where to start? Firstly a date for your diary: I met with

Philippa and Kate last week for discussionsabout the 2012 conference in Bristol on14–15 June 2012. We are hoping to getspecial rates for people wanting a two- tofour-day residential break to make aweekend of it. Clifton has great places to eatand Bristol has a fascinating history of theslave trade to explore. I have a special love of

Bristol as it is where I did my degree (as didKate and Philippa – so we were able to remi-nisce, as well as to plan). The proposedtopics on systemic issues for the Friday lookfascinating. Thursday will be a workshop dayon both the IAPT and the Dementia workstreams. Flyers will be out shortly. The venuecan only hold 100 people so first come firstserved.

I went from there to the IAPT South WestCollaborative in Taunton to talk about theIAPT work stream (see presentation on theirwebsite). The group was very enthusiasticand has been doing some fascinating workwith user groups about why they don’t accessservices and some useful outreach work withgroups such as the WI to try to explain howpsychological interventions can helpimprove mood. I hope they will submit thisfor a future Newsletter. The IAPT workstreams are going very well. The Departmentof Health has agreed to more formally adoptthe work we have been doing (although wehave to thank them for being activelyinvolved with us all the way through) andthey will have a member of their teamsinvolved in each of the four working groups– Commissioning, Workforce, Long termconditions, and People with dementia andtheir careers. We had teleconferences at thebeginning of this week to build on the workfrom 11 October and we have another fullday at the Society’s London office on 28 January. If anyone would like tocontribute to one of the work streams wewould be delighted to have you join us. Weare hoping to develop commissioning guid-ance, Q and A sheets, workforce, trainingand supervision recommendations, and toimprove the evidence base for this work.

Some of it will be showcased at Bristoland some through the October edition ofthe Newsletter.

Letter from the ChairCath Burley


Some of you will have received informa-tion recently through the IAPT collaborativefor an expression of interest in developingPathfinder sites for Long Term Conditions –the deadline for initial ideas was 3 January,but the detailed work will start in the newyear – please send in submissions andencourage your managers/commissioners todo so to – we need to highlight your goodpractice.

Julia Boot has also visited the NW collab-orative where many stunning pieces of workare going on – so we are slowly working ourway around the country. Also on the IAPTfront, a strong PSIGE contingent attendedthe New Savoy Partnerships conference inNovember – where Sue Watts and Ipresented a case for equality for olderpeople. We were vociferous as a group inquestioning the speakers and the conferencewas an excellent net working opportunity.Don set up a twitter relationship with ClaireGerada from the Royal College of GPs whowas an excellent speaker. The presentationsare available on the NSP website.

Liz Baikie is leading on the Dementiaworking group which has been activelycontributing to discussions with AlstairBurns, National Dementia Advisor and theDepartment of Health – their work plan isdeveloping and you will be asked tocontribute actively to this.

Polly Kaiser has been contributing to thecommissioning debate and the developmentof commissioning guidelines for olderpeople and in primary care. Many of usfollowed this further at the DCP conferencewhere the last afternoon was a very stimu-lating debate by four commissioners – theywere clear that they would welcome conver-sations from psychologists working in the

field at all levels – so please fnd out who yourlocal commissioners are and go and talk withthem. The DCP conference this year was veryrelevant to our work, with excellent presen-tations on sleep, pain and head injury. Checkout the sleep questionnaire on www.greatbri-tishsleepsurvey.com as interesting for clientsand ourselves.

At our last committee meeting we spentsome time reviewing work Don Brechin hasdone on the Constitution – which now looksmore up-to-date. We will be asking for yourcomments shortly at a special generalmeeting. We also discussed on a new title forPSIGE which would be more intelligible aswe now much more outwardly facing workwith colleagues from other professions andvoluntary agencies and need a name whichdescribes more clearly what we do and whowe are.

Back to today: the DoN would welcomecloses links between our two groups and isoffering to co-opt someone who is a PSIGEand DoN member to attend both their andour committee meetings to join up work thatwe are doing and represent us in bothgroups: please contact me if you would beprepared to do this.

Finally – the DCP continues to call forsuggestions for nominations for people forearly, mid- and late-career awards – pleasesend in some names and PSIGE will supportyour nominations –we need to publicise thestrength of what we do more widely andrecognise your skills and talents.

So – almost time to change trains, so I willsign off wishing you a healthy and active New Year.

Cath

Cath Burley


Using Terror Management Theory to understand the existential threat of dementiaRichard Cheston

This paper sets out an argument for understanding the subjective experience of people with dementia interms of Terror Management Theory (TMT). This theory is a broad and detailed account derived fromexperimental psychological research of the way in which material that represents an existential threat topsychological equanimity triggers a range of social and personal defences. These responses are mediated bylevels of self-esteem and include the process of mnemic neglect in which threatening material is processed lessefficiently and recalled less thoroughly. Using TMT to understand the responses of people with dementiahas a range of clinical implications.

DEMENTIA is not only a terminal ill-ness, but one which involves progres-sive decline and impairment caused by

neurological deterioration of most areas ofthe brain. The consequences of this deterio-ration in brain functioning are the gradualerosion of capacities that, for many of us,define what it is to be human. For thosepeople who are affected by this illness, the

process of dementia is likely to involve ever-increasing levels of dependency until thepoint of death. With increasing dependencycomes not only the loss of independenceand the threat of becoming a burden onthose we love and cherish the most, but alsothe occurrence of socially demeaning, even,shaming behaviours and capacities (such asincontinence and incoherence). As such,

Judith: I just wonder where it’s all going to end, that’s my fear … Janet: When it’s going to end?Judith: Where it’s going to end, where am I going to end up, just before the end, you know.Janet: Oh, I see you mean, I talk about death…Judith: YeahJanet: …to my family and I think the only thing that I’m frightened of is the unknown and that is death to me.Judith: and after that. Oh, no I’m worried about what comes just before [laughs] it could be years before,couldn’t it?Janet: It could be tomorrowRobert: Is it the dying that?Judith: I don’t feel that at all, no, because we all go through that, no I’m not frightened about that, no.It’s not really my religion to say it at all, but I don’t know if there’s anything else and I’m not going to worryabout that right now, you know.Facilitator: So what is the frightening, when you say about the future?Judith: Being, being useless, you know. Janet: Yes.Judith: Not having all my faculties, I dread that, I dread that, its as if I’m going to come to it one morning,perhaps, you know and think ‘Oh my godfathers, what’s left?’, I really worry about that … so I’m quitehappy in a situation unless I chose to sort of sit there and think. And it’s when I think about that, that thecurtain comes down.

From Cheston (2004).

dementia needs to be understood as beingmuch more than a neurological process, butrather as one that both includes a complexnetwork of social and personal factors, andas one in which death and deterioration arecentral features.

In this paper I will outline how findingsfrom experimental psychology that relate tohow people without memory problems reactto reminders of their own mortality, can beused to further our understanding of theresponses of people to their own dementia.Although these findings come from a branchof psychology that hitherto has not beenwidely applied to the experiences of peoplewith dementia, I will argue that existentialpsychology can help us to understand boththe nature of people’s experiences ofdementia, and also the reaction of thosepeople who live around the person withdementia – their family care-givers, and alsothe health and social care professionals.

Existential approaches to dementia.Where issues around death have been explic-itly addressed in dementia care, then this hastended to be in terms of palliative care or thereligious or spiritual needs of people withdementia. However, whilst an explicit exis-tential narrative may have been largely absentin dementia, care, nevertheless existentialthemes abound throughout the psychosocialliterature. We can see these existentialthemes in the concern about attachment(e.g. Miesen, 1993, 1999), through accountsof the person with dementia searching toestablish meaning in life (e.g Graneheim &Jansson, 2006; Örulv & Hydén, 2006), orstruggling with the dislocating loss of identityproduced by a deteriorating memory (Sabat& Harré, 1992; Kitwood, 1997). Death anddeterioration are sometimes like theelephant in the room in dementia care andresearch – we all are aware it is all about us,but finding a way to talk about it is harder:death permeates not just the experiences ofthe person with dementia, but also of thosearound him or her.

Existential psychologyExistential thought holds that there are fiveessential realities, confrontation with of anyone of which can be understood as a psycho-logical threat :● That death is both inevitable and final;● That the achievement of independence

and autonomy is limited and temporary;● That life is essentially meaningless, and

that no altruistic guiding hand orpurpose exists other than those which wecreate;

● That each of us is inevitably alone, andthat no matter how close ourrelationships are with others, we cannever be truly and fully known; and

● That our identity as unique and valuedindividuals with special and distinctivequalities is a construct that we impose onthe world.

Dementia places all of these threats beforeus: with increasing dependency comes thethreat of personal and social isolation. Theloss of cognitive integrity creates not only athreat to the way that we make sense out ofthe world, but also brings with it the threat ofdiminished self-esteem. In this paper,however, I will focus largely on the threat ofdeath and decay that is implicit in the diag-nosis of dementia

Death anxiety, terror managementtheory and ‘the denial of death’Yalom (1980) defines death anxiety as a‘dread of death that resides in the unconscious, a dread that is formed early in life at a time priorto the development of precise conceptual formation,a dread that is terrible and inchoate and existsoutside of language and image’ (p.189). Deathanxiety, he argues, often shows in manyapparently unconnected ways in the clinic:

‘It’s not easy to live every moment whollyunaware of death. It’s like trying to stare thesun in the face: you can only stand so much ofit. Because we cannot live frozen in fear, wegenerate methods to soften death’s terror. Weproject ourselves into the future through ourchildren; we grow rich, famous, ever larger; we develop compulsive protective rituals; or we


Richard Cheston

embrace an impregnable belief in an ultimaterescuer … But despite the staunchest, mostvenerable defences, we can never completelysubdue death anxiety: it is always there,lurking in some hidden ravine of the mind …Death has a long reach, with an impact that isoften concealed. Though fear of dying cantotally immobilise some people, often the fear iscovert and expressed in something that appearsto have nothing to do with one’s mortality.’(Yalom, 2008, pp.5–7)

Physical deterioration and death are funda-mental and ever-present parts of a widevariety of health care services – includingthose services that focus on the needs ofolder people. Death anxiety is largely deniedor repressed – it is not something that is typi-cally a part of conscious experience butrather, to use Yalom’s phrase, lurks ‘in thehidden ravine of the mind’. When we encounterreminders of death, even if this involves suchan apparently trivial act such as passing anundertaker’s office or a cemetery, thenresearch evidence suggests that this activatesdefences that reduce death anxiety(Solomon, Greenberg & Pyszczynski, 2004).The experimental study of these social andcognitive processes involved is referred to asTerror Management Theory (or TMT) andseeks to explain the way in which individuals,when confronted within an existentialthreat, may manage to prevent knowledge orawareness of that threat from impingingupon their daily life.

TMT is a broad theory that seeks toexplain how we deal with these existentialthreats. It is an answer to two, relatedquestions posed by Ernst Becker – first, whypeople are so enormously concerned withtheir self-esteem? Secondly, why is it thatpeople can often cling so tenaciously to theirown cultural beliefs and have such a difficulttime co-existing with others who holddifferent cultural beliefs to their own.

According to TMT, to have feelings of self-esteem is to have a sense that one is not merelyan animal destined to die and be forgotten, butsomeone who has lived a life or purpose andsignificance, someone who has made an

important and lasting contribution to ameaningful and enduring world. (Routledgeet al., 2010, p.898)

TMT argues that human society has evolveda series of structures and processes (such asthe development of organised religion) thatallow such existential terror to be managed.As a consequence of the use of these terrormanagement strategies, for the most part, wehumans are unaware of this terror in ourlives. We live, as Ernst Becker has argued,within social systems that have evolved inWestern society, to remove death from view,and to place the occurrence of death intohospitals, hospices and into the sanitisedcare of nurses and doctors (Becker, 1973).This removal of death to the margins ofsociety prevents it from impinging on themainstream consciousness – and thus thereality of death has, in effect been denied.

A central pillar of TMT is that whenpeople are reminded of the inevitability oftheir own death then there is a strongtendency for them to act in ways thatincrease their levels of self-esteem. The prin-cipal way in which this occurs, according toTMT, is by the person re-investing them-selves in what are termed cultural world views.These cultural world views may be religious,political, social or national in nature – theyare those modes of organisation and beliefstructure which provide people with a senseof meaning, identity, and purpose. For somepeople this might be through a belief in theimportance of their nation, whilst for othersit might be through religious faith:

‘These world views consist of humanlyconstructed beliefs about reality shared byindividuals in groups that provide a sense thatone is a person of value in a world of meaning.Psychological equanimity thus depends onmaintaining faith in an individualisedversion of the cultural worldview andperceiving oneself to be meeting or exceeding thestandards of value prescribed by the social rolethat one inhabits in the context of thatworldview.’ (Solomon, Greenberg &Pyszczynski, 2004, p.16)


Using Terror Management Theory to understand the existential threat of dementia

The development of cultural world viewsmeans that in the face of threat, the worldbecomes a stable and orderly place –reminders of threats to our existence para-doxically provide meaning, identity andopportunities to increase self-esteem. Exper-imentally induced reminders of death (e.g.asking people to write about their owndeath, seeing photographs of death-relatedimages) leads to participants:● Showing greater commitment to

romantic relationships (Mikulincer,Florian & Hirschberger, 2004);

● Having stronger feelings of affinitytowards others who share importantcultural beliefs and traditions,responding in a more hostile andaggressive way to those people seen tothreaten or to be critical of these beliefsand a stronger certainty that thesecultural groups are real entities and thatthey will exist into the future;

● Emphasising the importance of culturalicons (such as flags, anthems, people insymbolic positions of authority within theculture), and denigrating those symbolsthat seem to undermine one’s culturalbeliefs (Solomon, Greenberg &Pyszczynski, 2004);

● Stronger belief in the supernatural andin divine intervention, and a belief thatone’s collective self or cultural identitywill continue to thrive in the future(Batson & Stocks, 2004).

In addition, intra-psychic defences are alsoactivated: material that is threatening to self-concept is more poorly processed and thus isless well remembered than material that ismore peripheral to the person’s self-conceptor which is self-affirming. This phenomenonis known as Mnemic Neglect (see below).

TMT focuses on how humans cope withthe awareness of mortality and suggests thatpeople buffer the potential for death relatedanxiety by advocating cultural worldviewsthat give their life meaning, by striving toattain and maintain feelings of self-worth,and by investing in personal relationships.Experiments that have tested these theoret-

ical postulates tend to make use of themortality salience (MS) hypothesis. Thisproposes that if cultural worldviews provideprotection from the psychological conse-quences of death awareness, then the activa-tion of death thoughts through experimentalconditions such as showing people imagesassociated with death, or asking them to writeabout their own death (i.e. increasingmortality salience) will in turn increase theperson’s investment in their worldview, theirstrivings to maintain self-esteem, as well asinvestment in close relationships

In addition bolstering these structureseither before or after MS induction lessensthe need to deploy further psychologicaldefences (Routledge et al., 2008). In otherwords, these psychological defences preventthe awareness of death turning into anxietyabout death.

In sum, when individuals are reminded thatthey are mortal and thus transient entities,they cling to the relationships, groups andbeliefs that imbue their lives with purpose,stability and permanence; and these responsesprevent death cognition from turning intodeath anxiety. (Juhl et al., 2010,pp.309–310)

If, as I have argued above, the experience ofdementia acts as an existential threat, thenthe behaviour of many people with dementiacan be understood in terms of TMT. Morespecifically, many of the different ways inwhich people with dementia behave can beunderstood as serving a function ofpreserving psychological equanimity inresponse to an existential threat. Amongstthese behaviours are those that are oftenrepresented as indicating a lack of awarenessor insight – for instance the man who posi-tions himself in a psychiatric interview asunimpaired, or the elderly women whoavoids contact with services and asserts thatshe still cooks, cleans and sews for herselfeven when her husband insists that he hastaken these tasks over. Often this combina-tion of a person attempting to bolster theirself-esteem, and of selectively forgettinginstances in which a memory problem has


Richard Cheston

been revealed is maintained even when thiscauses conflict with people and distressaround them. At the same time, otherpeople respond to their dementia with athoughtful acceptance and determination tomake the best out of their life. As such, thesevariations in behaviour are likely to be linkedto social and personal differences inemotional resilience and fragility

Fragility and resilienceTMT suggests that self-esteem is a buffer thatserves to insulate humans from the anxietythat arises from existential threats. Peoplewith intrinsically high levels of self-esteem(i.e. a secure sense of their own identity andplace in the world) are less likely to react toreminders of their mortality by retreatinginto a cultural world view. Conversely, peoplewith low self-esteem – those, for instance,who, to borrow Yalom’s phrase have a strongsense of an ‘unlived life’ – are more likely tobe over-whelmed by both death anxiety andby the prospect of the decay and deteriora-tion of dementia.

Research also indicates that other factorsin addition to cultural worldviews and self-esteem may serve as a buffer against deathanxiety. Thus, the existence of close andloving relationships may function as a deathanxiety buffer. Social forces may also play arole as people may respond to death anxietyin gender stereotyped ways: males by with-drawing emotion and compassion (becausethey are socialised to display emotionalstrength and to value independence andinstrumentality), whereas females increasecompassionate responses (because they aresocialised to be responsive to the needs ofothers and to show concern and care)

Mnemic neglect – hiding away fromthreatening material

‘The mnemic neglect model posits that peopleare motivated to believe that they are good andto defend this belief.’ (Sedikides & Green,2009, p.1057)

Mnemic neglect is a term that has beencoined by Sedikides and colleagues (e.g.

Green, Sedikides & Gregg, 2008; Sedikides &Green, 2004, 2006; Sedikides & Spencer,2007) to account for findings from theexperimental literature which suggest thatthreatening material is processed in adifferent way to self-confirming material.The mnemic neglect model holds thatpeople tend to think of themselves in posi-tive terms – for instance, as worthwhile,competent and moral. However, it is onlypossible to hold onto this self-concept byguarding against material that is threateningto this version of self. Mnemic neglect is afirst line of cognitive protection, and can beoverwhelmed by more traumatic memories,which may be resistant to being pushed away.

Mnemic neglect suggests that althoughindividuals attend to threatening material,they subsequently process it in a superficialmanner, and without it being linked to otherknowledge and memories that the individualhas about themselves – in effect they tend tothink about this material less and toremember it on fewer occasions. By contrast,individuals not only attend to and encodeself-affirming feedback but also process itmore thoroughly. Consequently, links aremade between this self-affirming materialand other memories, and the material isrecalled more often. It is as if events or occur-rences that suggest a critical view of ourselves,and which go against a positive view ofourselves are less likely to be understood asbeing representative – they are somehowpushed out of our memory in a way thatevents which confirm someone’s view ofourselves are not. These, self-confirmatoryevents are more likely to be remembered,whereas self-threatening events are likely tobe ignored (Sedikides & Green, 2009).

Whereas some psychological theoriessuggest that people try to resolve inconsis-tencies in how they view themselves andothers, the mnemic neglect model empha-sises the way in which individuals try to main-tain the positivity of their self-conceptions,principally by protecting the self fromunfavourable social feedback. Feedbackwhich is negative (rather than positive),



which relates to central (rather than toperipheral) traits and which refers to oneself(rather than to others) is defined as self-threatening.

‘The thrust of the model is that people fail toprocess self-threatening feedback thoroughly.Self-threatening feedback … will receiverelatively shallow processing … less long-termelaboration will ensue, resulting in fewerretrieval routes, and ultimately poorer recall.In contrast self-affirming feedback … willreceive relatively deep processing.’ (Green,Sedikides & Gregg, 2008, p.548)

Thus people not only tend to be poor atremembering unpleasant things that havehappened to them, but are also poor atremembering things that threaten theirsense of self. Mnemic neglect thus seems tobe a self-protective strategy. At the sametime, people are able to switch from avoidingnegative feedback to trying to improve them-selves and looking for positive feedback.When Sedikides and his colleagues looked atrecognition rather than recall – that is to saywhen people were given an appropriateprompt – then they did remember what hadhappened. So at some level, this threateningmaterial did exist within a person’s memory– it was being pushed away rather than beinglost completely (Green, Sedikides & Gregg,2008).

A number of issues make the model ofmnemic neglect relevant to dementia care.First, there are potentially a huge number offactors that can threaten the sense of self ofa person with dementia: everything from anembarrassing moment of public forgetful-ness, to a private moment of incontinence. Ifthere are cognitive processes of self-protec-tion that push this threatening material outof conscious recall, then this adds weight toan understanding of insight as not just aprocess of neurological deterioration, butalso one that concerns emotions and theprotection of an individual’s sense of self.

A second important finding concerns thepotentially cumulative effect of favourableand unfavourable feedback. Thus, forpeople with dementia, there is normally not

just a one-off event which can be pushedaway, but a series of evens which are allpotentially threatening. When Green,Sedikides and Gregg (2008) looked at whathappened when they gave subjects a series ofdifferent sorts of feedback, they found thatwhile providing the person with a smallamount of positive feedback before givingthe negative feedback reduced mnemicneglect, receiving feedback which wasunfavourable seemed to enhance themnemic neglect effect. Thus if a person withdementia receives a series of unfavourablefeedback, then they will be less likely toprocess this feedback or subsequently torecall this. Conversely, if we want to talk tosomeone about something that is personallydifficult for them, such as aspects of theirdementia, then it’s probably best to beginthe feedback with a more positive message toprovide a boost to their self-concept.

Finally, there is the way in which researchshows that the phenomenon of mnemicneglect is flexible. Under the right circum-stances, for instance, subjects in researchtrials were able to switch from a self-protec-tive stance of avoiding negative feedback, toan alternative position such as striving forfeedback to improve performance. Experi-mentally, one set of circumstances that cantrigger this switch was when feedback wasprovided by somebody that participants wereclose to, rather than by a stranger. What thisholds out, then, is that if we are able toattend closely to the way in which feedback isgiven, then some people with dementia maybe able to a more realistic ay of talking abouttheir problems and thinking about theirneeds. Talking about your dementia within agroup of people with whom you feelcomfortable and safe is easier, and morerewarding, than talking about your dementiato strangers.

As Sedikides and his colleagues recog-nise, the process of mnemic neglect in manyways seems to be an experimentally derivedtesting of features about memory and self-concept which psychologists and others haveknown about for many years. For instance,


Richard Cheston

it seems to act in a similar manner to theanalytic concept of repression in whichthreatening experiences are unconsciouslydefended against. Moreover, research intoautobiographical memory suggests thatunpleasant things that happen to people arerecalled less well than are pleasant lifeevents. In part, this may be because positiveevents tend to happen twice as many times asnegative events, but it may also suggest thatas humans we are programmed to selectivelyremember some events more than others.

Mnemic feedback is also more likely tooccur when feedback is provided to an indi-vidual about traits that are seen to be centraland fixed, than about traits that are morelikely to be seen as peripheral and modifi-able. In this sense it is important toremember that dementia involves a threat toaspects of a person’s being that are bothcentral and fixed – dementia threatens suchfundamental aspects of a person’s being andwhich will not only persist, but becomeintensified over time. It is reasonable tosuspect, therefore, that dementia will almostinevitably trigger those self-protective cogni-tive processes described in the mnemicneglect model. That is to say that once aperson has been told about their diagnosis ofdementia, they will attend to this, butprocess it more superficially, and be lesslikely to make associations between thedementia and the rest of their life. They willbe more likely to attend to self-confirmatoryfeedback such as success in certain areas oftheir life, and to spend less time thinkingabout and processing those errors thatoccur.

The self-neglect for material related todementia is a ubiquitous part of working,and living, with people with dementia. Timeand again when I have met couples andasked them to talk about their lives, I havereceived a different version from the personwith dementia and their partner: the personwith dementia may acknowledge that theyhave been diagnosed as having this illness,but then describe how little their life hasbeen affected, and list the many things that

they continue to do as they have always done.In contrast their husband or wife may gently(and some times not so gently) refute this listof non-changes, reminding the person ofwhat they cannot do.

We can, of course, attribute the disparitybetween these two different versions to a lossof insight caused directly by the same neuro-logical impairment that caused the inabilityto perform these tasks in the first place.What is also true, however, is that we arewitnessing an interaction between neurolog-ical impairment and the self-protectivecognitive processes involved in mnemicneglect. That is to say, the failure to processand remember their dementia reflects theperson with dementia protecting themselvesagainst the threat to their self-concept thatdementia represents. As Linda Clare hasargued, awareness involves both self-protec-tive and self-maintaining strategies (e.g.Clare et al, 2008)

ConclusionIn sum, when death is salient, people deploy avariety of self-enhancement tactics and go togreat lengths to live up to culturalcontingencies of self-worth. Further, having apositive view of one’s self typically reduces theneed to rely on other psychological defences thatbolster the symbolic self. Therefore, if deathawareness has the potential to compromisepsychological adjustment, self-esteem may playa critical mitigating role. (Routledge et al.,2010, p.899)

Understanding dementia in terms of an exis-tential threat to psychological equanimity,which is mediated by levels of self-esteemand can trigger a variety of social andpersonal defences has important implica-tions for the work of clinical psychologists.First of all TMT allows us to understandmany of the things that people withdementia say and do. Rather than indicatinga lack of awareness, we can understand suchbehaviour as attempts to bolster self-esteemand to hold onto a world view which isconsistent with a higher level of self-esteem.Where possible, creating an environment



which enhances a person’s self-esteem, andwhich diminishes threats to the person’s self-esteem are more likely to lead to the personbeing able to talk or think about threats totheir self. Secondly, it is possible to createcircumstances that increase and decrease theability of people to think about theirdementia. If we provide the right sort of envi-ronment (for instance, in group psycho-therapy) where people can recognisethemselves, then this will enable them tobegin to discuss what is happening. More-over, if we can convert our feedback aboutproblems they experience into material thatrelates to peripheral and malleable aspectsof self (rather than central and fixedaspects) and have it delivered by people theyfeel safe talking to, then it can be more easilyprocessed. Once again this replicates an

important aspect of psychotherapy – the wayin which people with dementia in groups areable to move from being overwhelmed bytheir dementia and instead see themselves asbeing essentially unchanged – the sameperson as they have always been, but copingwith the effects of memory loss and the otheraspects of dementia. In the jargon of experi-mental research participants moved fromself-protection to self-improvement.

CorrespondenceRichard ChestonConsultant Clinical Psychologist,Charter House,Seymour Road,Trowbridge,Wiltshire, BA14 8LS.Email: [email protected]


Richard Cheston

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References

IT IS PREDICTED that by 2051 Black andEthnic Minority (BME) groups will makeup more than a third of the population of

England and Wales and there will be 3.8million older adults from BME groups(Lievesley, 2010). At present there are asmany as 10,000 older adults from a BMEbackground with dementia in England andWales (Shah, 2008), and as the number ofolder adults from BME backgrounds is set torise this will also increase rapidly. Given thisit is important to note that that those from aBME background appear to be at a greater atrisk of dementia. In the US, African-Ameri-cans have been found to have nearly twicethe prevalence of dementia as their whitecounterparts (Demirovic et al., 2003). Simi-larly research in the UK has shown a higherprevalence of dementia in those fromAfrican-Caribbean backgrounds (Adelman,2009; Richards et al., 2000). Richards et al.(2000) found that 22 per cent of an olderAfrican-Caribbean sample in London metthe criteria for dementia, compared to fourper cent for white British, after accountingfor differences in education and occupation.There is also evidence that those withdementia from this ethnic group areyounger, and have higher levels of vasculardementia, possibly due to higher rates ofhypertension (Adelman, 2009). Otherresearch suggests that the prevalence ofdementia is only higher in those from BMEbackground who have poor English(McCracken et al., 1997). However, thosefrom a BME background with dementia alsoappear to be more cognitively impaired(Cooper et al., 2010).

Despite possibly being at a greater risk ofdementia, there is considerable evidence fora lack of awareness in BME communities inthe UK (Azam, 2007; Seabrooke & Milne,2004). Many BME carers report having notheard about dementia before the personthey care for was diagnosed, and many stillnot know the appropriate diagnostic term(Adamson et al., 2001). Indeed there is noword for dementia in Asian languages(Azam, 2007; Seabrooke & Milne, 2004), andmany Asian service users with dementia donot see terms such as dementia orAlzheimer’s as applying to them (Lawrenceet al., 2011). Those from Asian backgroundsoften see dementia as a part of normalageing (Seabrooke & Milne, 2004; Turner,Christie & Haworth, 2005), and few see it asan organic disease (Seabrooke & Milne,2004). There is a lack of knowledge aboutsymptoms, with less awareness that person-ality and speech can be affected (Purandareet al., 2007), and those from BME back-ground are less likely to see dementia astreatable (Seabrooke & Milne, 2004; Turner,et al., 2005). In addition there are high levelsof social stigma around the illness in Asiancommunities (Azam, 2007; Seabrooke &Milne, 2004), with some seeing dementia asdue to a lack of family care (La Fontaine etal., 2007) or related to religion (MacKenzie& Coates, 2003). Similarly Eastern Europeancarers feel stigmatised and see dementia as‘insanity’ and often attribute memoryproblems to physical health incidents such asfalls (MacKenzie & Coates, 2003). Otherresearch suggests those from BME commu-nities sometimes blame the patient for theirsymptoms (Adamson, 2001; La Fontaine et


Dementia in Black and Minority Ethniccommunities in Hampshire: Developmentof a Time to Change campaignThomas Richardson & Ann Marshall

al., 2007), and those from Asian communi-ties may fear dementia in the familydamaging their prospects of arrangedmarriage (Mackenzie, 2006).

Perhaps as a result of this lack of aware-ness and stigma, research suggests that thosefrom BME backgrounds do not know whereto get help (Bowes & Wilkinson, 2003; LaFontaine et al., 2007). In addition languageproblems, stigma and concerns about confi-dentiality are seen as barriers to accessingservices (Westminster Advocacy Service for Senior Residents/Dementia AdvocacyNetwork, 2009; Seabrooke & Milne, 2004). A systematic review of evidence mainly fromthe US suggests that those from BME back-grounds access services later when theirdementia is more severe (Cooper et al.,2010). In the UK research suggests thatmany from Asian communities often try tohide problems (MacKenzie & Coates, 2003),and only come to the attention of serviceswhen symptoms are severe (Seabrooke &Milne, 2004), or when people comment orcarers can no longer cope (Mukadam et al.,2011). This means that it is harder forpreventive interventions to be employed(Seabrooke & Milne, 2004).

Thus, there is of a lack of awarenessabout dementia in BME communities, andsuch a lack of awareness appears to preventhelp seeking and may account for the under-representation of BME groups in dementiaservices (Moriarty, Sharif & Robinson, 2011;Seabrooke & Milne, 2004). There is evidencethat increasing knowledge about dementiain these communities and helping them seeit as an illness helps facilitate access toservices (Mukadam, Cooper & Livingston,2011; Seabrooke & Milne, 2009). Providinginformation and education for BME commu-nities is, therefore, indicated (Moriarty et al.,2011; Seabrooke & Milne, 2003).

The Time to Change campaign(www.time-to-change.org.uk/) is a nationalcampaign launched in October 2007 whichaims to reduce stigma against mental healthproblems. This has tried to tackle discrimina-tion in a number of different ways such as a

high profile media campaign with the help ofcelebrities such as Stephen Fry, communityevents, training for health professionals, andresources for employers. This campaign hasreached 34 million people in England so far,and has been shown to improve public atti-tudes and reduce discrimination. An overviewof campaign is provided by Henderson andThornicroft (2009). Recently Time to Changehas tried to target attitudes towards mentalhealth problems in the South Asian commu-nity, after research showed specific problemsin this community, such as causes beingmisunderstood, shame and secrecy, and fearof marriage prospects being damaged.Leaflets have been made available in Tamiland Gujarati, and a campaign was launchedthis summer in Harrrow for the South Asiancommunity. A local Time to Changecampaign has also been running in Hamp-shire with various events to improve aware-ness including a stand at an Asian festival.

In Older People’s Mental Health servicesin Hampshire, psychologists are currentlyworking with the local Time to ChangeCampaign Manager and other staff to extendthis anti-stigma campaign to target olderadults. This will focus predominantly on atti-tudes towards dementia. We will link this witha campaign shortly to be launched with theSouth Asian community (this is the largestBME population in Hampshire, HampshireCounty Council, 2009). Given the researchdescribed above, we believe it is especiallyimportant to tackle stigma and attitudestowards dementia in order to increase thenumber of ethnic minority older adultsseeking help for memory difficulties.

We hope to achieve this in a number ofways using similar methods to previous localand national campaigns. Current ideas are:1. Develop a leaflet on dementia for South

Asian elders specifically. This will take asimilar format to leaflets used on thenational campaign and translations will beavailable. This will include a quote from acommunity elder about stigma in theAsian community, as well as informationabout dementia and available services.


Dementia in Black and Minority Ethnic communities in Hampshire

2. Display a billboard at the local acutehospital. This is a work in progress, but islikely to contain a myth fact statement ashas been done in the national campaign:Myth: Dementia is a normal part ofageing. Fact: Dementia is a disease of thebrain. A focus group with a communitymental health team for older adults hasbeen conducted to develop additionalideas for anti-stigma for posters.

3. Liaise with local community elders,organisations such as the Asian elders’network, and religious leaders to helpdistribute leaflets and information.

4. Measure attitudes before and after thecampaign in a sample from the BMEcommunity.

5. Work with shopkeepers to tackle stigma:service users and carers reported findingit frustrating as some do not understanddementia and sometimes ban serviceusers from shops. It was suggested at alocal user carer meeting to developstickers for shops to put in their windowto show that they are ‘dementia friendly’.

6. Combine this work with a DVD which hasbeen developed for the trust for thosewith early stages of dementia attending a‘Memory Matters’ course. This includes asection by an Asian community elder onstigma.

7. Put descriptions of these activities on thetrust website, and discuss at trust events.

This project in the early stages of develop-ment at present, and how many of these aimswill be achieved is unclear. However, webelieve that this campaign is important giventhat BME communities appear to be espe-cially stigmatised towards dementia. Giventhe increasing number of older adults froma BME background, tackling attitudestowards dementia is essential so that help isaccessed as early as possible.

About the authorsThomas Richardson Trainee Clinical Psychologist,University of Southampton.

Dr Ann MarshallConsultant Clinical Psychologist, Eastleigh Community Mental Health Teamfor Older People, Southern Health NHS Trust.

CorrespondenceDr Ann MarshallEastleigh Community Mental Health Teamfor Older People, Newtown House, 2a/2b Newtown Road, Eastleigh, Hants., SO50 9DB.Telephone: 02380 620947.


Thomas Richardson & Ann Marshall

Adamson, J. (2001). Awareness and understanding ofdementia in African-Caribbean and South Asianfamilies. Health & Social Care in the Community,9(6), 391–396.

Adelman, S. (2009). Prevalence and recognition ofdementia in primary care: A comparison of OlderAfrican-Caribbean and White British residents ofHaringey. University College London.

Azam, N. (2007). Evaluation report of the Meri Yaadaindementia project. Bradford: Girlington Advice andTraining Centre.

Bowes, A. & Wilkinson, H. (2003). ‘We didn’t know itwould get that bad’: South Asian experiences ofdementia and the service response. Health &Social Care in the Community, 11(5), 387–396.

Cooper, C., Tandy, A.R., Balamurali, T.B.S. &Livingston, G. (2010). A systematic review andmeta-analysis of ethnic differences in use ofdementia treatment, care, and research. AmericanJournal of Geriatric Psychiatry, 18(3), 193–203.

Demirovic, J., Prineas, R., Loewenstein, D., Bean, J.,Duara, R., Sevush, S. et al. (2003). Prevalence ofdementia in three ethnic groups: The SouthFlorida Program on Ageing and Health. Annals ofEpidemiology, 13(6), 472–478.

Hampshire County Council (2009). Estimated residentpopulation by ethnic group, age and sex, mid-2009(experimental statistics). Retrieved from:www3.hants.gov.uk/ons_ethnic_group_estimates_2009.xls.

Henderson, C. & Thornicroft, G. (2009). Stigma anddiscrimination in mental illness: Time toChange. The Lancet, 373(9679), 1928–1930.

La Fontaine, J., Ahuja, J., Bradbury, N.M., Phillips, S.,& Oyebode, J.R. (2007). Understandingdementia amongst people in minority ethnic andcultural groups. Journal of Advanced Nursing,60(6), 605–614.

Lawrence, V., Samsi, K., Banerjee, S., Morgan, C. &Murray, J. (2011). Threat to valued elements oflife: The experience of dementia across threeethnic groups. The Gerontologist, 51(1), 39–50.

Lievesley, N. (2010). The future ageing of the ethnicminority population of England and Wales. London:Runnymede Trust and Centre for Policy onAgeing.

Mackenzie, J. (2006). Stigma and dementia: EastEuropean and South Asian family carers negoti-ating stigma in the UK. Dementia, 5(2), 233–247.

MacKenzie, J. & Coates, D. (2003). Understanding andsupporting South Asian and Eastern European familycarers of people with dementia. Bradford: BradfordDementia Group.

McCracken, C.F., Boneham, M.A., Copeland, J.R.,Williams, K.E., Wilson, K., Scott, A. et al. (1997).Prevalence of dementia and depression amongelderly people in Black and Ethnic Minorities.The British Journal of Psychiatry, 171(3), 269–273.

Moriarty, J., Sharif, N. & Robinson, J. (2011). Blackand Minority Ethnic people with dementia and theiraccess to support and services. London: Social CareInstitute for Excellence.

Mukadam, N., Cooper, C., Basit, B. & Livingston, G.(2011). Why do ethnic elders present later to UKdementia services? A qualitative study. Interna-tional Psychogeriatrics, 23(07), 1070–1077.

Mukadam, N., Cooper, C. & Livingston, G. (2011). A systematic review of ethnicity and pathways tocare in dementia. International Journal of GeriatricPsychiatry, 26(1), 12–20.

Purandare, N., Luthra, V., Swarbrick, C., & Burns, A.(2007). Knowledge of dementia among SouthAsian (Indian) older people in Manchester, UK.International Journal of Geriatric Psychiatry, 22(8),777–781.

Richards, M., Brayne, C., Dening, T., Abas, M., Carter,J., Price, M. et al. (2000). Cognitive function inUK community-dwelling African-Caribbean andWhite elders: A pilot study. International Journal ofGeriatric Psychiatry, 15(7), 621–630.

Seabrooke, V. & Milne, A. (2003). Developingdementia services for an Asian community.Nursing & Residential Care, 5(5), 240–242.

Seabrooke, V. & Milne, A. (2004). Culture and care indementia: A study of the Asian community in north-west Kent. Northfleet, Kent: Alzheimer’s andDementia Support Service.

Seabrooke, V. & Milne, A. (2009). Early interventionin dementia care in an Asian community:Lessons from a dementia collaborative project.Quality in Ageing and Older Adults, 10(4), 29–36.

Shah, A. (2008). Estimating the absolute number ofcases of dementia and depression in the Blackand Minority Ethnic elderly population in theUnited Kingdom. International Journal of Migra-tion, Health and Social Care, 4(2), 4–15.

Turner, S., Christie, A. & Haworth, E. (2005). SouthAsian and White older people and dementia: A qualitative study of knowledge and attitudes.Diversity in Health and Social Care, 2(3), 197–209.

Westminster Advocacy Service for Senior Resi-dents/Dementia Advocacy Network (2009).Bring dementia out of the shadows for BME elders: A report on the work of the Ethnic Minorities DementiaAdvocacy Project (Emdap). Westminster AdvocacyService for Senior Residents/Dementia AdvocacyNetwork.


Dementia in Black and Minority Ethnic communities in Hampshire

References

EXISTENTIAL THOUGHT alerts us toone of the starkest of realities: that nomatter the closeness of our relation-

ships, we can never be truly known by others– that nobody else can completely under-stand us, our motivations, our desires andneeds; no one else can truly walk a mile inour footsteps, let alone a yard or an inch. Inthis sense we are born alone, live alone anddie alone. Even within the closest relation-ship lies another truth – that none of us canever, ultimately, be known in the sense ofthat our experiences of life are, by theirnature, ours and ours alone (Yalom, 2008).

And yet, human beings are invariablysocial animals. Indeed, it has been arguedthat it is the development of the skills neces-sary for social life, such as empathy and theability to de-centre, that has enabled muchof human evolution. Thus, our passingthrough the world is experienced as ourbeing one among many – we build familiesand live in a multiplicity of groups. More-over, it is the closeness of relationships – thefeeling that I live as a ‘we’, and not as a soli-tary being that, for many, provides life withmeaning and purpose.

The dilemma, then, is that of finding away to balance what seems to be an almostuniversal need for companionship, friend-ship and love with a desire not to be over-whelmed or engulfed – to feel part ofsomething whilst at the same time to remain

unique. This need for both closeness andsupport in the face of the inherent loneli-ness that we carry through life becomes mostpoignant when the external world is at itsmost threatening.

Isolation, abandonment and dementiaPsychological ideas about the significance ofloss and separation are especially importantfor dementia care, precisely because of theexistential threat that dementia creates. Asdementia erodes a person’s capacity tocommunicate and to understand the world,so the ways in which someone has managedto create security is in turn undermined. Thesubjective experiences of people withdementia have thus been characterised asmarked by feelings of loss, insecurity andseparation, and represented within the para-digm of attachment (Miesen, 1993, 1999;Browne & Schlosberg, 2005, 2006). Withinthis conceptualisation, a person’s frag-mented experiences may lead to an increasein attachment-seeking behaviour, with theaim of restoring the person’s feelings ofsecurity.

The experience of being lost or of livingin a world that is both familiar and yet, attimes foreign and unrecognisable, seems topermeate the descriptions of many peoplewith dementia, especially when there aremoderate or severe levels of cognitiveimpairment. Graneheim and Jansson (2006)


The use of naturally-occurring objectswithin nursing homes by residents with dementiaAlex Stephens, Richard Cheston & Kate Gleeson

This paper presents material from 30 hours of observations within a nursing home in the south-west ofEngland. The residents’ use of objects is evaluated in terms of a framework developed from Winnicott’sdescription of transitional objects. The papers concludes that there is evidence that a number of residentswere using objects in ways that met Winnicott’s criteria, and that other instances of attachment-relatedbehaviour were also observed. The implications of this for dementia care is discussed.

provide just one example of how dementia isoften represented as being intimatelyconnected to loss and isolation. Theydescribed a small-scale, qualitative study inwhich three people with dementia in a smallresidential home were interviewed over 10sessions. Loss and isolation, even when thatperson lived in the midst of others, was thecentral aspect that connected the experi-ences of these three people living withdementia and their behaviour. Whatemerged from their observations and inter-views was:

A feeling of loss of meaning and emptiness …the meaning of living with dementia anddisturbing behaviour, as narrated by threepersons at a residential home, was being in aworld of disorder, wondering and restriction.Living with dementia further meant feelinglonely despite being surrounded by lots ofpeople. (Graneheim & Jansson, 2006,pp.1399–1400)

Transitional objectsA transitional object is an object that thechild can imbue with a wealth of emotions –anger, rage, grief, happiness. For children atransitional object eases the child betweendependency on his/her mother and greateremotional independence (Busch, 1974). Fora person with dementia, the goal is different.It is to cope with ‘trauma and grief, to attain thebest level of functioning, and to develop a treat-ment alliance for a patient with a progressivelydegenerative neurological illness’ (Loboprabhu,Molinari & Lomax, 2007). For a person withdementia, a transitional object or pheno-mena has ‘a soothing function in the setting ofgradual and progressive loss of self and object rela-tions (including the internalised representation ofthe mother and various internalised objects) due todementia’ (LoboPrabhu et al., 2007).

A handful of writers have discussed theuse of transitional objects in dementia (e.g.Perrin & May, 2000). Loboroaphu et al.(2007) have framed dementia as a reflectionof childhood development and an increas-ingly unsafe situation in which people withdementia find it progressively harder to

access safe internal objects. They suggestedthat transitional objects can act as an‘anchor’ in this period of uncertainty aidingthe person with dementia with the transitionto dependence.

One way in which the use of transitionalobjects by people with dementia has beenexplored has been through introducingdolls, or other objects onto a ward or nursinghome (e.g. Fraser & James, 2008). ThusJames, MacKenzie and Mukaetova-Ladinska(2006) introduced 14 dolls into two residen-tial homes and recorded the reactions of 37people with dementia living there. Theyasked carers in the homes about theirimpression of the impact of the dolls.Despite initial concerns, all staff reportedthat there were clear benefits of introducingthe dolls, and that they felt their residents’lives had improved as a result. Thirteen ofthe 14 key workers also thought dollsimproved communication. Residents tendedto be more active, showed greater levels ofinteraction with staff and fellow residents,appeared happier, less agitated and moreamenable to personal-care activities.

However, this research, like others relateto items, such as dolls, which are introducedonto a nursing or residential home. They donot concern how residents make use of mate-rials that, if you like, occur naturally withinthe nursing home environment.

The study reported here examines theway in which residents within a nursinghome used objects within their environment.The observations made across 30 hours ofobservations have been analysed in terms ofwhether or not they meet the seven criteriathat Winnicott established to define transi-tional objects (see Table 1).

By investigating the relationships thatpeople with dementia have with physicalobjects that occur naturally in their environ-ment allows us to examine how attachmenttheory and specifically transitional andprecursor objects apply to people withdementia. This would help to establishwhether these theories can be viablydiscussed in relation to dementia and may


The use of naturally-occurring objects within nursing homes by residents with dementia

provide insight into some of the ways peoplewith dementia find security. It would alsoadd weight to the further use of otherpsychodynamic and developmental modelsin understanding the internal worlds ofpeople with dementia.

AimsThe study described in this paper aimed touse focussed ethnography to explore howpeople with dementia use the objects aroundthem, and to consider whether they mayemploy some objects transitionally.

MethodThe study used a focussed ethnographymethod as described by Knoblauch (2005).Focussed ethnography is a shortened versionof ethnography and can be used to evaluatea new addition to a system, or to shed lighton a specific question or questions. Ethnog-raphy not only employs observations but canalso use interviews, information from conver-

sations, photographs and documents. It wasused in this study as it allows the observer toexplore the world of the person withdementia, and tentatively interpret what theyare observing (Hubbard, Downs & Tester,2003).

ParticipantsThe study was completed in an adultcommunity care home for people withdementia, Woodleigh1, which is situated inSouth-West England. At the time of theobservations Woodleigh had twenty four resi-dents all of whom had a diagnosis ofdementia. In total, 27 staff membersconsented to be involved in the study.Twenty-one residents also consented to beincluded in the study, following the proce-dures set out in the Mental Capacity Act(2005). The study received approval fromthe Local NHS ethics committee and alsocomplied with the lead Trust and the Univer-sity of Bristol research process.


Alex Stephens, Richard Cheston & Kate Gleeson

Table 1: Winnicott’s seven criteria for transitional objects.

Winnicott’s initial theory of transitional objects states seven criteria which must be fulfilled foran object to be considered transitional:● The person assumes rights over the object and others agree to this assumption.● The object is affectionately cuddled as well as excitedly loved and mutilated● It must never change unless changed by the person● It must survive instinctual loving, and also hating ● It must seem to the person to … show it has a vitality or reality of its own.● It comes from without from our point of view, but not so from the point of view of the

person … it is not a hallucination.● Its fate is to be gradually allowed to be decathected (attachment feelings are withdrawn),

so that over the course of years it becomes not so much forgotten as relegated to limbo. It is also possible to distinguish between transitional objects and precursor objects (Gaddini, 1978), which are soothing objects that infants can make use of before they have the capacity to invest in transitional objects.

Transitional objects may be particularly important during separation from the primary caregiver,supporting the child as they form an internal representation of the ‘mother’, and warding offanxiety and depression (Winnicott, 1953, 1971). Winnicott (1953) gives examples of transitionalobjects, including blankets, soft toys or repetitive words or phrases. However, he cautions thatwhat is important is not what the object is but how it is used.

1 The name of the care home, its residents and staff, have all been changed to provide anonymity.

ObservationsThirty hours of observations were completedover a two-month period by the lead author.The data consisted of behaviour observationsof the residents and staff and the researcher’sconversations with residents and staffmembers. The researcher also took partic-ular note of when a resident or staff memberwas interacting with an object in some way.

AnalysisEthnography alternates between data collec-tion, the generation of hypotheses and thegathering of further information to confirmor deny the hypotheses in an iterativeprocess (Hammersley & Atkinson, 2006).After a number of days of data collection andanalysis, seven people were identified whoseemed to represent different levels of func-tioning and had attachments to objects orother related behaviour. Although subse-quent observation periods focussed aroundthese people, other residents were notexcluded from the observations.

Results For clarity the results that are presented herewill be organised around Winnicott’s sevencriteria of a transitional object (see Table 1).

1. The person assumes rights over the object and weagree to this assumption. Encapsulated withinthis theme is the dual idea both that theperson knows that object belongs to themand that others understand its value to theperson. There were many examples both ofpeople at Woodleigh ensuring that othersknow the object belongs to them, and of staffunderstanding the value of certain objects.Evidence for this came from residents beingdistressed when they are separated from theobject, as well as carers and other residentstaking care to reunite the resident with theobject.

Alice – Alice had arrived at Woodleighwith her husband. For a number of reasonsher husband had had to go to another carehome. Since his departure Alice had carriedaround a plastic doll in the style of a young

baby. Over recent months she had begun touse the doll only at night. On the one occa-sion Alice was observed with the doll duringthe day she would not let go of it, andbecome distressed at the thought of it beingtaken from her:

(1.1) Day 4, page 10: Paul (a care assistant)returns to help Alice with her tea, she is staringstraight ahead, the doll up by her chin.P: Why so serious? (Paul goes to move the dollaway from her chin) I’m just moving the babydown.A: My ba baby. You can’t have my ba baby.No! (she hangs onto the doll’s foot).

2. The object is affectionately cuddled as well asexcitedly loved and mutilated. There were manyexamples of objects being affectionatelycuddled, generally these were dolls or softtoys, but other objects were held affection-ately, for example, a cup and a tambourine.For instance, Henry was a gentleman withDown’s syndrome who had recently arrivedat Woodleigh. During the observationsHenry was regularly seen with a Popeye doll;he was also observed to carry teddy bears andmagazines in Popeye’s absence. However, itseemed clear from his facial expressions thathe had a preference for Popeye.

(2.1) Day 1, page 11: Henry holds Popeye tohis chest and then picks it up so they are faceto face. He touches noses with it. (.) Hewatches Popeye and then shakes him from sideto side.

Mutilation was operationally defined asmisuse, including being spat upon, ripped ortorn. At times the person with dementia didnot show any obvious indication that theywere consciously aware of the misuse of theobject, but the object would nonetheless berequired to withstand this rough treatment.Thus, Ruby had been at Woodleigh for anumber of months. Before her arrival shehad started to carry a knitted doll at home.She had named him Robert, but oftenreferred to him as ‘my baby’.

(2.2) Day 5, pages 5–6: Ruby puts her dolldown on the table; she places him on a gravypatch. She picks him up again.



R: He’s all wet, he keeps getting wet. I don’tknow.She puts him in the gravy again. I notice thatshe has gravy all over her hands.

3. It must never change unless changed by theperson. Just as many parents recognise that tochange their children’s transitional object,risks the object losing some special qualityknown only to the child, so staff atWoodleigh also recognised that they shouldnot alter those objects which seemed impor-tant to the residents. In a preliminary visit tothe home the deputy manager explainedthat Robert would often get very dirty butthe staff knew Ruby would not want himwashed. If he got particularly bad they wouldtry and take him from Ruby in the night andwash him and tumble dry him so he wasavailable quickly. During the observationperiod Ruby became distressed at Robertbeing changed:.

(3.1) Day 9, page 2: Ruby enters the sunlounge. She has spilt some juice and Roberthas got wet. She sits down next to me.R: My baby. (She raises Robert to her mouthand goes to kiss him.) You smell Robert you do,I don’t want you now.She puts him on the chair next to her. She thenpicks him up, holds him and puts him downagain. She picks him up and stands. ‘I’m going home’ She leaves the room.

4. It must survive instinctual loving, and alsohating, and, if it be a feature, pure aggression.Winnicott’s fourth criterion differs from thesecond (the object is affectionately cuddledas well as excitedly loved and mutilated) inthat it requires the object to be strongenough to survive primitive loving andhating. This concept is tied up with MelanieKlein’s work on primitive relating; the childtests out aggressive and loving instincts withthe transitional object and the object isrequired to withstand both.

(4.1) Day 1, page 3: Henry wakes and picksup Popeye. He holds the doll’s nose to his noseand rubs noses with him. He lifts Popeye uphigher and then bounces him on his knee.

He lifts him up as high as he can and bringshim down saying ‘Weeeee’. He then cuddlesPopeye hard holding him to his chest andvigorously pats his back saying ‘Ahhhh’.Henry holds Popeye tight and rocks him hard.

Here Henry bounces Popeye in an aggressiveform of loving and he is expected to with-stand this. This is similar to observation 3.1where Ruby states she doesn’t want her doll.However, in this example, the doll isexpected to withstand this strong physicalexpression of affection and still be availablewhen Ruby reaches for it.

5. ‘It must seem to the individual to give warmthor to move, or to have texture, or to do somethingthat seems to show it has a vitality or reality of itsown.’ There were many examples ofinstances when the object seemed not onlyto give warmth or have texture, but also to beanimated by residents, who seemed to givethem ‘life’. It seemed that these individualsboth ‘knew’ their objects were not real butalso acted ‘as if’ they were real.

(5.1) Day 4, page 8: (Alice) looks down andsmiles at the doll.A: So yeah, yup, yeah (she bounces the doll upand down) up, yeah (she smiles at the babyand then rubs her knee). Yeah yeah, um um,yeah yeah (she is looking at the doll and thisseems to be a soothing chant to the doll) yeahyeah.

Later on the doll is moved and Alice hangsonto it just by its foot, indicating that shemay know that it is not real. In this sense theobject appears to have both the qualities of ababy (who can be played with and affection-ately cuddled) and also an inanimate doll,who can be suspended upside down.

6. ‘It comes from without from our point of view,but not so from the point of view of the person.Neither does it come from within; it is not a hallu-cination.’ This is a particularly difficult crite-rion to observe and involves the idea that theobject both ‘stands for’ part of the infant butalso ‘stands for’ part of the mother.

(6.1) Day 8, page 2: After a few minutesMarge comes in carrying the blanket, her



cardigan/book bundle and now a coat hanger.Paul asks if he can carry something for her, butshe says she has responsibility for them. She isstruggling to carry all of this and her twosticks. I approach her.I: Are you alright Marge? What are youcarrying?M: Myself dear.

The observations at Woodleigh indicatedthat there were times when the objects stoodfor an attachment figure. However, as theindividuals had experienced numerousattachment relationships the object couldpotentially stand for any, or all of theseattachments.

(6.2) Day 4, page 3: Marge starts handing thecards to Phoebe again.M: They remind me of my children. I ammother to one and aunt to another.

When writing about transitional objects,Winnicott (1971) was clear that althoughthey partly stood for the attachment figurethey could become more important to thechild than the attachment figure. Thisappeared to occur for the participants andsome individuals held onto their importantobjects throughout visits from their family.In addition the researcher was told Ruby hadarrived at Woodleigh with Robert and thatshe had used him while still living at home.

(6.3) Day 14, page 2: Ruby came (toWoodleigh) with Robert. … When her familyvisit she holds onto Robert just the same aswhen they are not there.

In summary there often seemed to be aconnection between the person’s objects andeither their attachment relationships or them-selves. Frequently the same object seemed tobe representing both at different times.

7. Its fate is to be gradually allowed to bedecathected (attachment feelings are withdrawn),so that over the course of years it becomes not somuch forgotten as relegated to limbo. People mayhave changing relationships with objectsbased on their internal state. For instance,objects may be more important to people attimes of greater insecurity, such as movingfrom one form of care to another. This is

perhaps best illustrated by Alice who wasusing her doll less frequently during the day.

(7.1) Day 6, page 7: The staff also said thatthey thought Alice felt differently now about herdoll than she used to. They thought shewouldn’t be as upset now if someone tried totake it.

Carers who had been at the home for anumber of years remembered Alice carryingher doll everywhere. Now, as Alice mainlyheld the doll during the night, carersbelieved it helped her sleep, and instead shespent much of the day rubbing the fabric ofher clothing and her skin.

DiscussionThe results suggest that at least two residents(Ruby and Henry) employed their objects ina traditional transitional object way, in thattheir objects fulfilled all the criteria of a tran-sitional object and they had used them over aperiod of time. Alice appeared to have usedher doll in a transitional way but her use ofobjects seemed to be moving into a moreprecursor phase and she made use of thetactile nature of her surroundings. She stillused her doll at night, but its importanceduring the day was gradually being lost.Finally, Flo appeared to use objects in a waythat is described in the literature as purelyprecursor way. She would stroke and feel herenvironment, move her mouth in anexploratory way and suck hard on anythingthat was introduced into her mouth. The keydifference between precursor objects andtransitional objects is that precursor objectsare thus not discovered by the individual, butgiven to them by another. Precursor objectsare thus not invested into in the same waytransitional objects are, rather it is somethingabout their tactile quality which is important.

Use of transitional objects in dementiaWhile the course of this study was for amatter of weeks, and not months or years,the history provided by care staff suggeststhat at least three residents had used theobjects over at least a year. However, someobjects that residents used, seemed to be



used on a temporary basis, in that atdifferent times they seemed to have ameaning that was subsequently not present.Interestingly, the child literature suggeststhat transitional objects can occasionally betransient and change over time (Mahalski,1983). In these cases the objects often allhave some similar special quality, such as aspecific tactile sensation, and in actuality it isthis sensation that serves as the transitionalphenomena.

One reason for the temporary nature ofsome objects in dementia is our differingresponses to people with dementia andchildren. In child development parents mayencourage their children to form attach-ments to objects by carrying them round andmaking them available (Litt, 1986). Theobservations did not show staff consistentlyacting in the same way and while staff wouldhelp an individual to find their treasuredobject, at other times the temporary transi-tional objects would be taken from an indi-vidual. If staff had more effectivelyencouraged attachment to objects ratherthan to remove them, then more people mayhave had traditional transitional objects.

Why might transitional objects be useful forpeople with dementia?Winnicott (1953) suggested that there existsfor all of us a third space between externaland internal reality, the transitional space. In childhood, with good enough mothering,this space can be traversed and the transi-tional object aids this process. In healthydevelopment the third space never disap-pears but is thinned, and expressed in playand creativity. A similar, but reversed,process may be occurring in dementia whereincreased cognitive impairment results inincreased difficulties in making sense of theexternal world. Consequently people’s senseof self and their internal objects are underthreat or degraded (Loboprabhu et al.,2007). As a result of these changes the inter-mediate space may be opened further and atransitional object could again be useful tohelp the person traverse this space.

Just as the child is soothed by investingthe object with a sense of their attachmentfigure, so in the dementia care home attach-ment figures are not always present and theprocess of dementia may render internalrepresentations of these attachment figuresunavailable at times. Therefore, a transi-tional object may help people with dementiaby being something tangible which repre-sents an attachment figure or figures, whenthe internal representations of these may beelusive. The observations indicated that attimes people did invest their objects with asense of their attachment figures, forexample, Ruby naming her doll after herhusband or Marge saying that the cardsreminded her of ‘her children’.

Why might precursor objects be useful for peoplewith dementia?Initially, in child development, precursorobjects are thought to gain their effective-ness as they are reminiscent of the sensationsthe infant experiences during feeding.Hence the first precursor objects are ‘intothe mouth’ objects. Later a tactile precursorobject may also provide soothing qualities,but this too represents the tactile sensationsexperienced during feeding (Gaddini,1978). In dementia something subtlydifferent may be occurring. While thesoothing nature of an oral or precursorobject might not represent the feedingsensations experienced in infancy, there issomething inherently comforting abouttactile and oral soothing gestures, which maycome in part from this early experience. Thiscould explain the repetitive stroking andoral movements observed during this study.

In summary it appears that at least someof the people at Woodleigh were using eithertransitional or precursor objects for some ofthe time. It could be that these objectsenable the person to ‘conjure up’ a sense ofgood enough attachment relationships thatthey have experienced throughout their lifeand thereby support them with their transi-tion from independence to dependence.



Conclusions and clinical implicationsThe process of the research looked at thesymbolic ways in which people used naturallyoccurring objects and it was clear that oftenobjects would serve purposes other than astransitional objects, such as activity or status.Similarly, the use of repetitive movementscould also be seen as offering occupationand activity as well as being a ‘precursorbehaviour’. Although Winnicott’s theory ontransitional objects may not offer a definitiveexplanation for how people with dementiause objects it is a useful theory to helpexplain what is happening in the relation-ship between people and their objects andwhat psychological struggles this may repre-sent. It can be a framework for not onlyunderstanding why interventions such asdoll therapy may be effective, but also whypeople have a need to ‘hang on’ to objectsbeyond their initial use. In addition it mayprovide at least one explanation as to whypeople with dementia use repetitive move-ments and vocalisations.

Dementia care research is at an earlystage in applying both attachment theory ingeneral and Winnicott’s theory on transi-tional objects to the experience of dementia.However, this study shows that people withdementia can make use of transitionalobjects and thereby lends weight to the useof Winnicott’s theory on transitional objectsin exploring and explaining the internalworlds of people with dementia. If theseobjects are indeed an ‘external sign of aninternal process’ (Winnicott, 1953), thenWinnicott’s theory on transitional objectscan be a valuable tool in understanding thebehaviour of people with dementia, inlooking at why certain interventions such asdoll therapy or Simulated Presence Therapy(Cheston et al., 2004) might prove benefi-cial, and in training and supporting people

who work in this area. In order for dementiacare to develop a fuller understanding of thephenomenology and needs of people withdementia, it is important that other psycho-dynamic theories including object-relationsand attachment should be considered whenworking with people with dementia andtheir carers (Davenhill, 2007).

AcknowledgementsThe authors would like to thank the resi-dents, staff and families at Woodleighwithout whose help this research would nothave been possible. A great deal of thanksalso goes to the Inreach Team who intro-duced the researchers to Woodleigh, andhelped in the initial stages of the project.Thanks also to Rachel Davenhill, whooffered the authors some important supervi-sion on psychoanalytic concepts indementia. Finally, thanks goes to DianaSimms who first got us talking about transi-tional objects in dementia.

About the authorsAlex StephensFrenchay Hospital, Bristol.

Richard ChestonConsultant Clinical Psychologist,

Kate GleesonResearch Tutor,University of Surrey.

CorrespondenceRichard ChestonConsultant Clinical Psychologist,Charter House,Seymour Road,Trowbridge,Wiltshire, BA14 8LS.Email: [email protected]



Browne, C.J. & Shlosberg, E. (2005). Attachmentbehaviours and parent fixation in people withdementia: The role of cognitive functioning andpre-morbid attachment style. Ageing & MentalHealth, 9(2), 153–161.

Browne, C.J. & Shlosberg, E. (2006). Attachmenttheory, ageing and dementia: A review of theliterature. Ageing & Mental Health, 10(2),134–142.

Busch, F. (1974). Dimensions of the first transitionalobject. Psychoanalytic Study of the Child, 291,215–219.

Cheston, R., Thorne, K., Whitby, P. & Peak, J. (2007).Simulated Presence Therapy, attachment andseparation amongst people with dementia.Dementia: The International Journal of SocialResearch and Policy, 6(3), 442–449.

Davenhill, R. (2007). Looking into later life: A psycho-analytic approach to depression and dementia in oldage. London: Karnac Books.

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References

IN COMMON with most trusts, there hasbeen a need locally in recent months totry and re-focus the area of professional

and personal boundaries, the lines that needto be maintained between staff and thepeople they care for in their work. Ashappens from time to time, there were aseries of incidents in which boundaries werenot observed, where relationships betweenstaff and patients or relatives were muddled,and clear lines were not observed. The Trusthas a clearly defined policy on professionaland personal boundaries, which states that‘staff must recognise and understand thatthey are in a position of power… (which)must not be abused at any time. … This isessential to protect service users at a timewhen they are vulnerable, and to protectstaff from risk of potential false allegations.’The policy goes on to list the ways in whichthings can go wrong, such as sexual miscon-duct, financial abuse of patients, use ofservice users’ belongings and intrusion intheir homes, to name but a few.

However, as with any policy, it was notclear how many staff knew of its existence,and had read it, and understood its signifi-cance. On talking to staff, views ranged fromknowing nothing about boundaries or thepolicy, to full knowledge and understanding,but there was concern among somemanagers that too many staff seemed to haveno idea about why maintaining boundaries isso clinically important. It emerged that manystaff have had no training in this area, and itis not something that is addressed at induc-tion. Arising out of this concern, coupledwith some disciplinary issues in other localareas, it was decided that there should besome training delivered to reinforce themessage of the policy. In the course of doing

the training, the issue of supervision cameup over and over again. Many of the issueswe were discussing could and should havebeen raised in supervision, but it seemedthat, especially on the wards, supervision wasnot always happening at the appropriateintervals, or even at all in some cases, partic-ularly, it seemed, for unqualified staff.Health care support workers in particularseemed to lack supervision, or to have hadnegative experiences in their supervision.Good, supportive supervision relies on manyfactors, some resource-based such as confi-dential room space and time, but there arealso some psychological factors such as thequality of the relationship between partici-pants. For it to be supportive and helpful,the supervisee must be able to trust theirsupervisor, particularly in terms of confiden-tiality. Good supervision is described asgiving ‘…empowerment and support … the cornerstone of clinical/professionalpractice’ (Faugier & Butterworth, 1994).Our local policy describes the focus to be to‘…allow time for exploration of problems …to reflect on the content and process of theirwork.’ It is self-evident that good supervisionis a complex psychological process whichneeds time and attention to work well.

There had been an audit of supervisioncarried out some months prior to this, whichestablished good figures for the frequency ofsupervision for clinical staff. However, thisonly looked at the regularity of supervision,not the quality of the experience for eitherparty. Therefore, we thought it would behelpful to look at this in more detail – theimportance of good supervision is stressed inall professions, it is deemed to be essential togood nursing, medical and psychologicalpractice, and if there were problems,


Maintaining professional boundaries:Looking at the quality of supervisionLiz Young & Kate Keetch

it seemed vital to know this. So a small-scalesurvey was carried out to try and get an ideaof staff’s experience of supervision.

MethodA questionnaire was designed by the clinicalpsychologist and the assistant psychologist,and we tried to make it short and user-friendly to encourage co-operation. Therewere eight questions, relating to satisfaction,confidentiality and time available, offeringyes/no options but with space for furtherexpanded replies if wished. The last twoquestions are more open ones, asking aboutthe value of supervision to them, and aboutanything respondents would like to changeabout their supervision.

The questionnaire was sent out to allclinical staff in the locality OPMH service,except doctors, as they have differentarrangements for clinical supervision. Thepotential number of respondents was 184.The questionnaire was sent out via email, asbeing the quickest way to reach all staff, andthe route was via managers of community

teams and inpatient areas, which we wereadvised was the most efficient route. Theemail was sent for forwarding on to all staff,and in terms of return, we offered severaloptions. Respondents could choose to emailit straight back to us, and it was pointed outto them that this would not be anonymous,or alternatively to maintain anonymity theycould complete the questionnaire, print itout and send it back to us through the post,or place it in a sealed envelope in the boxwhich we provided in each area for thispurpose.

ResultsWe received 64 responses, out of a possibletotal of 184, a response rate of 35 per cent.The numbers and percentages for eachresponse are set out in Table 1.

In general, most people were largely satis-fied with their supervision, and feelsupported and valued. The large majorityfelt that supervision happens in an appro-priate space, that they have enough time totalk and that it is confidential. Most feel safe


Liz Young & Kate Keetch

Table 1: Responses to the questionnaire.

Questions Yes No Other comments

How satisfied are you in general with your 50% 8% ‘Somewhat’ and supervision? (N=35) (N=5) ‘Not’ = 46% (N=29)

Do you always have supervision at the 71% 28%appropriate time interval? (N=46) (N=18)

Is it in a comfortable confidential space? 92% 8%(N=59) (N=5)

Do you feel you have enough time to talk 84% 15%about everything you need to? (N=54) (N=10)

How much do you trust supervision to be 89% 11%confidential? (N=57) (N=6)

How safe do you feel to talk about issues, 81% 19%whether professional, or personal issues (N=52) (N=12)which you feel may affect your work?

What do you feel is the value of supervision? See Seecomments comments

Is there anything you would like to change 16% 48% No answer = 36%about supervision? (N=10) (N=31) (N=23)

to talk about difficult issues, and when askedto give details, people felt supported andvalued the opportunity to discuss any issuesand concerns, both clinical and personal.Those that chose to give comments aboutthe value of supervision were very positive:

‘I have been able to discuss many aspects of myrole including professional issues andreflection on practice. Supervision is an aspectof my working role that I look forward to eachmonth.’‘I feel supervision is of great value. I also feelsupported by my supervisor and find hertrustworthy and she tackles any issues andconcerns relevant to my job role.’‘To be able to have confidential discussionswith my manager whether about clinical orpersonal issues.’

However areas of concern were identified.We identified several themes of dissatisfac-tion from the questionnaire data:● Lack of frequency and protected time;● Lack of appropriate space;● Lack of confidentiality;● Issues raised not addressed;● Box-ticking exercise;● Changes needed.

Lack of frequency and protected timeEighteen people did not think they hadsupervision at the appropriate time interval(Question 2).

Ten people did not think they hadenough time to talk about everything theyneeded to (Question 4).

‘Too rushed. Staff required to give patient careor staff have too much to do to relax and givefull attention, often disturbed.’‘Tends to be whenever it can be ‘squeezed in’between clinical work and sometimes it becomesoverdue because of workload other commit-ments.’‘Done during lunch leaving barely any staff toserve lunch.’‘Usually go six months in between.’‘I went for over 18 months without super-vision, even though I kept requesting it. I havea new supervisor now, last had supervisionFebruary 2011.’

Lack of appropriate spaceFive people did not think they had supervi-sion in a comfortable space, or no roomssuitable

‘There are no really comfortable spaces, weusually use the manager’s office but can beand quite often are disturbed.’‘No rooms on ward suitable.’‘(Takes place) at nurses station due to need tokeep watch on patients.’

Lack of confidentialitySix people did not trust their supervision tobe confidential (Question 5). Twelve peopledid not feel safe to talk about issues affectingtheir work (Question 6).

‘Has left confidential documents lying around.Worry it will be gossip.’‘People’s personal paperwork left lyingaround.’‘I have overheard ‘gossip’ about other people’saffairs.’

Issues raised in supervision are neveraddressed Nine people felt no value to supervision(Question 7).

‘I can’t see the point of supervision at it doesn’tsort out any difficulties.’‘Issues raised never seem to be addressed.’‘Not listened to, opinions not valued. I feel de-skilled and undervalued.’‘No interest is taken, no support or loyalty.Things, problems, queries do not get sorted.Staff feel undervalued. Morale is very low.’

Box-ticking exerciseNine people felt no value of supervision(Question 7).

‘Rushed, it’s a paper exercise, always short-staffed, no time to talk.’‘A rushed paperwork exercise for thesupervisor. A compulsory ‘thing’ that has to bedone!’‘Tends to be a ‘box-ticking’ exercise, and anopportunity for management to ‘dump’ morework and responsibility on me!’‘No value, paper exercise, don’t feel supported.’


Maintaining professional boundaries: Looking at the quality of supervision

Changes neededTen people wanted to change things abouttheir supervision (Question 8).

‘I would like to feel supported. I would like tofeel that my contribution and experience countfor something and are taken intoconsideration, instead of feeling health caresupport workers are dogsbodies that have nointelligence or right to speak.’‘To choose my own supervisor. Have enoughnotice to prepare for next session. Have apersonal copy of the supervision session.’‘Supervision should be set in advance andstaff given date and time so they have time toprepare anything they may wish to discussespecially if they feel the allotted time is notadequate.’‘Perhaps that there is more protected time forthe supervisor as one feels that somehow theyare always pressed for time and that this is nota valuing experience for the person beingsupervised’‘There should be protected time for this tohappen, if there is a shortage of staffsupervision is postponed and it should not be.There is a lot of supervision to be completedevery month for so many staff so the staffinglevels should reflect that.’‘I have only had two supervisions since joiningthe Trust, both with different people, so I wouldlike consistency.’

DiscussionThe method chosen for this survey mightappear highly inefficient, in that in the formof an email it left room for people to simplyignore it, and it may also be that noteveryone actually received the survey, since itrelied on managers to disseminate it to staff.It is also probably the case that some staff stilldo not often use email, or may not have easyaccess to a computer at work. It is certainlytrue that another method might haveachieved a greater return rate, but the disad-vantages should be weighed against thebenefit of anonymity. Using this methodhelped to ensure anonymity as far as possiblebecause people did not have to use email toreturn the questionnaire, and did not even

have to send it back through the post. Thus,people were hopefully freed to say whateverthey wished in the knowledge that they ortheir work area could not be identified.However, this of course makes it hard toknow which areas are doing well in terms ofsupervision, and which are not and mayneed attention, but it seemed important toaccess people’s honest views and opinions,since a 100 per cent return without real opin-ions is worth very little. Therefore, we feltthat ‘quick and dirty’ was better than thealternative.

It was good to see that the majority ofpeople are fairly content with their supervi-sion, and many people expressed positiveviews. Some made a point of saying howmuch they value the chance to discuss issuesand concerns, both clinical and personal,and it helped them to feel valued andsupported. They feel listened to, can plantraining needs, and reflect on clinicalpractice.

However, it is also vital to know some-thing about where the process is goingwrong, and a proportion of staff made somevery pertinent comments. Problems raisedwere that supervision does not happen oftenenough, it’s too rushed, or it doesn’t happenat all (e.g. six to 18 months without). Some-times there is no appropriate space,including supervision at the nurses’ station,supervision is often disturbed, confidentialdocuments have been left on view and issuesraised have been repeated to others. Somecannot see the point of supervision, staff feelundervalued and morale is low, difficultiesare not sorted out. To some, it feels like justa paperwork exercise done so that the boxcan be ticked, but with no real interest ormotivation.

It is disturbing to hear that these kinds ofproblems are occurring about supervision,and there are implications to consider. Firstly,if people are not receiving good quality super-vision at regular intervals, they will feel under-valued, morale will be low, and retention ofstaff may suffer as a result. Care given topatients may not be as good if staff are not


Liz Young & Kate Keetch

supported to do the job well, which is ofcourse a concern. There may also beproblems with professional boundaries whichgo unchecked if staff cannot raise these issuesin supervision, problems such as overly closerelationships with patients, offers of money,or issues with families of patients, forexample. Good supervision should enablestaff to talk about these issues before theybecome big problems. But in order for staff tofeel able to talk about difficult things, super-vision must be seen and felt to be confidentialand the supervisor trustworthy, it must be in aplace and at a time that is protected, andthere must be enough time to do this.

Difficulties in ensuring this may stemfrom various issues such as staff shortages,which may mean that staff members cannotbe released to go to supervision, managersmay feel they have not got the time and thatthere are too many other demands on them.Supervision may come low down in thepriority order on a ward, and if it is too lowdown it may never happen. However, thesedifficulties in turn may not be the fault of themanager, who may value supervision veryhighly, but who may be frustrated herselfwith all the demands on her time. So respon-sibility must come back to localities andtrusts to ensure that supervision can beprioritised, and that there are both the timeand staff numbers to make this possible.There may also be training issues – have allmanagers had the opportunity to do anysupervisor training, and if they have donethis training, is it a one-off event, or should itbe repeated every few years?

To sum up, most respondents respondedwith positive comments about their supervi-sion, but a significant number made verynegative comments, including one or twowho were considering leaving because of theperceived lack of support. It seems that thereare issues to be addressed here, and thatperhaps more training is needed, both inwhy supervision is vital to good patient care,and also how to make it happen, and this isalso something that trusts need to ensure.

In general, then, it seems that for some,supervision a positive experience, while forothers it may be stressful, uncomfortable, orfrustrating, or indeed may not happen at all.In discussing these findings with senior staff,the importance of supervision was recog-nised, but they admit that, in a time of scarceresources, it has to come further down thepriority list than patient care, and may welljust not get done. Vital tasks of patient carerightly come first, and there is often not thetime or space to prioritise supervision.

This may mean, therefore, that issuesrelating to professional boundaries cannotalways be discussed in the appropriate way, ina timely manner, and may therefore bemissed. Staff may not be supported tomanage difficult professional boundary situ-ations in the best way, which may in turnallow problems to occur which could havebeen forestalled with good supervision.

Like so many other issues to do withworking practice, when looked at from apsychological viewpoint, things become moresubtle and complex, and this is difficult tomanage in the context of high demand andfinancial pressures. It seems that there has tobe a compromise, between good workingpractice and staff support, and the efficientand appropriate allocation of resources andtime, in order to maintain both staff job satis-faction and good patient care.

CorrespondenceLiz YoungClinical Psychologist,Souhern Health Foundation Trust.Email: [email protected]

Kate KeetchAssistant Psychologist,Souhern Health Foundation Trust.

ReferencesFaugier, G. & Butterworth, T. (1994). Clinical Supervi-

sion: A position paper. Manchester University (UK)School of Nursing Studies.


Maintaining professional boundaries: Looking at the quality of supervision

THE PROSPECT of facing dementiaunderstandably provokes strong andpowerful feelings. Dementia is a

progressive illness, that can be treated butnot cured, and which leads to the loss ofmany of those aspects of our being that mostpeople see as defining themselves. A recentpoll supports the argument that dementiapresents an existential threat to psycho-logical well-being. A 2011 YouGov pollcommissioned by Alzheimer’s Research UKshowed that 31 per cent of 2000 respondentsof all ages feared dementia more than anyother illness – more than feared cancer (27per cent) or death itself (18 per cent). Whenretirees were specifically questioned aboutwhich condition they worried about, then 52per cent said that they worried aboutdementia, compared to only 33 per cent whoworried about cancer and 30 per cent whoworried about having a stroke.

This paper outlines how the AssimilationModel of Problematic Voices (APV), a modelof change developed within psychotherapyprocess research by Bill Stiles and colleagues(e.g. Stiles et al., 1992; Honos-Webb et al.,1999; Stiles, 2001; Osatuke & Stiles, 2006)can be used to describe the relationshipwhich a person with dementia has with theirillness. The assimilation model suggests thatmost experiences in a person’s life areunproblematic and can be assimilatedroutinely into that person’s existing under-standing of the world. However, some expe-riences are so traumatic and theirimplications are so threatening that theyresist an easy or early assimilation. The

psychological processes that are oftenreferred to as avoidance and repression (andwhich in the APV model are described as‘warding off’) may act to push knowledge orawareness to one side. Yet unless thesedefences are exceptionally strong, the occur-rence of such problematic experiences arealmost invariably signalled by powerfulemotions that accompany the partial assimi-lation of painful material.

Dementia as a problematic experienceEvents may become problematic for one ofthree reasons. First of all it may be that someevents because of their extreme and trau-matic nature are such that almost anyonewould struggle to take the experience onboard easily. Secondly, the capacity ofdifferent people to bear the emotional diffi-culties and pain inherent in assimilation willvary – with the intra-psychic processes ofsome people being more fragile or lessresilient than others. Finally, if the ability ofthe social world around the person to sustainthat person’s attempts at exploration andassimilation is limited, then it will be hardfor any change to occur.

The concept of dementia can be under-stood as being problematic, then, in thesense that the profound existential threatthat dementia presents for individualsprevents an easy assimilation into existingschema. Within the Assimilation framework,the process of assimilation of problematicevents within psychotherapy is representedas progressing through a series of eightlevels, from Level 0 (‘warding off’) to Level 7


From warding off to working through:Helping people facing a diagnosis ofdementia to change their relationshipwith their memory problemsNaomi Betts & Richard Cheston

(‘mastery’). Not everyone who experiencesevents as problematic will pass through alleight stages – some may enter therapy withmaterial already relatively well processed,whilst others may lead satisfying lives withoutever fully integrating all their experiences.

The model outlined by Stiles and hiscolleagues has been applied to psychologicalintervention with people with dementia(Cheston, Jones & Gilliard, 2004; andWatkins et al., 2006). However, in this paperthis model will be adapted to focus on thepsychological tasks that dementia confrontspeople with, so that the eight levels of Stiles,will be grouped in terms of their tasks:helping dementia to emerge as the problemswithout being overwhelmed; identifyingdementia as the problem while gainingdistance; and working through by trying outproblem solutions or partial solutions.

First task: Helping dementia to emergeas the problem without beingoverwhelmedThe process of recognising dementia as theproblem in a person’s life is inevitably apainful and difficult one. This is not just acognitive process involving recognising,remembering and acting upon knowledge ofa diagnosis, but a process that fundamentallyinvolves affective and social components.Stiles and his colleagues suggest that theemergence of awareness is characterised byambivalence in which opposing voices grad-ually become clearer.

Warding off. At first, in order to prevent theperson from being emotionally over-whelmed by their experiences, informationand knowledge about dementia is pushedaway or warded off. Clients working at thislevel attribute all of their dementia-relateddifficulties to less threatening causes, such asa physical or sensory disability or just to aprocess of growing older. The person activelyavoids discussing dementia and subjectsrelated to dementia and does not recognisedementia or the problems associated withdementia as having relevance in their life.

Clients may avoid and not acknowledge diffi-culties in daily living or tensions within theirrelationships with others arising fromgreater dependency.

Successful warding off any problematicexperience requires a high level ofemotional energy, not only through theintra-psychic process of turning away fromand avoiding any reminders of the problem-atic material, but also because of the highlevels of conflict that consequently oftenarise within relationships. While levels ofaffect related to dementia are reduced, therecan be powerful expressions of emotionrelated to the need to avoid situations associ-ated with dementia. In this way, although theperson with dementia maintains a powerfuldetermination that nothing is wrong, oftentheir avoidance of dementia-related experi-ences (such as agreeing to meet a doctor ornurse from a mental health team) suggeststhat they know enough to not want to knowanymore.

Unwanted thoughts. Material related to theperson’s experience of dementia tend toleak through and begin to come intoconscious awareness. This can be intenselydistressing or frightening as it threatens theloss of psychological equilibrium. Thinkingabout dementia is seen to be too disruptiveor threatening to be tolerated. Dementiamay be referred to indirectly – for instance,as ‘the problem’ or as ‘it’ or externalised, forinstance, as a problem belonging only toother people. The person with dementiatends to change the conversation when thetopic is brought up, or to stray quickly fromthe discussion of problematic, dementia-related experiences, typically leaving it toothers to introduce the topic. One verbalmarker of this level of assimilation can beseen when people describe a fear of loosingcontrol if they continue to think about thematerial. This occurred during the firstsessions of the therapy group described inWatkins et al. (2006) where Mr E explainswhy he feels he needs to leave:


From warding off to working through

Mr E: I find what we’re doing now, it bringsall memories to me, so and being aroundlistening to you all, talking. I find I just wantto be … I don’t think a memory loss and Idon’t, talking, and being around each other… I’m not being funny about that. I’m tryingto make a point that I’d rather be at homedoing what I need to do, and want to do …And I’m more energetic shall we say, moreenergetic than. And this is why I really don’twant to talk about that you know, I mean I’msure it’s being selfish but, it’s just the way I feelabout it, I don’t really want to be here.Facilitator: Sometimes the things you rememberthat are the most painful, and you do want toforget about it all.Mr E: Yes, that’s exactly, yes that’s exactly whatit is … Well I just, don’t want to be here. I justwant to be. I’ve got lots of things I’d like to do,and er. Well, I can’t think about coming here,it just brings it all back.

Honos-Webb and Stiles (1998) describe howthe client in psychotherapy ‘feels he or sheshould be able to cope with the distressing materialwithout acknowledging its psychological/ emotionalbases. And may use phrases such as ‘tough it out’ or‘soldier on’. The emphasis is on controlling orsuppressing painful emotional material.’

Vague Awareness – the emergence of talk aboutdementia-related problems. In this level, theclient manages to acknowledge the existenceof problems related to dementia, but will, inthe most part, not be able to name theirproblems as specifically being ‘Alzheimer’sdisease’ or ‘dementia’. Alzheimer’s ordementia are acknowledged to exist, but aretalked about in general terms. While theperson with dementia can talk about some-thing being wrong, that ‘something’ may notbe specifically associated with dementia. Thehallmark of this level is intense, negativeemotion.

The person with dementia may describebehaviours or episodes from their daily lifethat were unexpected and which they cannot fully explain. These experiences areconnected to cognitive or other errors thatare potentially associated with dementia.

The client questions his or her own reactionsbut does not specifically associate theseerrors with dementia. The client describesthe feelings of pain, vulnerability or distressassociated with their experiences ofdementia but without stepping back fromthis – it is as if they are at risk of being over-whelmed by these intense feelings, withoutbeing able to step back from them. Indica-tions of this level include expressions offeeling stupid, silly, hurt, sad and anger. Thefeelings are implicitly associated with anexperience or aspect of dementia, but thisassociation is not made explicit. Thus oneparticipant in a group said:

But it’s the, it’s the quality of the emotionsinside me that really, really gets to me. BecauseI think I’ve done something terribly wrong. Notwrong entirely wrong, it’s just that it goeswrong. I mean today, I didn’t have a cluewhere I was going to go to put my car. I don’tthink that comes into your, your mind, and assoon as that started, I just felt ridiculous. I can’t describe how really, really stupid I felt.

The person with dementia is in distress,therefore, and this distress seems to comefrom some internal conflict relating either todementia or to a primary symptom ofdementia, and in talking seems to be caughtup in the moment of the emotion. Thus theperson may express feelings of sadness,depression, worry or anxiety or be angry orirritated about some aspect of dementia, orthe reaction of people to them. At times theperson may describe feeling overwhelmedand feel that things are getting worse.

Second task: Identifying dementia asthe problem while gaining distance andperspectiveClarifying dementia as the problem. Thenaming of dementia as the problem enablesthe client to talk about the impact thatdementia is having on him or her and todescribe how the dementia makes them feel(e.g. being angry, silly, embarrassed or sad).However, within this level, the person is notas caught up in the emotion of the momentas they are in the previous levels. This level is


Naomi Betts & Richard Cheston

marked by the emergence of mixed feelingsabout dementia – the person is able todescribe both the sense of something beingwrong, and also other aspects of themselves.The person with dementia is engaged in aprocess of stepping back and looking at himor herself and noticing how he or she isreacting to the dementia. Sometimes thistakes the form of ‘yes … but…’ statements inwhich the person seems curious about theirfeelings.

Mr K: I tend to forget things that I’ve done theday before. It can be a bit embarrassing. If I’m,if I’m er, I’m reminded I get cross … I supposeI’m feeling a bit silly when I’ve forgotten …Well I realise I’m being silly, but even so I get abit cross at times.Facilitator: Are you cross with yourself oranother person?Mr K: I suppose it is against myself and I’malso, initially, I’m cross with the person whoreminds me [laughs].

In the later stages of this level, the clientidentifies aspects of their experience ofdementia that makes it hard for them to talkabout the dementia, or which producesanother method of covering up. The step-ping back from one’s feelings may be indi-cated by using the past tense, and also theway in which a behaviour (e.g. hiding away,covering up, being silent, being angry) isassociated with a feeling that the dementia-related experience has caused (e.g. beingembarrassed, being scared). One womantold her therapy group that RC lead:

I went into the local shop, around the cornerfrom ours and I got to the front of the queue,and they asked me for my money, and I couldn’t find it. I didn’t know what I wantedor where I was so I ran out, and my husbandwas there. He said ‘What are you making sucha fuss about?’ He always treats me as if I’m alittle girl, it’s embarrassing, but he’s right –I need to try harder and to do things, but I’mscared to do them, so I don’t know what to do.

Understanding and gaining perspective. At thispoint, the person with dementia begins to beable to take some perspective on their

illness, and to talk about, rather than to beimmersed within their feelings. They beginto make links between their reaction to theproblematic material and other aspects oftheir lives. The most awful aspects ofdementia are understood not to apply in allsituations, once again resulting in anincreasing level of complexity in the person’sdescription of their dementia. For instance,the person may talk about a way in whichtheir fear that they are going mad, causesthem to avoid going to places where thisfeeling would be intensified, or where theirdementia would be uncovered. Both the feel-ings about dementia, and also the reactionto these feelings can be described. Theperson’s level of affect may be mixed withsome unpleasant recognition, but withcuriosity and even pleasant surprise as theybegin to make sense out of the feelings thatthe dementia has provoked.

What distinguishes this level from theprevious level is that the person withdementia understands how their feelingsabout dementia or aspects of their illness,relates to their wider life. For instance, theymay make links with their past, or find someway in which their feelings can be managed.In this way, the person is moving away frombeing overwhelmed by the dementia tobeing able to talk about it, and to have somedistance from it. The stuckness of previouslevels begins to give way to some sense thatthe feelings around this dementia can bemanaged. As one woman said in a group:

I know that my husband finds it hard when I can’t remember things, it must be awful forhim. So I try not to say anything at those times,or to go to my room when I want to cry. I knowthat it’s silly, to have to cry, but I want to hideit from him, so that he doesn’t worry. He’s gotenough to put up with, and even if it makes mefeel a bit more lonely, well I feel that at least I’mdoing something for him for a change.

The person with dementia acknowledges theexistence of a dementia or a central aspect ofdementia such as a memory problem and isalso able to describe how this makes themfeel or how they react to this (but is able to



stand back from their feelings). Additionally,they either make links between the past andthe present or between how they respond tosome aspects of dementia and others areas oftheir life or other areas of dementia. Alter-natively, the person is able to identifyinstances where their feelings are more orless intense, or their problems are more orless difficult or otherwise show that they haveachieved some emotional distance from thedementia, rather than being overwhelmedby it, for instance, through use of humour orby comparing themselves with others in aworse position.

Third task: Working through, trying outproblem solutionsIn the final levels of the assimilation modelthe person with dementia is able to findpartial solutions to their problem, forinstance, through making decisions abouttheir life and their care. Often, they are ableto talk about having made a change in howthey understand their life and theirdementia – and how others see them. At thesame time, people understand that theproblem of dementia has not left them andthat indeed, their physical well-being willdeteriorate. Watkins et al. (2006) describedhow Robert, a member of a psychotherapygroup, looked back on the changes that hehad made during the group.

Mrs A: You have to face it to start with.Robert: Well I think that’s inevitable, we allwouldn’t be here if we didn’t do that. And soonce we’ve accepted it, you need help from otherpeople, you need help from ourselves, we needhelp from groups like this. I find I’ve got agreat deal of moral uplift by coming here.Meeting with you, listening to the way you doit. And I don’t see the problem now itfrightened me the way, the problem of decliningmemory, until I came here the way I didbefore…Mrs A: You didn’t accept it then before?Robert: Well I did accept it but it frightenedme, because I thought, well I’m going mad,

I’m going crazy. What am, what am I going tobe like in another five years? But now I realisethat everyone here has the problem. So rightstage two, so we’re all going to get the problem,what do we do about it? You have to developtechniques to help you to remember.

It may be that the person with dementia whois functioning at this level is more able toengage in trying out other strategies whichoffer a partial solution to aspects of theirdementia, from using mnemonic aids toengaging in planning for a decline in theirhealth by making an enduring power ofattorney.

Case study: Laura1

Laura is 59-years-old and is married to Steve.They have three children and two grandchil-dren. When she was referred to the memoryclinic, she had just chosen to take earlyretirement in the expectation that she couldspend more time sewing and walking theirdogs.

At her first meeting in the memory clinic,Laura told the psychology assistant (NB) thatwhile her memory wasn’t much of a problemfor her, it was worse when she was stressedand that consequently her confidence hasdeclined. She felt there had been a gradualdecline over the previous year but when shehad first seen her GP about her memory shesaid he had told her that the memory losswas probably due to the menopause. Herhusband, Steve, felt the decline has beenmore rapid in the last six months, saying thatLaura is more repetitive, that she repeatedlychecks things about the house, that she isoften unsure about the day and date andthat she struggles to learn new things. Healso believed that Laura’s personality hadchanged – she had become more bad-tempered and tearful. In terms of her day-to-day life, Laura continues to drive withoutdifficulty and enjoys walking the dogs.Although she and Steve now share thecooking because he says she now needs help,this annoys Laura who strongly disagreed



1 All names and personal details in this case study have been changed to provide anonymity.

with him, saying that she didn’t need anyhelp at all. She maintained in the interviewthat she does the housework and that sheoften does her sewing (which is her hobby).Steve quietly corrected her, saying that theyhave a cleaner who had only been to theirhouse that morning and that Laura hasn’tdone any sewing for the last two years. Simi-larly, while Laura said that she organised allof the household finances, her husband clar-ified this by saying all the bills are paid bydirect debit and that all she does in paycheques into the bank.

Laura found it difficult to listen to herhusband’s account and quickly justified ordenied his observations. Laura could notremember that the cleaner had been to thehouse that morning. Talking about her func-tional ability made her very defensive andthere was clearly tension between the two ofthem, as Laura swore at him in a half-joking,half-serious way.

At this point, Laura did not agree withSteve that there were significant problemswith her memory. Any difficulties that hebrought up, she attributed to poor concen-tration or to the menopause. Given thatLaura’s initial presentation includedchanges in behaviour, such as a decline inmotivation, unexplained euphoria and irri-tability the possibility of frontal lobe changescould not be discounted. However, Laura’snervous laughter and heightened emotionwithin the assessment could equally be inter-preted as fear and anxiety.

In retrospect, Laura’s justifications andbehaviour changes can be seen to fit withinthe assimilation model presented above.Whilst she vaguely acknowledged memoryproblems, her attribution of these to poorconcentration or to symptoms of themenopause are consistent with someonewho is struggling to acknowledge theirdementia without being overwhelmed bythis. In Stiles’ APV model, these descriptionsfall within the ‘unwanted thoughts’ level.Similarly her behaviour (e.g. her defensiveapproach towards her husband andchoosing to stay in bed until mid-day), seem

to be an effective ways to avoid hearing ordealing with this problematic experience.This, together with her heightened levels ofaffect, are, again consistent with someonewho is struggling to think about theemotional threat of dementia.

The results of the neuropsychologicalassessment revealed a series of deficits thatwere consistent with Alzheimer’s disease. Atthis point, however, the doctors within thememory service were reluctant to confirmthe diagnosis as Laura was still waiting tohave an MRI scan. In this interim period,without a diagnosis, NB agreed to meetLaura weekly to work on improving herconfidence by putting in place some strate-gies to aid her memory, plan some goals andto practise relaxation.

On NB’s first visit and several subsequentvisits Laura repeatedly responded to hergreeting by saying ‘I’m fine. I’ve been cooking,sewing, walking the dogs.’ It felt like a roteresponse. Initially, she found it difficult toengage with the relaxation session, but didagree to setting some goals, including wantingto start sewing again. Laura initially plannedto completely make a pair of dungarees forher grandchild but then compromised andset a more modest, but achievable goal.

NB’s next visit was very positive becauseLaura had achieved her goal of cutting thematerial for the dungarees and had reallyenjoyed getting back into sewing. Laura alsoengaged much better with the relaxationexercise, and after this had finished, shegradually began to talk about her childhoodand the area where she had grown up. Even-tually the conversation returned to hercurrent memory problems and she and NBdiscussed her using strategies to supportmemory, such as writing instructions, using acalendar or diary and acknowledging that it’sokay to rely more on recipes when cookingrather than stopping cooking. Again, she setgoals for this next week included finishingher dungarees and baking.

Once again, Laura achieved her goalswith success. She presented the cutest pair ofdungarees which were completely finished



and to a very competent standard and shehad also baked a lovely banana cake. She andNB reflected on her success and discussedhow she felt more confident in herself. Thisweek she engaged fully with the relaxationand asked NB whether she could notice animprovement in her.

At NB’s next visit Laura reported that shehad written herself instructions for oper-ating the television and washing machineand had started writing the day’s events andfuture plans in her Filofax. She had imple-mented these strategies independently,without help from her husband and was verypleased with herself, as she had found themhelpful. This was really the first time thatLaura seemed to acknowledge that she had amemory problem.

Laura was really feeling the benefits ofregular relaxation and made one of hergoals to do some relaxation every day. Shealso acknowledged other ways she relaxed,such as walking her dogs daily. She was nowestablishing more of a routine for her weekand getting up with her husband instead ofsleeping in, and while she still repeated herrote response of, ‘I’m fine. I’ve been cooking,sewing, walking the dogs’, she was talking morein the sessions about her memory loss andhow she was managing it. She was devel-oping a more resilient attitude towards thesituation often stating, ‘It’s not going to beatme.’ She was also much calmer and thenervous giggles and outbursts of emotionhad subsided. She and her husband felt likethey had the ‘old Laura’ back. What hadinitially seemed possible indicators of frontallobe damage, now seem much more clearlyto have been caused by fear and anxietyabout her memory problems.

The emergence of talk about dementia-related problems indicates that Laura wasbeginning to deal with this problematicexperience and progress through the levelsof the assimilation model. By developingstrategies to support her memory, Laura wasdemonstrating some ‘vague awareness’ ofthe problem but still not at a stage where shewas able to identify dementia as a cause. She

was still clearly referring to the problem as‘it’, for instance, when she told NB ‘It’s notgoing to beat me.’ However, her initially highlevels of distress had significantly reduced.There is no clear-cut progression from‘warding off’ to ‘unwanted thoughts’ andthen ‘vague awareness’, but her avoidancehad clearly reduced and Laura was begin-ning to both be more open about hermemory as a problem and starting tomanage her difficulties more effectively. Thisoscillating to and fro between the differentlevels represents attempts to resolve theinternal conflict caused by a threateningproblematic experience.

While Laura was functioning better, hermemory loss was still very evident. One weekNB asked after her grandchildren, whoLaura looked after once a week. She stoppedtalking, her face went blank until sherecalled that her 6-year-old grandson hadbeen attacked by a dog. She was unable torecall which hospital he was in and mistak-enly replied that he was still waiting forplastic surgery, when in actual fact he hadalready been discharged. This tragic eventhad only happened four days before NB’svisit, and she had visited the local hospitaleveryday while he was admitted.

In the weeks preceding her diagnosticappointment, Laura was now talking abouther memory loss more openly. During onesession with NB she commented, ‘If the Doctorsays, ‘Laura, you have Alzheimer’s’, I will beknocked off my feet but I’m not going to let it beatme.’ This was the first time that Laura hadraised the possibility that dementia could bea possible cause for her difficulties. Until thispoint Laura had maintained her positionthat the problem was due to the menopauseor poor concentration. This spontaneoususe of the word ‘Alzheimer’s’ suggested thatLaura was beginning to tackle the secondtask that dementia creates – to identifydementia as the problem while gainingdistance and perspective. While Laura wasstill scared that she might have dementia,she was coping with this much better andhad also started talking to others, including



her husband, about her fears. Furthermore,she was planning a future for herself, regard-less of the diagnosis thus demonstrating thatshe was understanding the problem andgaining more of a perspective regarding itseffect on her life as a whole.

The next time that Laura met her psychi-atrist, he confirmed to her that it was likelythat she was suffering from Alzheimer’sdisease. NB met with Laura a week later andshe appeared to be coping well with the diag-nosis. She said she felt relieved to finallyknow what was causing her problems and feltthat her sessions with NB had prepared herto cope with living with memory loss. Shedidn’t feel the word ‘Alzheimer’s’ needed tochange her approach to life in any way,acknowledging that she will continue toproblem solve and work towards maintaininga balanced life by monitoring her stress andcontinuing with relaxing activities, in orderto achieve a good quality of life.

ConclusionsWithin the Assimilation model, apparentfailures of memory for threatening materialmay reflect the activation of self-protectivemechanisms which are initiated as anattempt to retain psychological equilibrium.For a person with dementia, a difficulty intalking about memory loss, or the causes ofthis may reflect the role of psychological andsocial factors, and not just neurological ones.As such, some people with dementia may beable to benefit from supportive andthoughtful interventions that address notjust their need for cognitive rehabilitation,but also their fear and distress.

An apparent lack of awareness on thepart of a person with dementia about theirillness, or their partial and variable expres-sion of insight is not an incidental aspect ofclinical work with people with dementia.Rather the need to help individuals withdementia to develop and to sustain theirunderstanding of their illness needs to havea central role within dementia care. Whilstclinicians may not be able to modify neuro-logical damage directly, we can support and

sustain (and perhaps change) the way inwhich people with dementia respond to thepsychological threat of this neurologicaldeterioration.

It is unlikely that a person with dementiawill progress neatly from one level to anotherin the assimilation model. As the conditionprogresses and the person is challenged withfurther decline it is reasonable that theyshould move up and down the levels as thework to resolve a series of internal conflictscaused by the new challenges that theirdementia causes. Moreover, as Stiles and hiscolleagues repeatedly show, the process oftherapeutic change rarely runs smoothly –even with people who face the problems oftheir life without cognitive impairment.

Laura’s behavioural changes along withher apparent lack of insight when she firstattended the memory clinic could easily havebeen mis-attributed to possible frontal lobechanges. Instead, the pre-diagnostic coun-selling sessions that she received allowedLaura time to address her fears and enabledher and Steve to think about a future ofliving positively with memory loss. Thereduction in negative behaviours, due to fearand anxiety, aided the diagnostic process byruling out frontal lobe changes.

Yet, very few clients are able to access pre-diagnostic counselling and without it manyclients face the same range of confoundingproblems that Laura and Steve had toaddress when they were first referred: such aschallenging behaviour, depression and adecline in quality of life. If this distress is notaddressed, then the avoidance that it oftengenerates may cause people to disengagefrom our service. With the role of healthservices and many clinicians often so heavilyfocussed on achieving a diagnosis, then thereis a clear risk that some people who arefrightened about their dementia will with-draw from services as a way of managing theirfeelings. By giving people a safe space toexplore their difficulties, we are facilitatingan opportunity for them to learn to cope withtheir difficulties, which improves their livesand the lives of those that support them.



About the authorsNaiomi BettsAssistant Psychologist, Green Lane Hospital, Devizes.Email: [email protected]

Richard ChestonClinical Psychologist.Email: [email protected]

CorrespondenceRichard ChestonConsultant Clinical Psychologist,Charter House,Seymour Road,Trowbridge,Wiltshire, BA14 8LS.



Cheston, R., Jones, K. & Gilliard, J. (2004). ‘Fallinginto a hole’: Narrative and emotional change ina psychotherapy group for people with dementia,Dementia: the International Journal of Social Researchand Policy, 3(1), 95–103.

Honos-Webb, L. & Stiles, W.B. (1998). Reformulationof assimilation analysis in terms of voices.Psychotherapy, 35, 23–33

Honos-Webb, L., Surko, M., Stiles, W.B. & Greenberg,L.S. (1999). Assimilation of voices inpsychotherapy: The case of Jan. Journal of Counselling Psychology, 46, 448–460.

Stiles, W.B., Meshot, C.M., Anderson, T.M. & Sloan,W.W. Jr. (1992). Assimilation of problematicexperiences: The case of John Jones.Psychotherapy Research, 2, 81–101.

Stiles, W.B. (2001). Assimilation of problematic expe-riences. Psychotherapy, 38, 462–465.

Osatuke, K. & Stiles, W.B. (2006). Problematicinternal voices in clients with borderline features:An elaboration of the assimilation model. Journalof Constructivist Psychology, 19, 287–319.

Watkins, R., Cheston, R., Jones, K. & Gilliard, J.(2006). ‘Coming out’ with Alzheimer’s disease:Changes in awareness during a psychotherapygroup for people with dementia. Ageing & MentalHealth, 10, 166–176.

References

ON A FREEZING morning in Februarythis year I wandered around the backstreets near the Houses of Parliament

to the offices of the Winston ChurchillMemorial Trust for an interview. This bodywas set up after the great man’s death in1965 with the stated aim of:

‘The advancement and propagation ofeducation in any part of the world for thebenefit of British citizens of all walks of life insuch exclusively charitable manner that sucheducation will make its recipients more effectivein their life and work, whilst benefitingthemselves and their communities, andultimately the UK as a whole.’

I was submitting an application to studyMarte Meo, a particular process ofimproving dementia care that has beendeveloped in the Netherlands and otherparts of northern Europe but has notreached Britain yet. To do this I had tosubmit a brief plan of what I wanted to doand, importantly, how I would propagate anyknowledge gained on my return. The inter-view was gentle but probing and extremelyposh (a Lord, a Dame-Professor, anacademic GP and a Major General). Thepanel seemed genuinely interested in theproject and a couple of weeks later wrote tosay I had been successful.

I have not been on my trip yet but I amfull of enthusiasm and hope that othermembers of PSIGE will consider applying forthis great opportunity.

A few factsApplicants have to be British citizens. Travelhas to be abroad and for a minimum of fourweeks, maximum eight. The Trust will payyour travel and living expenses and alsoinsurance. You do not have to study healthcare; I have seen a presentation on ‘Lightingin small churches in Germany and Italy’,surprisingly interesting. Applications usuallyare taken in the middle of the year with adeadline about October.

My advice is Go For It if you can. Thewebsite is: www.wcmt.org.uk.

Marte MeoThis is a form of Video Interactive Guidancethat has sprung from the infant developmentfield and has been used with people withlearning disabilities and recently people withdementia. The aim is to use video recordingsof episodes of care or of interactions to iden-tify good practice, to enhance sensitivity andresponsiveness to the patient’s communica-tions. Generally videos of about care lastabout five minutes and the Marte Meo ther-apist will then spend maybe half-an-hourgoing over the clip in discussion with thecarer or a group of carers. The emphasis isremorselessly on the positive and buildingon strengths.

I am attracted to Marte Meo as it prom-ises a way of building up very practical andconcrete skills in applied real life situations.It appears to be accessible to all levels of carestaff. The founder, Maria Aarts, said of herinstruction manuals that if you found a diffi-cult word in them you could have yourmoney back! As such it seems a fittingcomplement to more theoretical or attitude-based approaches like Dementia CareMapping.

The website is: www.martemeo.com.


God Bless Sir WinstonPaul Whitby

CorrespondencePaul WhitbyEmail: [email protected]

Suggested readingAlnes, R.E., Kirkevold, M. & Skovdahl, K. (2010).

Insights gained through Marte Meo counselling:Experiences of nurses in dementia specific careunits. Int. J. Older People Nursing, 6(2), 123–132.

Alnes, R.E. (2011). J. Res. Nursing, 16(5), September,415–433.

Moser, I. (2010). Perhaps tears should not becounted but wiped away: On quality andimprovement in dementia care. In A. Mol, I. Moser & J. Pols (Eds.), Care in practice: On tinkering in clinics, homes and farms. Verlag:Bielefeld.


Paul Whitby

SIR WINSTON CHURCHILL STATUE, LONDON.

IAM A second-year trainee clinical psychol-ogist who has been on placement with theOlder People’s Psychology Team, a

service which provides psychotherapy,consultancy and neuropsychological assess-ment. The following are my reflections(written as a diary entry) on the use ofAcceptance and Commitment Therapy withan 80-year-old lady called Jean. Thisapproach was used as she had had CBTbefore, but did not feel it was right for her.Some information has been changed tomaintain confidentiality.

Dear Reflective Journal.‘Be willing, be willing, be willing.’ I remember this was my mantra before eachACT therapy session with Jean, my first ACTclient. Isn’t it interesting how nothing hasreally changed? At the time I thought theanxiety of providing a therapy I was unfa-miliar with was the product of being atrainee. Perhaps it largely is, but discussionwith colleagues has left me wondering if itmight be a product of being a clinicalpsychologist, forever facing the unknown.Either way, I discovered that ACT has asmuch application to me as the therapist as itdoes to the client: ACT concepts readily lendthemselves to being practiced alongsidetheir delivery. I hope to capture my learningin this entry.

Experiential avoidance/control: The mostobvious example of trying to avoid experi-encing distress came on day one of therapy,well, let me be honest, in the weeks runningup to starting therapy. Many thoughts wererunning through my mind on a daily basisgenerating enough distress to kick my avoid-ance/control strategies into overdrive. Such

thoughts as ‘I have no idea how to do ACTtherapy’, ‘Jean will spot you are a fake’, ‘Howcan you relate to someone who has so muchlife experience?’, ‘How can you tell Jean thather lifelong strategies aren’t as successful asshe thinks?’ I tried distraction, rumination,reassurance seeking, thought suppression:there was no shortage of effort in trying tocontrol my experience of the distress, attimes it lessened, but unfortunately it alwaysreturned. Yet this is the crucial point, it is notthrough a lack of trying that Jean, or anyoneelse, ends up continuing to experiencedistress! It just isn’t successful in the longer-term. For someone like Jean, who had 80years of experiential control under her belt,I was hesitant to ask her to identify hercontrol and avoidance coping strategies andwhether they had been successful for her inthe longer-term. I discovered that rein-forcing that it was not due to a lack of effortand highlighting the part society plays inencouraging our avoidance of distresshelped us both to be more empathetictowards the use of such an approach.

Willingness/Acceptance: Introducing the alter-native to the avoidance/control agenda wasa moment I won’t forget. The look on Jean’sface may have a great deal to do with mytentative and somewhat mumbling explana-tion, but in short, you would think I hadasked her to chop off an arm! Well, I may beexaggerating, but it was evident that in her80 years she had not considered the possi-bility that distress may be a realistic part oflife, to be honest I’m not sure I had trulyconsidered it either. Each time I meet a newclient I am confronted by their wish to havethe distress dramatically reduced, if notcompletely removed. I can understand why,


ACT in an older people’s psychologyservice: A note to selfEmma Hodges

but just how achievable is this? In somecircumstance it may well be, but when life isintent on throwing up distressing obstaclesto cope with, perhaps it is unrealistic. Fromdiscussions we had I think Jean’s status as anolder person made it particularly difficult attimes for her to contemplate a future of will-ingness rather than continued avoidance/control. However, true to Jean’s style, after afew weeks she said to me ‘I guess if avoidancetruly worked we would have found themiracle cure.’ It was with this is mind that wepursued the option of living a life withdistress as part of it and not always engagingin avoidance/control to eliminate it (Butjust between you and me reflective journal,by the end of therapy Jean reported adecrease in her distress levels: a bonus, butnot the aim, of being willing perhaps?)

Values: I feel I must quickly follow on fromthe previous passage with some talk aboutvalues; after all, it is only in the context ofvalued living that willingness and acceptanceare differentiated from resignation.However, if you asked me to define my valuesright now I would struggle! It potentiallyremains the ACT component that I andclients find the most difficult to articulateand yet the most crucial for progress. I hadnot anticipated how complicated it would beto define what one values. Values are notequivalent to goals – they cannot be tickedoff when achieved. Some people refer tothem as a ‘direction’ for life, such as heading‘east’ on your life compass; you nevercompletely reach ‘east’, but aim to head thatway each day. However, I realise now thathaving a neatly packaged set of values fromday one is not necessarily the aim. Rather itis the process of introducing the concept ofvalues, contemplating, reflecting, altering,debating, redefining and so on that assistsclients with bringing to life the reasons theyare engaging with the challenges of therapy;values turn willingness and acceptance froma possibility to a reality. With Jean it isevident that as soon as she began to contem-plate the type of life she wanted to lead and

the kind of person she wanted to be (void ofother’s expectations of course), the acts ofwillingness and acceptance took on a muchmore manageable and favourable light. Inher eyes, resigning to a life with distress wasno longer my request.

Defusion/Self as context: I guess it would beeasy to stop here, reflective journal – Jean isworking on being willing to experiencedistress in pursuit of valued living – job done.Yet that would be failing to identify thecunning ways of distress, that is: ACTproposes that one should be willing toaccept distress as it is and not what it says itis. When my distressing thoughts wererampant, ‘You’re a fake’, ‘You won’t be anygood at this’, it was time to take a look atthese thoughts for what they really were.ACT reminds us of the power of language tomakes us believe we are as it says we are. Takemy thought of ‘I am useless’; it’s all too easyto take this to heart and feel the distress thatresults. ACT encourages us to see languagefor what it is: symbols and sounds with noreal power until we bestow it by seeingourselves as the content of the thought or bybecoming fused with the thought. I had notcome across a therapy with as many tech-niques and metaphors up its sleeve as ACTproved to have! Many of these are designedto help us to see ourselves as separate fromthe thought (by saying, for example, ‘I amhaving the thought that I am useless’) and asthe observer of such thoughts. Jean reapedparticular reward after we completed anexercise in externalising the distress. Initialupset from being in contact with the distresssoon parted to make way for an A gradeexample of willingness: she described thedistress objects as ‘pets’ , which could accom-pany her through life and that she was nowwilling to have, amazing.

Being in the present moment/mindfulness: Jeanwas a lifelong yoga fan and user of relaxationtechniques, which both helped andhindered her with learning to be mindful.On the one hand she was experienced in


Emma Hodges

setting aside time to focus on a skill, on theother she was used to trying to empty hermind of all distraction. Mindfulness is aboutpaying attention to the content of our mindsand not judging it. ACT points out the needto live in the present moment if we are tolearn whether our current behaviour iscommitted to our values or part of the avoid-ance/control agenda: being mindful assistswith making this decision. Jean and I alsobenefited from reminding ourselves that thedecision to be willing and to commit tovalued action occurs moment by momentand sometimes we will fall back on avoidanceand control. When Jean engaged in avoid-ance/control strategies during therapy it wasthe perfect context for us to revisit the coreACT concepts, you could say I welcomed it!Given my anxieties I began regularly prac-ticing a few minutes of mindful breathingprior to sessions with Jean, I have since trans-ferred this to most of my client work!

Therapeutic relationship: As with all therapymodels, the therapeutic relationship is a keycomponent of ACT. On reflection it appearsto have a more active role compared toworking with other models. Many of thetechniques I shared with Jean required ademonstration; consequently a sense ofhumour was imperative. At times I foundmyself uttering ‘Arriving at platform two isthe thought that I am a failure’ in the style ofa train announcer, or ‘I am useless’ in thesultry tones of Marilyn Monroe. Yes, thecringe factor is huge, but it is this that makesit effective, the distress is revealed for what itreally is! I have also come to see that thismakes ACT a truly collaborative process.

I have to say I have made life easy formyself with this entry by splitting up the corefeatures of ACT and telling you about eachone in turn. Whilst therapy with Jeancertainly started with looking at the unwork-able nature of the avoidance/controlapproach and contemplating the alternative

of willingness and acceptance, from then onwe hopped from concept to concept andback again. I really struggled with this lack ofstructure at the time seeing it as a result ofmy lack of experience (what else). However,as I become more familiar with ACT I realiseit is the nature of the beast: many of the tech-niques and skills tap into more than oneACT component. For example, ‘I am havingthe thought that…’ illustrates self as contextand cognitive defusion. Whilst this makes lifetricky for a novice it inevitably becomes afeature of the therapeutic process.

To refer back to the point I made at thebeginning of this entry, the way ACTconcepts operate enables them to be utilisedby me as therapist whilst engaging in ACTwith a client: I can’t think of a better way tolearn.

CorrespondenceEmma HodgesTrainee Clinical Psychologist, Southampton University.

ResourcesThere were a number of resources I foundextremely helpful along my ACT journey.

Flaxman, P.E., Blackledge, J.T. & Bond, F.W. (2001).Acceptance and Commitment Therapy: The CBTDistinctive Feature Series. East Sussex: Routledge.This is a very useful ‘pocket-sized’ book coveringthe essentials of ACT, very reader friendly andeasy to digest.

www.contextualpsychology.orgA comprehensive website offering resources,training information, opportunities to network.Asks for a donation of the amount you wish topay to become a member.

Hayes, S. & Smith, S. (2005). Get out of your mind andinto your life: The new acceptance and commitmenttherapy. Oakland, CA: New Harbinger Publica-tions.A self-help book, but also very useful for activitiesto use in therapy.


ACT in an older people’s psychology service: A note to self

T THE MOST RECENT meeting of theCounselling Psychology Forum Editorial

Collective, we took part in areviewing workshop to generate greaterclarity for both reviewers and contributors inthe expected standards to meet for publica-tion in CPF. Six papers were circulated priorto the meeting and members of the EditorialCollective were asked to read each paper andcome to a decision on whether they wouldreject or accept each. During the workshop,each paper was discussed, establishingwhether reviewers were of the same opinionand why each paper was either rejected oraccepted.

Five out of six papers were rejected, withunanimous agreement between reviewers.Four of these five had been originallyrejected by reviewers. To give a flavour of thecontent, Paper 1 was regarded as a ‘bit of arant’, outlining a rather superficial string ofideas with nothing to hold it together. Paper 2 said nothing new, and had an insuf-ficiently developed argument. Paper 3 was a

rather standard local service evaluation, withlittle relevance beyond the locality of thestudy. It did not add to the existing knowl-edge base, nor demonstrate complex, criticalthinking. Paper 4 was confusing, with inco-herent methodology, although could havebeen better presented as a reflective piece.Paper 5 was another classic example of alocal study. This paper was rejected by theEditorial Collective, even though the orig-inal reviewer had accepted it. Finally, Paper 6was accepted by both the original reviewerand the Editorial Collective. We judged thispaper as clearly written, relevant to theprofession, original, and with clear linksbetween research questions and results. Itwas also well contextualised, drawing onclinical experience, with substance andreflection.

The Editorial Collective agreed that agood selection of papers had been providedfor the workshop and drew up a list of Do’sand Don’ts for future contributors andreviewers.


Advice from the Editorial Collective to contributorsPenny Priest

This article was first published in Clinical Psychology Forum, 227, November 2011.Thanks are due to the Editorial Collective of Clinical Psychology Forum for allowingus to reprint the article.

A

Do● Try to captivate the reviewer’s interests;

reviewers would be more interested inbringing work up to scratch if it’soriginal, creative and innovative.

● Critically appraise your own opinions.● Consider submitting service evaluations

which demonstrate changes or improve-ments as a result.

● Make sure, as research supervisors, youcoach trainees in how to write researchup properly; all the thinking, time andgoodwill trainees contribute can bewasted if the supervisor does notcommunicate this back to the trainee.

● Get local feedback on what you arewriting about before submitting so thatpossible flaws can be eradicated.

● Use the whole word count available.● Check that all co-authors have read the

paper.● Consider policy in relation to practice.● Make sure you draw on the most recent

relevant publications.● Consider how relevant your work is

outside your own locality and why otherswould want to read it.

● Thinking carefully how you structureyour piece and use headings and sub-headings appropriately.

● Use a good standard of English. Ifunsure, ask a successful author to checkyour article before submission.

● Read the Guidelines for Contributors on theClinical Psychology Forum website beforesubmitting (www.bps.org.uk/cpf).

Don’t● Present any ill-thought-through ideas.● See a rejection as a turn-off part of your

career.● Exceed the word count.

Dr Penny Priest, CPsycholOn behalf of the Editorial Collective.


Advice from the Editorial Collective to contributors


Book Review

Teach Us To Sit Still: A Sceptic’s Search forHealth and Healing Tim ParksLondon: Harvill Secker (2010)

& Reviewed by Paul Whitby

One of the disappointments of being apsychologist is that many of the books onehas to read are, frankly, poorly written. I canjust about live with the lifeless prose ofempirical work but I do find the clumsinessof much other writing sometimes hard tobear. This is especially so with self-helpbooks, or ‘client manuals’, and theirfrequent resorts to folksy little tales some-times culled from clinical cases, sometimesevents from the author’s own life. So it is apleasure to find Booker-nominated novelistTim Parks showing how it should be done inthis tale of living with really nasty chronicpelvic pain. Of course, this is not a self-helpbook and it surely is not a ‘Psychology Book’;it is subtitled ‘A Sceptic’s Search for Healthand Healing’ and that is sufficient descrip-tion.

While the central tale is Parks’ bladder,or his prostate, or maybe all of his body andprobably his mind, he finds time to includereflections on literature, kayaking, painting,Coleridge, Virginia Woolf, ChristopherHitchens and much more. His mind is active,probably too much so by his own admission,and amazingly intense; Parks, one feels, doesnot take life easy. The result is an exciting,erudite and really quite funny reflection on apainful and embarrassing chronic condition.

The author takes pride in his rationalityand disdain for religion, or worse anythingNew Age. He trails around to various doctorsto little effect except some fine dark humourat his own expense. He is not hugely criticalof Western medicine and he is not rudeabout the doctors he meets, but he is clearlydisappointed by the results of the consulta-tions not to say alarmed by some of the

further procedures suggested (some fairlyunsettling illustrations are provided). Thedisappointment is palpable and the criticismis implied rather than overt. Modern medi-cine, that has performed such miracles in somany areas of illness and suffering (justthink antibiotics or hip replacements) hasnothing to offer for prostate pain exceptincreasingly radical interventions with noguarantee of relief. The investigations canfind nothing wrong, could it all be in hishead?

One can see that Parks is the sort ofpatient who makes clinicians feel bad. But,where to turn to next?

Throughout this first part of the narrativewe are given a pretty full account of hisattempts to understand his situation. Someof this looks a lot like what I would identify asrumination. There are long tracts on

possible unconscious motivations, or not,with some hefty literary references thrown infor good measure. Parks does not just sufferpain, he wants to write essays about it. He islike a dog with a bone but this gets himnowhere and he concludes that all theconstant chewing over and intellectualisingis a significant contribution the problem.But he is lucky, part of this febrile search formeaning involves lots of late night Googlingduring which he serendipitously turns up abit of gold from among the dross. He comesacross a non-invasive treatment that relies ona very specialised and prostate-specific relax-ation programme (I say non-invasive, actu-ally direct prostate massage using an analwand is suggested, but our hero declines).The descriptions of his rather bumpyprogress through paradoxical relaxation andlater into meditation are a fitting, gentleclimax to the story. Parks writes beautifullyand his descriptions of the trials of medita-tion, the difficulties, the irritations, thefleeting nature of early improvements, themumbo jumbo that accompanies it andsticks in his throat, are all delightfullyworked through. His descriptions of thetriumphs are all the more impressive as thisrequires he use words to articulate a statewith no words and no thought. This is aparadox that he relishes and in my opinionhe deals with it better than any other writer Ihave come across.

An important part of his tale is how hehas to, for at least some of the time, put asidewhat he calls ‘The Word Project’, the driven,literary-rational approach to life that hasguided him up until now. The constantstriving to possess and control his existencethrough language, logic, argument, litera-ture and essays has to stop; the only realitywe have access to is now, with this breath.

Fortunately for us Parks has not stoppedwriting, otherwise we would not have thisintriguing book. He has managed to come tosome accommodation between his olddriven self and his newly-found appreciationof wordless being. The final chapter, ‘Cathe-dral’, is quite sublime. We are given a pictureof a more amiable, possibly even avuncular,Parks calmly invigilating over his students inan crucial exam. The air conditioning hasbroken down so the windows are open andnoise pours in, including the inevitablestrimmer. A few years beforehand he wouldhave been in a frenzy of irritation. Now herefuses to contribute to his own suffering.But Parks has not entirely given up all his oldways and we are treated to critical reflectionson Christopher Hitchens, Virginia Woolfand Samuel Beckett to help make this point.Parks has not given up all his attachments tothis world. As he says, much of the world isreally quite beautiful.

Excellent.

Paul WhitbyClinical Psychologist, Devizes.


Book Review


EAST ANGLIAKathryn Sams, co-convenorNick Oliver, co-convenorChatterton House, Goodwins Road, King’s Lynn, Norfolk PE30 5PD.Tel: 01553 815117; Fax: 01553 815181;Email: [email protected] Email: [email protected]

HERTS & ESSEXVacant

NORTHERNLynne Patience Clinical Psychologist, Older Adult and Neuropsychology Services, St. George’s Park,Morpeth, Northumberland NE61 2NU.Tel: 01670 501747; Email: [email protected]

NORTH THAMESAnna ScotfordPrincipal Clinical Psychologist, Mental Health Services for Older Adults,3rd Floor, Bentley House, 15–21 Headstone Drive, Harrow HA3 5QX.Tel: 020 8424 7709; Email: [email protected]

NORTH WALESCarolien LamersClinical Lecturer Admissions Tutor, North Wales Clinical Psychology Programme,School of Psychology, Bangor University, Bangor, Gwynedd LL57 2DG.Tel: 01248 388068; Email: [email protected]

NORTH WESTSarah ButchardClinical Psychologist, Mossley Hill Hospital, Park Avenue, Liverpool L18 8BU.Tel: 0151 250 6112; Email: [email protected]

NORTHERN IRELANDBrenda Carney-Gallagher Consultant Clinical Psychologist, Department of Psychiatry, Lagan Valley Hospital,Hillsborough Road, Lisburn BT28 1JP, Northern Ireland.Tel: 028 926 65141 x 2639 (Work); Mobile: 07754 792693;Email: [email protected]

Geographical Group Convenorsas at February 2010


Geographical Group Convenors

OXFORDCandy Stone West Oxfordshire Community Mental Health Teams, Older Peoples’ Services, Nuffield Health Centre, Welch Way, Witney, Oxon OX28 6JQ.Tel: 01993 202100; Email: [email protected]

SCOTLANDSandy McAfeePsychology Department, St. John’s Hospital, Howden Road West, Livingston EH54 6PP.Tel: 01506 523615; Email: [email protected]

SOUTH THAMESTamsin FryerMental Health Services for Older People, Kent & Medway NHS & Social Care Partnership Trust,Highlands House, 10–12 Calverley Park Gardens, Tunbridge Wells, Kent TN1 2JN.Tel: 01892 709200; Fax: 01892 536181; Email: [email protected]

SOUTH WALESSarah Morgan Resource Centre, Tonna Hospital, Neath SA11 3LX.Tel: 01639 862869;Email: [email protected] or [email protected]

SOUTH WESTPhilippa WilsonPoplar Unit, The Coppice, Callington Road Hospital, Brislington, Bristol BS4 5BJ.Tel: 0117 919 5800; Fax: 0117 919 5809; Email: [email protected]

P.F. Joyce Templer House CMHT, Newton Abbot Hospital, 62–64 East Street, Newton Abbot,Devon TQ12 4PT.Tel: 01626 362179; Email: [email protected]

TRENTShonagh Scott (Secretary)Clinical Psychology, Michael Carlisle Centre, Nether Edge Hospital, Lyndhurst Road, Sheffield S11 9BF.Email: [email protected]


Geographical Group Convenors

WESSEXPaul WhitbyCMHT, 2nd Floor, Bewley House, Marshfield Road, Chippenham SN15 1JW.Tel: 01249 707987; Email: [email protected]

WEST MIDLANDSPaul Bradley Older Adult Psychology, Greybury House, Walsall WS1 IEP.Tel: 01922 858451; Fax: 01922 858453; Mobile: 07825 061090; Email: [email protected]

Caroline Formby (Secretary)Dudley Community Mental Health Team for Older People, Clee Building,Bushey Fields Hospital, Bushey Fields Road, Dudley, West Midlands DY1 2LZ.Tel: 01384 365 048; Email: [email protected]

YORKSHIRE/HUMBERSIDEMichael JubbClinical Psychologist, Leeds Older People’s Psychology and Therapies Service,The Mount, 44 Hyde Terrace, Leeds LS2 9LN.Tel: 0113 305 5587; Fax: 0113 305 5659; Email: [email protected]


Chair: Cath Burley

Outgoing Chair: Don Brechin

Vice Chair: Polly Kaiser

Secretary: Fiona Macleod

Dementia Lead and Scotland Representative: Elizabeth Baikie

Newsletter Editor: Louisa Jackman

Treasurer and Welsh Representative: Becci Dow

Geographical Group Liaison: Mhairi Donaldson

IAPT Lead: Julia Boot

Service User & Carer Liaison: Shirley Mcgraff

Ordinary Member: Cerys MacGillivray

Ordinary Member: Reinhard Guss

Ordinary Member: Gemma Murphy

PSIGE National Committee 2011/2012


Notes

Notes for ContributorsThe PSIGE Newsletter welcomes the following submissions for publication: Articles, Research Updates, Letters to theEditor, Book Reviews. These can be on any aspect of psychological theory or practice with older people.

ArticlesArticles form the bulk of contents submitted to the PSIGE Newsletter. As the PSIGE Newsletter aims to cover a broad,cross section of work with older people, we are happy to consider academic, descriptive, discursive, or review articles forpublication. These can cover empirical investigations, pilot studies, descriptions of service developments, audits andevaluations. Articles should be submitted three months before publication (i.e. October for the January issue, January forthe April issue, April for the July issue, and July for the October issue).

Articles of any length up to a maximum of 3000 words will be considered. Experimental reports should followconvention in terms of subheadings and sections: Abstract, Introduction, Method, Results, Discussion, References.

References should follow conventional format as in journals such as Psychological Review:(1) Book reference:

Mischel, W. (1986). Introduction to personality. New York: CBS.(2) Journal article:

Martin, A. & Fedio, P. (1983). Word production and comprehension in Alzheimer’s disease: The breakdown ofsemantic knowledge. Brain and Language, 19, 124–141.

(3) Paper in a book:Garrett, M. (1980). Levels of processing in sentence production In B. Butterworth (Ed.), Language Production(Volume 1) Speech and Talk. London: Academic Press.

Research UpdatesThe PSIGE Newsletter is particularly keen to publish contributions concerning ongoing research. These can reflect anystage in the research process, for example, ideas for discussion or early stage results, which are not ready for formalpublication. Try to keep these submissions below 500 words.

Letters to the EditorThe Editor welcomes correspondence which combines brevity with rational argument. Letters may be edited if more than250 words in length.

Book ReviewsSubmissions up to 250 words reviewing a text of relevance and interest to the PSIGE membership will be considered.These submissions must include full details of the book (including publisher).

The Editorial Board reserves the right to make minor changes to any submissions. Where major editing is necessary, the authors will be informed.

ImagesThe PSIGE Newsletter is published in black-and-white. It is not advisable to send complicated, colour diagrams. If youare unsure, try printing the image or photograph out on a mono laser printer to check for clarity.

Please send original image files (.tif, .jpg, .eps or the like), not simply a Word document with the pictures imported intoit, as these do not print properly.

Submission ProcedureAll submissions must be written in language that is inherently respectful to older people and consistent with the British Psychological Society’s guidelines.

All contributions must be word processed. Formatting should be consistent with the British Psychological Society’sguidelines.

Please submit articles as a Word file via email to the Editor.

When submitting articles please send the following information:Full name;Affiliation (title, place of work);Contact details (should you be willing to be contacted by the membership);Acknowledgements (as appropriate).

Finally, all reports of research should indicate whether or not Ethics Committee approval was awarded, and by whichEthics Committee, or whether the work was carried out as an audit/service evaluation project.

All contributions should be sent to: [email protected]

St Andrews House, 48 Princess Road East, Leicester LE1 7DR, UKTel 0116 254 9568 Fax 0116 227 1314 E-mail [email protected] www.bps.org.uk

© The British Psychological Society 2012Incorporated by Royal Charter Registered Charity No 229642

Contents1 Letter from the Editor

Louisa Jackman

4 Guest EditorialPaul Whitby

5 Letter from the ChairCath Burley

7 Using Terror Management Theory to understand the existential threat of dementiaRichard Cheston

16 Dementia in Black and Minority Ethnic communities in Hampshire: Development of a Time to Change campaignThomas Richardson & Ann Marshall

20 The use of naturally-occurring objects within nursing homes by residents with dementiaAlex Stephens, Richard Cheston & Kate Gleeson

29 Maintaining professional boundaries: Looking at the quality of supervision Liz Young & Kate Keetch

34 From warding off to working through: Helping people facing a diagnosis of dementiato change their relationship with their memory problemsNaomi Betts & Richard Cheston

43 God Bless Sir WinstonPaul Whitby

45 ACT in an older people’s psychology service: A note to selfEmma Hodges

48 Advice from the Editorial Collective to contributorsPenny Priest

50 Book Review:Teach Us To Sit Still: A Sceptic’s Search for Health and HealingTim ParksReviewed by Paul Whitby

52 Geographical Group Convenors

55 PSIGE National Committee 2011/2012

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