Recent posts
Asquith, I., 2024, Bakhtin and Dementia: Initial dialogic ideas on understanding behaviours that challenge, Reformulation 57, p.22-24
Introduction
I currently work into an inpatient dementia ward and a Care Home Liaison Team, and frequently interact with professional carers to make sense of behaviours that challenge in the context of dementia. During Cognitive Analytic Therapy (CAT) training, we were encouraged to broadly consider how to apply CAT theory and I took the opportunity to think within an essay about the implementation of CAT within dementia care. Subsequently, I have read and understood more of Mikhail Bakhtin’s work and how this has influenced CAT, which also resonated with my dementia care role. Taking inspiration from my essay and subsequent reading, this article considers the prospect of thinking about the relationship between the professional carer, the person with dementia and behaviours that could be labelled as challenging, with subsequent focus on Bakhtin related concepts.
Kitwood and Malignant Social Psychology
Over the past 20 years, the concept that social psychology has an impact on dementia has been more firmly accepted. Kitwood (1997), a leader in the social psychology of dementia, understood that the person with dementia was and continues to be socially formed in relation to others, and that negative social interactions, described as social malignancies, can be significantly detrimental to the person living with dementia. These social malignancies include forms of disempowerment, such as failing to allow those with dementia to use their existing skills, and invalidation in which the carer does not validate or acknowledge the individual’s perspective (Kitwood, 1997). Kitwood (1997) also warned of losing sight of the person to the diagnosis of dementia and thereafter seeing the dementia as the root cause of all difficulties encountered. Thinking around the clinical understanding of behaviours that challenge has moved to viewing it as a social construction, as the behaviour itself has to be understood in its context, based on the labelling, judgement and tolerance of the staff, other residents and the person themselves, and as a method of the person trying to communicate a need (James and Jackman, 2017).This means that carers who are tasked with disentangling distressed behaviours and changing their responses accordingly are helped towards taking a role of socially aware to socially understood.
Cognitive Analytic Therapy and social positioning in the dementia care
Due to its relational nature, Cognitive Analytic Therapy has been identified as a helpful model for reflecting upon caring relationships in dementia (Hamill and Mahony, 2011). The importance of the social position of the carer as seen through a Cognitive Analytic lens, has been highlighted by Sutton (2004), who states that professional carers may enact unhelpful social roles and an understanding of this can lead to improved recognition and ultimately revision, leading to improved patient and carer communication. However, in my experience professionals can, at times, be unaware of their involvement in the relational dialogue.
Carer: “They are constantly shouting, all of the time!”
Clinician: “Can you tell me what they are shouting?”
Carer: “… No, I just heard them shouting”
This is a contrived example, but is taken from my clinical experiences with professional carers and can be seen as social malignancy being played out in an “ignoring unhearing to ignored and unheard” reciprocal role. Sutton (2003) also describes how engagement with people with dementia may begin to occur in a “mindless” way as a consequence of the abandonment of the knowledge that the person with dementia continues to be an emotional being. In this same article Sutton not only considers how Kitwood’s (1997) concept of malignant social psychology may be played out in problematic reciprocal roles, but also reflects on their opposite, i.e. how positive and caring reciprocal roles may be present or can be developed by carers.
As Cognitive Analytic Therapy has grown, Bakhtin’s dialogism has been further integrated into the model (Leiman, 1992). Relevant for psychotherapy, Bakhtin postulated that an individual’s internal world is developed through an ongoing social process in which the utterances from others are internalised and can shape how they interact with the world; importantly, the person can have multiple voices (called polyphonic), meaning they can internalise different voices, roles and positions to act from (Pollard, 2008). Crucially, the person is viewed as unfinalised and that humans as social individuals will always create and implement signs between them to understand their reality (Pollard, 2008). For me, this is what gives hope in psychotherapy, particularly for older people; the ongoing dialogic nature of the self is crucial for believing a person can change through psychotherapy, regardless of age. Hepple (2006) provided thoughtful reflections on how a specific Bakhtin principle (the witness and the judge) can be used to consider the therapeutic relationship in the context of older people, who may have waited years to have their trauma and abuse witnessed.
Unfinalisable, finalisable and dementia care
Reading about Bakhtin’s concept of ‘unfinalisable’ (Pollard, 2008) made me wonder whether, for the carer, a dementia diagnosis closes down the possibility contained within the idea that a person is “unfinalized”, and therefore closing down hope of engaging in a dialogic relationship. When a dementia diagnosis is given the person is subsequently viewed as “finalised”. By unconsciously holding this view, the carer may approach the person with dementia as though there is no (social) learning to be had; they no longer look to co-create signs to understand distress. Hitting out comes to be seen purely as being part of the dementia and not a communication of a need. Perhaps explaining why people see dementia and not the person. Now the carer attends to the superficial elements of the individual, their immediate behaviours, in an attempt to curb rather than understand, potentially enacting a superficially engaging to inhumanely dismissed reciprocal role. The person with dementia’s expressions are not understood as a dialogically developed voice, but as an irrelevant statement which is not engaged with meaningfully. The carer may then enter into less meaningful, potentially more harmful exchanges which inadvertently invalidate and ultimately push people with dementia to exhibit distressed behaviours, in order to develop signs which might be better understood.
I was particularly struck by Leiman’s (1992) perspective that Bakhtin’s work indicates that because of the importance of utterance, for a human the worst experience they have is a lack of response. From the reflections above, this rings true for those living with dementia. As a remedy to this, we clinicians must hold the view that the person with dementia is still engaging in a meaningful dialogue. By providing a willingness to understand signs being presented to us, it is possible that those living with dementia can be better understood and worked with to meet their unmet needs. By highlighting the social and dialogic nature of the person, we can imbue hope to the individual caring for a person with dementia and facilitate the development of a hopefully and caringly listening to compassionately understood relationship.
Ian is a clinical psychologist who is completing his Cognitive Analytic Therapy practitioner training. He works in Rotherham Older People’s Psychology Team, Rotherham, Doncaster and South Humber NHS Foundation Trust
He would like to thank Dr Gemma Graham and Dr Katie Ackroyd for their initial thoughts on the first draft. email: i.asquith@nhs.net
References
Hamill, M. and Mahony, K. (2011). ‘”The Long Goodbye”: Cognitive Analytic Therapy with carers of people with dementia’, British Journal of Psychotherapy, 27(3), pp. 292-304. Doi: 10.1111/j.1752-0118.2011.01243.x
Hepple, J. (2006). ‘Developing a language for psychotherapy in later life’, Reformulation, Winter, pp 23-28.
James, IA, & Jackman, L. (2017). Understanding Behaviours in Dementia that Challenges: A guide to assessment and treatment, Second Edition. London, UK: Jessica Kingsley.
Kitwood, T. (1997). Dementia Reconsidered: The person comes first. Maidenhead, Berkshire: Open University Press.
Leiman, M. (1992). ‘The concept of sign in the work of Vygotsky, Winnicott and Bakhtin: further integration of object relations theory and activity theory’, The British Journal of Medical Psychology, 65(3), pp. 209-221. Doi: 10.1111/j.2044-8341.1992.tb01701.x
Pollard, R. (2008). Dialogue and Desire: Mikhail Bakhtin and the Linguistic Turn in Psychotherapy. Abingdon, UK: Routledge.
Sutton, L. (2003). ‘When late life brings a diagnosis of Alzheimer’s Disease and early life brought trauma. A Cognitive-Analytic understanding of a loss of mind’. Clinical Psychology and Psychotherapy, 10(3), pp. 156-164. Doi: 10.1002/cpp.366.
Sutton, L. (2004). ‘Cultures of care in severe depression and dementia’ in Hepple, J. & Sutton, L. (Eds.). Cognitive analytic therapy in later life. Hove, UK: Brunner-Routledge. pp. 201-220.