The second of Kitwood’s five fundamental needs is occupation.
Being occupied is important for well-being. We can take this for granted if we are employed and have structure, purpose and routine in our day. Being occupied can provide the satisfaction of making, digging, painting, folding, sorting, washing up, cooking and so much more. You get the idea. If we achieve it is good for our self-esteem, our confidence to try other things or even just to keep doing the things we do every day which reinforces memory. This is why dressing, washing, eating, grooming are important activities to maintain for a person with dementia. As the condition progresses the person may require gradually increased assistance to achieve success but it is crucial that we do not take over. Our role is to provide the scaffolding for them to successfully perform the task themselves.
Occupation is good for memory because it causes us to retrieve past skills from memory and use them again and again and again. This reactivates the old skills and knowledge and increases the chances of these abilities lasting longer in the face of dementia. Use it or lose it.
If we don’t have the structure of someone around us prompting what is going to happen next we can sit around waiting, stuck and bored particularly if the disease affects the motivational area of our brain. A person in this state is at risk of depression, in addition to the physical problems that can develop due to inactivity.
Boredom is a problem for some people with dementia. This usually occurs if they have difficulty starting themselves. If their “starter motor” is not working as it used to do, they may need you to prompt and prod or make suggestions. You need to work out what manner, tone and approach is going to get the best result. Adjust your approach until you get the right combination of words, tone and manner that triggers the person with dementia into action.
Occupation provides an opportunity to reaffirm our sense of ourselves. Who am I? I am a carpenter, a mother, a gardener, a farmer. How do I know this? Because I do the things that carpenters, mothers, gardeners and farmers do.
The first of the five fundamental needs of Kitwood’s model is comfort.
Comfort can be physical and emotional. Physical comfort may come from having enough food, a bed that is right for us, or furniture that fits us. Comfort may come from living in a house that is the right temperature, not too draughty or dark, or too glary.
Emotional comfort may come with affection from people we love, validation of what we are saying or from being able to trust the reliability of people who keep turning up. It may be from the familiarity of doing activities that have always soothed us.
We need a temperature that is pleasant, not too hot, not too cold, and to dress accordingly. However, if we are forgetful and lack awareness of our surroundings we may go outside on a cold rainy day in a t-shirt and shorts. Or we may dress for winter weather when the day is hot and steamy, risking dehydration and sunburn.
Familiarity of our surroundings also gives comfort. We sit in the same chair. We walk the to the shops to buy the same newspaper everyday for years on end. We wear that old pullover or jeans because they are comfortable, familiar. We eat food because it is familiar and satisfying. More than that, to be in familiar comfortable surroundings, clothed in familiar clothes, with familiar people is pleasurable and calming.
And this is where we confront the stresses that dementia can cause. It is difficult to be comfortable when you can’t remember the people, the place, the clothing. In fact, it is more likely to be concerning and irritating. In other words, our need for comfort can be sabotaged by dementia and we can be plunged repeatedly into the discomfort of strangeness.
Personality and temperament may play a role here as we may vary on how much familiarity we need to feel comfortable. Some people thrive on new situations and enjoy wearing different clothes, engaging in novel activities and meeting new people. These people are not going to find the forgetfulness of dementia as discomforting as someone who relies on the familiarity of predictable routine for comfort.
Life experience may also influence how much comfort a person needs and what they utilise to provide that comfort. A former tradesman may want to be outside doing something rather than sitting inside and watching television. Then again, the former tradesman may be relieved to sit inside and be out of the weather watching his favourite football team. That may be just what he needs to do to signal to his brain that he can relax. It just depends.
There are many models of human needs that have been developed over the last century or so. Perhaps the most well-known is Maslow’s Hierarchy of Needs. We won’t go into it here as there is a great deal of information on the internet about this model. You could try this site as one of many examples. Suffice to say it is a useful way to understand what motivates people to act the way they do.
When our needs are met we tend to be calmer, more contented and less anxious, angry and acting out. When our needs are not met we can become irritable, frustrated, angry, sad, depressed, withdrawn, lose confidence, or act out to get our needs met.
A model of needs has been developed with people with dementia in mind. It consists of five basic needs: Comfort, Occupation, Inclusion, Attachment, and Identity. This was developed by Professor Tom Kitwood. If we look at each need we can understand more about the motivations of people with dementia. These are universal needs that everyone experiences and they can help us understand the motivation behind much behaviour we see of people with dementia, and of ourselves. Over the next five posts we will examine each need in turn. This will begin on Monday next. No post tomorrow.
Why do any of us do the things we do? What motivates us? People with dementia are motivated by the same needs and wants as you and me. What we say here about people with dementia is just as true for people without dementia. And this is a fundamental point that is often confused by the way we speak about people with dementia. People with dementia are just people. They have the same needs, wants, desires, motivations as you and me. They don’t become some type of strange alien because they have a diagnosis of dementia. As a person they are continuous with who they were before the diagnosis. They are not mad, or insane, or bonkers. Some of our language has improved over the last few decades but much still needs to be done to encourage people to speak accurately and respectfully when communicating about people with dementia.
What does change in dementia is our ability to process the problems that you and I process automatically and therefore unconsciously (out of awareness) and work out what to do about these problems.
At its most fundamental, behaviour is anything we do or say. And what makes us behave? A stimulus, a trigger, a cause. I smile at you. You smile back. I cry and you feel sad inside. Stimulus-response is a basic way of understanding behaviour. A stimulus or trigger is anything that causes you to do something, or experience something inside and then act.
Triggers for behaviour are external and internal. External triggers are those in the environment around us. The situation you are in may be triggering you to feel hot, cold, calm, annoyed, sad, or frustrated. You walk past a bakery at 7am not having had your breakfast and the smell of freshly baked bread triggers your tummy to rumble. Your brain has registered the aroma and the associations it makes with pleasure and eating trigger your stomach to release gastric juice in readiness for this tasty food. In this way external triggers can cause internal reactions. They can also trigger you to interrupt your early morning walk and turn into the bakery to buy a croissant! The external trigger causes you to act. If you think about it in terms of a sequence it may be clearer:
Smell fresh bread – stomach rumbles – enter bakery and buy croissant
Internal triggers are those we experience inside our bodies and minds. Memory, thoughts, emotions and senses all come together to create our sense of the world and what to do about it. Our brains work out what to do about it extremely quickly and efficiently.
If we think of it in terms of emotional moments in the day we can see how our feelings become involved in explaining our behaviour. Our feelings have physical components and mental or psychological components. For example, when we feel upset/sad we have a thought/image and a physical experience that come together to make the sadness feeling. It may be in response to something we have seen, such as a picture of someone from our life who has died. Memories come and we feel the love we have for them still. A wave of sadness rushes up and we feel tears in our eyes, our chest and throat fill and we reach for the tissues.
We see the picture of our loved one who has died (trigger/stimulus) – remember and feel the love we have for them (internal response, mental and physical) – wave of sadness rises, eyes fill with tears, chest and throat feel full (internal response, mental and physical) – sobbing releases grief (behaviour response) – reach for tissues (behaviour response).
This sequence is mostly internal but is triggered by an external object (picture of loved one) and also involves a box of tissues. Everything else is internal. It cannot be seen or heard by anyone else. Internal experience is private and unknowable by others until we act and reveal what is going on inside ourselves in our behaviour (crying and reaching for tissues). An onlooker may be confused by our upset, not knowing of our love for the person we have seen in the picture. They may provide comfort simply on what they can see without knowing the internal memories and emotions that have been triggered.
Memories as well as emotions may trigger behaviour. As you can see from the above example crying may be triggered by memories of a loved one which in turn trigger feelings. Memories and emotion are often connected. They seem to come at once but studies have shown that there can be a brief moment between them that show that one may cause or trigger the other. Memories can cause emotion. Emotions can cause memories to come. Sadness in response to a photo of a person you loved can trigger past losses and hurts. This is also true for trauma. Current experience can trigger past trauma. Memories, sensory and physical experience can come together to create an overwhelming moment of stress as though the past experience is happening right now.
There will be times when you need to be flexible and quick thinking to move from one approach or position to another in order to bring about success or a goal of being dressed or washed or ready to go shopping.
An example of this is getting dressed. If the person with dementia dresses in a manner inappropriate for the weather or the social situation, i.e., is ready to leave for a family gathering and is dressed in underwear only, adamant that they are ready. You may begin in the Expert position to bring it to the person’s attention, “I think you might need some trousers to go to lunch”. But you cannot remain there if you get a negative response or resistance and wish to avoid upset and be late for lunch. Given how certain he is that he is ready. You may need to move for instance to the Columbo position for a moment. “Oh, I forgot to tell you Aunt Grace is going to be there today. She really likes those black trousers of yours/that jumper of yours. Do you think that would be good to wear? I don’t know. What do you think?” Your goal is for him to be dressed appropriately. However, given the risk for upset if you impose your preferences on him, you may decide that so long as he has trousers, a shirt and a pullover on that will be OK. Which trousers doesn’t really matter. To achieve this you become the Collaborator, who works to achieve the goal of being at the family gathering in a peaceful mood. Or if it gets to be too difficult you may need to move to Companion for a few moments and sit quietly, “It’s all a bit much isn’t it?“
The Companion is the position of sitting with the person with dementia in their lack of motivation or direction or knowledge of what to do about the situation. Companion is the position of presence. Motivation and activity are low. It can be tiring to function at such a low level of activity. It can also be anxiety-provoking to sit with the lack of direction and action. However, it can bring you together in a way that you may not normally get to do when you are active and busy. This can be a companionship that brings comfort and calmness. It is the position of “being with” rather than “doing with”.
It may be that these are the times when dementia becomes the third presence in the room. Feelings about the dementia can emerge in each of you and come to awareness. How do you each feel about this “thing’ that has changed your lives? May be that is what you end up doing – talking about ‘not doing’.
Tomorrow we look at how to move from one position on the relationship compass to another
This is a position of collaboration in which you can work together to enjoy moments of attunement and contentment. These can be rare but important in sustaining you both. It often means holding back from being the expert in order to allow the person with dementia an opportunity to use their skills and contribute knowledge so that their sense of agency and effectiveness can flourish.
As dementia progresses these moments may be less frequent and you may need to move to the expert position. The person with dementia may well feel relieved and calmer when you take over because it may provide them with security and a sense of safety. They are with someone who knows what to do. It is important here to do this in a manner that is gentle, calm and kind. Avoid being domineering, abrupt and bossy. That will activate either push back or withdrawal, both of which are unpleasant and unhealthy for the person with dementia, and damaging of trust and respect in your relationship.
For those unfamiliar with the 1980’s American TV character, Columbo was the bumbling cop who came across to villains as an ignorant fool because he asked questions that showed he didn’t understand. However, he gets the crook by the end of the show. As Columbo you adopt an “I don’t know” stance that values what the person with dementia thinks and wants. You apologise for not understanding. You ask questions. You seek to understand. You put them in the expert position
Yes this is strategic. It is also the right thing to do from an ethical point of view. What the person prefers is valuable. Your goal here is to lift them up in the interaction by giving them importance and priority so they can contribute their perspective. They may be having difficulty finding the words to explain what they want. You can ask questions that help them clarify to themselves and to you. This is useful if you are both stuck in a disagreement about what should happen next. Often the steam will go from the interaction and you can then move to Collaborator with the person to find a mutually agreeable solution.
This is the Expert position. You know what needs to be done. You know what is wrong. You understand. You can give advice. And the person with dementia doesn’t know nor understand or is not seeing the risk that you see.
There are times the Expert position is necessary such as when physical safety is at risk. The person with dementia turns to walk into traffic with no awareness of the possibility of being injured. You can see the risk and they don’t. The responsibility for acting is with you to prevent them being injured.
This is also the position of advice giving. You have knowledge and can share it. They may not have knowledge for the situation. You know the plan for the day is to go to lunch at the golf club and requires a rather formal standard of dress. You can suggest or tell (perhaps) the person what to wear. “You’ll need to wear a tie. That green one looks good on you”. This is the Expert position.
This brings us to the various positions you can take when caring for a person living with dementia. As a Sherpa you will likely take up all of these from time to time. Being in a relationship with someone we need to be flexible. Try to avoid becoming stuck in one position or think you should be a certain type of carer or behave a certain way all the time. It may be that you have the idea of how a carer should act from watching someone you admire or perhaps you only know of one person who has cared for a person with dementia and they did it this way, or this way. So I should be like that. This will only make things worse for you both and cause problems, conflicts and upsets for both of you.
If we think of a compass there are many points around it. There are also many ways you can be with someone with dementia. On a relationship compass you will need to move around the many possible positions for you to maintain the person with dementia and yourself in a condition of wellbeing. This requires flexibility and timing to use the right position or approach at the right time. Have a look at Figure 1.
COLLABORATOR (WE BOTH KNOW)
COLUMBO (YOU KNOW & I DON’T KNOW)
EXPERT (I KNOW & YOU DON’T KNOW)
COMPANION (NEITHER OF US KNOW)
There are many ways you can be with the person with dementia, depending on the situation. Let’s look at each of four situations that are common. You might like to add your own combinations or relabel the positions here to make sense for your relationship.
Next posts will explore each type of relationship in turn