7 rules for mental health at Christmas

What is Christmas dinner like at your place? Advertisers would have us believe we need a full table, happy smiling people all the time, all decked out in the latest clothes and having a wonderful time. Unfortunately, or maybe fortunately you might say, the real family Christmas is often far from that fantasy.

Christmas is different things to each of us and there is no one right way to celebrate this time of the year. It is often when we place unrealistic expectations on ourselves that we end up creating tension, anxiety, depression and withdrawal for ourselves and difficulties between us and those we love.

Expecting it to all go smoothly and have no difficulties means we can be overwhelmed when it doesn’t go to plan.

So Rule #1 is to keep your expectations realistic. This can avoid much anxiety and depression that can occur because we don’t met these unrealistic expectations. Family dinners are often tense times and just because you have arguments around the table because someone did not bring the food they were to bring doesn’t make it all a failure.

Rule #2. Life is not black or white, it is often very colourful and mottled. At Christmas, it can be easy to think in terms of fantastic or dreadful. Keep it within reasonable bounds and remember that life is varied and it is normal for life to be complex and colourful.

Rule #3 is that just having one problem does not make Christmas a failure. Just because the turkey didn’t come out the way you wanted or you didn’t get the presents you wanted or Aunt Joan cannot come for Christmas, doesn’t make it a failure. This can help you keep it in proportion and not become catastrophic in your thinking.

Rule #4 is be prepared to let others help you. Do not try to do it all yourself. Being a martyr for the cause is not going to make Christmas any more enjoyable and probably will make it tense for those around you as you try to cope and possibly unpleasant as they deal with your tension. Engage others to do things to help you prepare so it is a team effort.

Rule #5 is make a list of what needs to be done so you can be organized and plan ahead. This makes for a calmer environment for everyone and those around you can be involved in doing what needs to be done in a timely way.

Or offer to help the hosts. This can give you a sense of inclusion and no doubt your hosts will be very grateful.

Rule #6 stay in the present. Avoid flying off into the future in your thoughts about Christmas and worrying about details and events that have not yet happened. Stay in the present. If it has not yet happened it needn’t take up your mind.

Rule #7 think about what you can control and avoid worrying about what you cannot. If you cannot control the outcome of something don’t worry about it. Other people are responsible. If you take over it makes other people less responsible and in the end, less accountable. You doing it all, only makes others more childlike around you, instead of more adult and equals. If you want cooperation you must give people responsibility.

In the end remember, there are no rules!!

Appreciative Inquiry as a new method of response to behavioural and emotional difficulties in dementia

What could we do in dementia care if we were not focused on problems and deficits, but focused on what the person can still do and wants to? Have we become so focused on what is wrong with the person that we forget who they are, who they can be?

I don’t know about you but if I am surrounded by people who love me and appreciate me for who I am I am a better person than if I am surrounded by people who are not interested in me or have misconceptions of me. What is it like for the person with dementia who maybe can’t use words to understand and communicate their own feelings and experience anymore?

Most ‘behavior management’ (don’t like that term anymore) is focused on what is wrong, the problem caused to others. Usually the person themselves is regarded as the problem by the time a professional is called in to ‘solve’ the problem for them. This loses sight of the person and who they are disappears under the weight of negativity, frustration and judgments about the person.

I suggest we may  be better to go in a different direction. Let’s look to Appreciative Inquiry.

Appreciative Inquiry focuses on approaching  organizational change from a standpoint that the organization is a “solution designed in its own time to meet a challenge or satisfy a need of society” (Cooperrider and Whitney, 2005). This approach focuses on what is working well and effective in organizations rather than on seeing the organization as a problem to be solved. In this way I think we can approach the individual person as a solution designed in its own time to meet a challenge or satisfy a need. This is indeed what the human brain is constantly trying to do. It is trying to work out how to survive, how to make sense of the massive inputs it receives from the world around it so that it can keep the person alive long enough to pass its genes onto another human being. The desire to stay alive is phenomenally strong in the human being.

As the human being faces the threat of diminishment by a condition that destroys the very organ that is designed to keep it alive, the human being goes into survival and responds to this by seeking out attachments, by fighting or fleeing, by behaving in ways that make perfect sense as efforts to ‘make sense’ of the confusing world and to simply survive.

Traditionally in modern dementia care we take a psychiatric approach in response to this range of actions that people engage in when threatened with annihilation. We call it a symptom of an illness (Behavioural and Psychological Symptoms of Dementia – BPSD) and medicalise the normal reaction into an abnormal sign of illness; and ‘disturbed’, or challenging’ or disruptive’ all of which says more about its effect on us and our perceptions of it than anything about the behaviour itself. We gather evidence of this problem and label it aggressive, wandering, repetitive, vocalising, mood swings, agitation, or attention seeking, or manipulative, or clinging. And then we medicate it away because if it is a symptom then medical solutions are called for. So we use psychotropics to modify the person so they don’t do these behaviours. The unfortunate side effects that we tolerate are sedation and confusion, dull emotions and slowness. But its a small price to pay for peace and quite, isn’t it?

Appreciative Inquiry uses 4Ds as a process: Discovery, Dream, Design, and Destiny. Lets look at each a little as they might be applied to an individual ‘behaviour management’ issue.

Discovery:We seek to understand the situation by engaging all stakeholders to articulate the strengths and best approaches to responding to this person. In this way the person can begin to come alive in our minds and the ‘problem” can diminish in our perceptions. What works? What is the best of what is and what has been in this person and our time with them? Let’s ask what is working in this person’s life right now that we want to maintain? What is going well? What are the threads or aspects of this person’s life that they and we want to maintain? What does the person say is going on for them, from their point of view? Rather than focus on  the ‘problem behaviour’ let’s focus on the success this person has in functioning in the face of a condition that undermines their very confidence in their own perceptions and memory for reality.

Dream: What is it we want? What is the result we want here if this is what is working for the person and for us? What is this person calling us to do and be with them? What do they need from us?

Design: Create ‘possibility propositions’ of the ideal relationship with this person, articulating an ideal arrangement of people, routines, relationships that we think this person is capable of engaging in and drawing upon  and magnifying the positives about the person to realise thsi ideal relationship and situation with them.

Destiny: Strengthen the affirmative capability of the situation, organisation, family, enabling it to build a hopeful and sustainable momentum for positive change and high performance of excellent human relationship.

As Cooperrider and Whitney state a crucial step in this process and centre of the process is affirmative topic choice. this is what will define and direct the process. If we remain focused on the topic as a problem for everyone we will ultimately see the person as a problem and not just what they are doing. However, if we can reframe the topic in an affirmative way the topic can become an agenda for relationship with that person, for improving their quality of life and an agenda for care actions and care planning.

Lets have a look at an example: Monique is refusing to come away from the door to the aged care home stating that she needs to go home to her mother who said she has to be home by dark or she will be in big trouble. She is packed and is not prepared to back away. Staff have been approaching her and trying to cajole, to persuade to lie to her, to bully her and most recently to threaten her and physically manhandle her in order to get her away from the door. She is not letting anyone get through the door until she gets through the door first. She doesn’t believe anyone and is firmly convinced that her view of things is correct and others are liars.

If we take an AI approach we begin with Discovery by asking what is going well in Monique’s life. What is working in her care? You might think that not much is working in her life right now and she may say the same thing. However, it is clear that she has a strong attachment if fearful to her mother. This is a positive. A child wants to please their mother by doing the right thing and right now she sees herself as a child needing to go home to satisfy her mother and so avoid trouble. Also a positive is that she has enough ego strength to resist the efforts of numerous cognitively intact people to maintain her stance. This is a positive. Her brain has not yet relinquished its ability to protect its own interests. What might be construed traditionally as resistiveness may be reframed as ego strength and capacity for relationship. We want to assist her to sustain these abilities.

Dream: We ask what we want. What is the desirable future state we want? We want the door way to be open and we want Monique to be contented and peaceful. Happy is too transient a state. Contentment may be more achievable and desirable. The other thing to do is ask what Monique wants. She clearly wants to leave in the short term. She also wants to see and be with her mother, to be attached or connected to her mother. She wants to be a good daughter, an obedient daughter with a satisfied mother who is not angry.

Design: We want to be able to create strong attachment relationships in which Monique feels safe to be angry and afraid and sad, where her emotions are acceptable and it is OK for her to be wanting her mother. We want to have people in our staff group who have the capacity to be unafraid of Monique’s rage and sadness at not being able to get what she wants and who are not overcome with fear at her rage and sadness, who can stand with her at the door and remain in relationship with her rather than pull her away. This may not heal the wound in Monique but it may contribute to a more peaceful life for her.  This is a possibility proposition. It is an ideal and it is what we work toward achieving for Monique and for us.

Destiny: We work to select and training staff who have the personal capacities and motivation to achieve our goal of an emotionally robust staff group who can stand with people in their distress and empathise and be in relationships that are equal with enough peace and enough contentment.

Appreciative Inquiry can be a useful way to reframe the current medical model of ‘behaviour management’ and the symptomology of BPSD into a more humane and affirmative, healing and hopeful approach to life with dementia.


Socio-emotional consent, sex and people with dementia

Sexual interactions and people living with dementia is a topic that causes much discussion and concern among family members and professionals who are asked to guide or support decision making about these important interactions.

For many people who live with dementia sex remains and in some cases becomes an important part of their wellbeing. They want to experience sexual interaction in some form. In addition to the issue of where the interactions occur (i.e., public situations vs private) the question that causes distress for many is that of consent. If the person is not capable of giving consent because of their diagnosis how can they be regarded as capable of saying yes to something for which we normally require the capacity to give consent?

My proposal is as follows. Although the person may not be able to give full legal consent such as required by law to sign documents or enter into contracts, they may still be able to provide what is known as implied consent. This is the type of consent recognised by law that is based on signs of the person’s behaviour and words that imply or communicate their intent or willingness to engage in the activity. The experience they have is often at an emotional level of attraction or contentment, or anxiety about being in close proximity to another person who may or may not remind them for important attachment figures such as a spouse. In this situation it is not simply sexual experience that is important but intimacy, the experience of closeness and bond that expresses love and affection. This is the social and emotional context of them being able to signal to you that they either want to be in the relationship/interaction or they do not.

The signals they give you by their behaviour are important signals of their internal willingness to participate or not. These signals may include: leaning toward the other person, moving toward the other person, relaxed posture, making and holding eye contact, touching in a relaxed or affectionate manner, smiling at the person and others while with the other person, being content with receiving touch from another, and talking in a relaxed tone and volume. These are the signals that they wish to engage or remain with the interaction. If you do not see any of these signals the interaction should be interrupted.

The signals that the person is not OK or willing to remain in the interaction may include: staring ahead, lack of verbal communication where you would expect there to be some, tense body posture or rigidity, lack of eye contact, movement away from the person, passive cooperation, tension in the voice, other overt signs of anxiety such as shaking, chest pain, headache, and trembling.

Some of the second group of signals above are indicators of freezing that are commonly associated with traumatic reaction to overwhelming experience and may indicate that the person is experiencing something overwhelming that they do not have the words to communicate to you or to the person they are with. They may freeze and show only passive cooperation and no overt signals of distress, i.e., they look calm but on further examination they may not be calm but frozen with fear. What you see is the absence of what you would expect to see if there was overt distress or pleasure. You see nothing. If all you see is calm and no signals of overt pleasure or enjoyment you should interrupt the interaction until such time as you have enough evidence to facilitate it continuing, if at all. No one has the right to impose themselves on others regardless of their diagnosis or marital status.

Some may see this move to interrupt as overbearing paternalistic control. However, the action is required by our duty of care where there is a risk to emotional wellbeing. The risks must be weighed up. What is the benefit if i facilitate this relationship by not doing anything? What is the risk if I interrupt it and one of the parties is annoyed and the other is relieved and can no relax and enjoy him/herself?

I hope this focus on socio-emotional consent and the listing of specific behavioural indicators may help in guiding people to make decisions that either facilitate in the right place or interrupt in the right place, all for the wellbeing of the people involved.

Bernie McCarthy

Check out this trailer for the new Pixar film on emotions – ‘Inside out’

The new Pixar film ‘Inside out’ is due for release on June 19th. Check out this trailer https://youtu.be/WIDYqBMFzfg It takes a marvelous look into the emotional life inside our heads and bodies that usually dumbfounds us, scares us, makes us defensive, simply overwhelmed. These same emotions can allow us to come close to others, live satisfying lives and understand the inner life of each other.

Check out this fantastic effort to make our emotional life understandable. I imagine this gem of a film might be enjoyed by the adults as much as the children.


Power – love – justice

Just saw this quote from Dr Martin Luther King Jr

“Power at its best is love implementing the demands of justice, and justice at its best is power correcting everything that stands in the way of love.” 
Dr. Martin Luther King Jr
What does justice demand in your life? Is it to remedy the excess disability  of a person with dementia so they can feel their own mind again?

Behaviour is not a disease

Behaviour is not a disease. It is a way of communicating our inner experience when we interact with the world around us. In dementia care behaviour is often treated as though it is a disease. “She’s got behaviour” as if she has some terrible disease. We pathologise normal behaviour and make it into some form of illness. We also ignore some problem situations that we should take more seriously such as withdrawal, anxiety, repetitive questioning or people intruding into other people’s space.

Wellbeing is the goal and respectful, warm relationship is the means to that end. Treat people as human beings – not as some ill object to be washed, pumped, fed, wiped and kept seated.

People with dementia are no different to you and me. When was the last time your brain let you down?




BDNF from CSF linked to Cog Impairment in late life depression

Brain Derived Neurotrophic Factor (BDNF) has been linked to cognitive impairment in people with late life depression. The study conducted by Breno Diniz and team from Federal University, Brazil, and published this month in The Journal of Gerontology Series B, is the first study to link BDNF from cerebrospinal fluid with cognitive impairment (CI) and late life depression (LLD). Other studies have found inconclusive links but this study uses CSF which because of its close relationship with the brain tissue indicates a clear relationship with cognitive impairment. The study used three groups of participants who each had a spinal tap (ouch) to obtain the CSF. One group was a Control and the other two groups were those with Late Life Depression and No Cognitive Impairment and the third group had Late Life Depression and Cognitive Impairment. The Control group had the highest level of BSNF, the LLD No Cognitive Impairment group had next lowest and the LLD Cognitive Impairment group had the lowest levels of BDNF.

The meaning of this is that it indicates that BDNF is not only present in lower quantities in those with cognitive impairment but that late life depression works as an intermediary, causing a vulnerability to cognitive impairment. This is suggested to be due to reducing the number of active neurons, thus creating the vulnerability to diseases such as Alzheimer’s etc..

BDNF is known for its link with exercise and cognitive function, ie it is released following vigorous exercise and memory and other cognitive funcitons improve. It is clearly an important factor in overall functioning.

So if you exercise you will improve your mood and your cognitive function! Simple huh?