Psychodynamic Approaches to the Experience of Dementia

Perspectives from Observation, Theory and Practice

Sandra Evans, Jane Garner, Rachel Darnley Smith, Sandra Evans, Jane Garner, Rachel Darnley Smith

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351661850
• Edition: 1
• Topic: Psicología
• Subtopic: Psicoterapia

Psychodynamic Approaches to the Experience of Dementia: Perspectives from Observation, Theory and Practice demonstrates the impact of healthcare approaches that take into account not only the practical needs but also the emotional experience of the patient, their partners, families and friends, lay carers and professional staff.

Currently there is no cure for dementia, but the psychosocial and therapeutic approaches described in this volume have appeared to help people, both patients and carers, feel more contained and less lonely and isolated. Psychoanalytic theory provides a disciplined way of thinking about the internal world of an individual and their relationships. Each author provides their own commentary on the personal and interpersonal effects of dementia, endeavouring to understand behaviours and emotions which may otherwise seem incomprehensible. The subject is approached from a psychodynamic perspective, considering the unconscious, previous and current experiences and relationships, including those between patients and staff.

Psychodynamic Approaches to the Experience of Dementia illustrates the practical and theoretical thinking of clinicians from a wide range of disciplines who are engaged in the care of people in late life with a diagnosis of dementia. It will be essential reading for mental health and health professionals in practice and training in the field of dementia.

Chapter 1
Encountering dementia

Louis Resnick

It was a fruitful afternoon on urology. I had come to work: taking histories; examining patients.

An elderly gentleman, smartly dressed in crisp white shirt, green tie and tweed blazer was pacing up and down the corridor. He periodically stopped, looking lost before journeying on. Was he alright? Did he need help?

He was kempt, thin wisps of white hair combed into a side parting. He smiled and nodded when I offered to accompany him. Polite conversation ensued. He spoke with charm and intelligence of his service in the Second World War and the successes of his three children.

However, something was wrong. He told me the floors we walked on used to belong to an army barracks where he was stationed after the War. He made vague references to a hotel, the other patients as guests and me, a member of staff. He mentioned his wife who would pick him up soon.

After a few laps of the corridor I wanted to get back to work. He was pleasant but keeping me from learning opportunities. I steered him towards his bed, into his armchair and drew conversation to a close.

Flicking through the gentleman’s notes – Alzheimer’s Disease – I felt a twinge of sadness to read that his wife had died two years previously. Overall I felt I had “done well”; demonstrating appropriate and sensitive engagement with a person with dementia. I returned to work.

Before long the gentleman appeared at the office doorway. He tried to gain my attention: ‘I’m sorry, Sir, I have work to be getting on with, I will see you in a while’. This failed to placate. Lingering turned into pestering and polite refusal turned into ignoring. Entering the office he tapped me on the shoulder. Feeling a boundary had been crossed, I got up, ushering him from the room. He stopped me in the corridor and grabbed my forearm.

He was angry, explaining that for the past two hours I had been keeping him waiting for the hotel manager. I responded with ‘But Sir I was with you only five minutes ago …’ Alas our realities were not reconcilable. Hostility ensued. He insisted I account for my actions, I persisted I had done no wrong. Irritation replaced patience. I no longer liked this man, I wanted him to go away. I played my last card, apologetically informing him that, far from being a guest at a hotel, he was in hospital with “memory problems”. He looked pained, replying with indignation:

‘Do you expect me to believe that? I’m an intelligent man!’

I felt guilty, helpless and spent of strategy. I announced my resignation:

‘I’m sorry, Sir, but I don’t know what else to say to you.’

A nurse came to my rescue. Breezy and pacifying, she took the man by his arm and persuaded him to sit down for a cup of tea. I watched as anguish melted from his face. Leading him back to his chair she turned round and mouthed a supportive “Don’t worry”.

Returning to the office, my feelings were of uselessness and embarrassment. Uselessness because I had experienced a communicational dead end, and embarrassment at how quickly I had come to resent him. Earlier feelings of pride at a successful interaction were replaced by scorn. In the moment I hated him. A charismatic chap who delighted in telling me of his service during the war had become an angry customer deliberately antagonising me and distracting me from work.

What had just happened? Why had my gentle enquiry and supportive listening failed to appease? Why was I left without tools to reconcile our realities?

I took a few minutes to cool off, then went back to work.

Introduction

There can be no knowledge without emotion.

Arnold Bennett, 1867–1931

I can find dementia difficult. Experience has seen me engage with patients with whom communication has been a real challenge. With this powerful emotions have emerged: sadness, anxiety, resentment and even fear. These feelings can be difficult and I am unsure how to process them. This project represents my desire to understand and learn how to better manage these experiences.

As a medical student there is seldom space for emotional expression. Johanna Shapiro’s work (2011) on medical alexithymia resonated with me. She suggests doctors are subscribed to a profession that extols virtues of openness whilst tacitly encouraging an ethic of detachment and objectivity. Therefore I write as a medical student stranded in something of an emotional hinterland; although theoretically aware of the important role emotion can play in the doctor-patient relationship I am also unsure of its acceptability. Am I allowed to feel sad, angry, annoyed?

With this in mind I undertook a series of observations in this personally provocative area – dementia care – to reflect and gain insight into thoughts and feelings aroused. Dementia is challenging in many ways: diagnostically; physical demands of dependency; the presentation of psycho-behavioural disturbances (mood lability, agitation, aggression, nighttime wakening etc.), the latter of which, if present, correlate with higher levels of caregiver stress (Donaldson et al., 1998). This project allowed me to experience the illness from the perspective of both patient and caregiver and to discuss the theoretical underpinnings of associated feeling states.

The project

I spent six hours directly observing care of patients with dementia on a short-stay dementia ward at a psychiatric hospital: five 1–1.5-hour-long observations over the course of four consecutive weekdays.

Ward consultants were supervisors for the project. The charge nurse gave information to the nursing team and introduced me to all the patients before the first observation.

Observations were loosely based on the psychodynamic method outlined by Davenhill (2007). During the observations I wore an identity badge and sat in an armchair in the communal lounge. I had a diary to record sound bites when appropriate, however left the bulk of the write up until after each observation. I tried to remain as unobtrusive as possible and limited interaction with patients although sometimes this was unavoidable (for example when it concerned patient safety).

Time not formally observing was spent helping with nursing tasks, principally feeding patients at dinner time. On the last day I also joined an Occupational Therapy craft session. Although this time was not strictly observation, I still recorded my thoughts and feelings.

Consent was gained from next of kin via telephone and followed up by a project proposal letter. Permission was sought through introductions with each patient before the first observation.

Although I undertook the observations primed with relevant theory, I was not looking for particular themes to accord with this experience. It was more important for me just to ‘be’ and reflect upon my experience in the moment. Notes taken during the observation are here recorded in italics.

Findings

I experienced two main senses during the observations. The first was a feeling of unwantedness when healthcare staff were performing tasks and not spending time with patients. The second feeling was one of connectedness experienced when staff were with patients free from undertaking tasks. These states will be illustrated using examples from my observational diary.

Key to understanding these feeling states was a contrast in perspective gained through formal observation (enjoying a patient’s perspective) and when engaged in other activity on the ward (enjoying a nurse’s perspective). These two perspectives will be referred to as ‘patient’ and ‘nurse’ (because most healthcare workers observed were nurses the term ‘nurse’ will be used synonymously with ‘staff’).

Feeling unwanted: nurses performing tasks

A significant extent of observation saw nurses undertaking ‘tasks’. This was experienced as a patient:

Medication round. It is apparent this is another ‘job’ for nurses. Meds (sic) are dished out like military roll call.

And the multiplicity of pressures discussed with nursing staff:

… stresses and strains of bureaucracy and paperwork. Not being able to spend enough time just ‘with’ patients, feeling rushed to do other things when they are.

It was noticed that a substitute for quality time spent with patients took the form of snippets of interaction with patients whilst moving between jobs:

I notice that staff walk briskly across the lounge to the staffroom. Most will engage with patients en route. Bits of banter, lots of “are you alright?”. It almost feels like addressing someone you meet in the street but don’t want to stop to talk to.

When I was a nurse I felt these snippets were helpful, striking a balance between task and patient. However, when experiencing them as a patient I felt unattended to:

The insight into how patients are doing is very different when one is sat in a goldfish bowl [the office] surrounded by notes and a ringing telephone. I had such a positive impression of the liveliness of patients when I was a nurse. Walking from the kitchen to the office and saying ‘hi!’ to a patient before locking myself away for an hour creates an impression that all is well. As a patient I experience the slow burn of tedium. When a member of staff walks by I feel like a dog waiting outside the supermarket for its owner: the expectation, elation felt when the doors slide open followed by the disappointment when they walk past.

These fragments did provide a momentary surge in activity in an otherwise unstimulating environment:

There is no stimulation, no life, no excitement. Literally nothing is happening … The tiniest of moments became a spectacle: a door opening; a patient adjusting in his seat.

However, these parings, often coinciding with the symbolic exit of staff through a security door, ultimately left me feeling unwanted:

The moment they get out their keys to unlock the door is a powerful moment. The keys are sturdy so the sound of unlocking cuts through the room. It is a signal that the interaction has ended.

Therefore as a patient there was a palpable sense that one was secondary to practical jobs.

Feeling connected: nurses being ‘with’ patients

However, there were instances I felt the warmth of connection with a member of the team, when nurses spent time just being ‘with’ patients seemingly free from tasks. For example:

In response to moments of aggression or distress:

Afterwards the patient is sat down. [The Occupation Therapist] crouches on the floor and holds his hands. Lovely image seen through the doorframe. Like a crystallised scene in a stained glass window.

When providing company to patients:

James is being led round by a young nurse. He is zombie-like, jaw agape … Nurse looks at him lovingly, almost longingly. “What’s the matter, David?” She understands his world. They look as though they are dancing together, like a couple in the corner at a party. She hugs him. “Is that what you were wanting?” … They are intimately close; it almost looks as though she is going to kiss him. She looks into his eyes and then away as they continue to dance.

I experienced this myself when I fed dinner to a particular patient every day:

I enjoy being with him. It is peaceful and I feel there is a common understanding between us.

Of these two feeling states, the more common feeling was of unwantedness when not in the company of healthcare staff.

The discussion will explore the feeling of unwantedness in an effort to understand why nursing staff appeared preoccupied with tasks instead of spending time with patients.

Discussion

There may be many reasons why staff seem to dedicate so much time to tasks in favour of spending time with patients. Some ideas are explored in this section. An important driver of this discussion was the contrast in feelings of ‘all is well’ when in the role of nurse compared to the unmet need I experienced as a patient. I offer four reasons for this. Two are pragmatic: a lack of time and the fact that engagement with some patients with dementia is effortful. And two are psychological: Menzies Lyth (1959) suggested that nurses use task-orientation as a social defence mechanism and Steven Sabat (2006) argues staff malignantly position patients.

Lack of time

A theme emerged that nurses simply did not have time to complete all the tasks. Therefore, time just ‘to be’ with patients became a scare resource.

Jones (1992) found dementia care workers with a shortage of time felt pressurised to “become task-orientated rather than com...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of figures and illustrations
• List of contributors
• Foreword
• Acknowledgements
• Introduction
• 1 Encountering dementia
• 2 Where lies the expert?
• 3 Working with people with mild neurocognitive disorders (mild NCD) or mild cognitive impairments (MCI)
• 4 Prognosis and planning: advance care planning through a psychoanalytic frame
• 5 The experience of loss in dementia; melancholia without the mourning?
• 6 Dementia and dialogue: acute hospitals and Liaison psychiatry
• 7 Psychodynamic interventions in dementia: the Australian and New Zealand experience
• 8 Art therapy with people with dementia: the present and the past
• 9 Attachment in confusional states and in dementia: theory into practice
• 10 The fragile thread of connection: living as a couple with dementia
• 11 Maintaining boundaries: counselling in a care home
• 12 Music as mirror in the care of elderly people with dementia
• 13 Groups for people with cognitive impairment and with dementia: what should we be doing?
• 14 Disintegration and integration in dementia care: mentalization as a means to keep whole
• 15 A psychoanalytic and philosophical exploration of boredom and disengagement in dementia
• 16 Continuing care review: a report on a thoughtful project and its untimely demise
• 17 Negotiating the border: music therapy for people in the last hours of dementia
• 18 Can anything good be born of a dementia: potential for reparation?
• Index