Abstract
This book offers a fascinating and overdue insight into living with dementia from a psychodynamic perspective. As the title suggests, the book is not only about working psychodynamically with people with dementia, but also uses this perspective to explore how living with dementia affects a person’s relationship with their inner self and those around them, throughout the course of the disease. Bringing together expertise from psychiatrists, psychotherapists, clinical psychologists, arts therapists and counsellors, this book will have something to offer readers who are interested in the psychosocial impact of ageing and cognitive impairment. Readers of this journal will find the two chapters which deal directly with music therapy especially pertinent. As a Music Therapist and researcher with several years’ experience of working in dementia care, there was so much in this book that felt familiar and insightful, in relation to clients and institutions that I have worked with, as well as my own responses to working with people with dementia.
Although not formally structured into sections, the order of chapters describes roughly the progress of dementia, from the initial stages of coping with the diagnosis, through planning for the future, residential care and finally to Adrienne Freeman’s moving chapter on music therapy for those at the end of life. The final chapter strikes a hopeful note, with Jane Garner asking ‘Can anything good be born of a dementia?’. I experienced the placement of this chapter as a kind of rebirth, as though we had come full circle – and indeed, the cyclical nature of dementia is commented on by several of the chapter authors. It is perhaps a cliché to describe dementia as a second childhood, and this book avoids doing so. However, early relationships and their effect upon later life are key to psychodynamic theory, and in dementia the boundaries between past and present can become more porous, bringing these early ways of relating to the fore. Freeman references T.S. Eliot’s blending of the start and finish of life: ‘In my end is my beginning’ (p. 215).
Early in the book, Julia C. Segal challenges the notion that counselling and psychotherapy are inappropriate for people with cognitive impairment. She emphasises that these therapies do not depend simply upon cognition, but upon ‘the experience of emotional contact, person to person’ (p. 31). Words are a form of communication, but there are many other channels for non-verbal communication which allow therapist and client to come into contact with each other. This theme is picked up by Rachel Darnley-Smith whose chapter is entitled ‘Music as mirror in the care of elderly people with dementia’ (p. 144). Darnley-Smith begins by outlining some of music’s key features which make it a suitable therapeutic medium: it is our earliest form of communication, it permits us to express ourselves and to receive the self-expressions of others, it is personal and individual but also highly culturally specific. Music therapy draws on human capacity to communicate through music, which exists before speech, and two people making music carries the opportunity for intersubjectivity between them. In her clinical examples, Darnley-Smith focuses not just on the content of the sessions but on the musical and non-verbal communication and the feelings that the work engendered in her. Mrs G, a woman with dementia, has almost no speech but is engaged and responsive during sessions. It is interesting to see work which is clearly meaningful and valued by the client (and therefore successful) but throughout which there is, as Darnley-Smith points out, not much change in the form or content of sessions and very little of anything which might be called ‘progress’. This example will be familiar to Music Therapists working with people with dementia and raises questions about whether and how we evidence the value of our work when we are not working towards specific goals.
Freeman’s chapter (p. 214) describes how psychodynamic music therapy is still relevant at the very end of life, when speech is no longer available for most people. She invokes the Chinese character for ‘to listen’ which contains elements meaning ears, eyes, undivided attention and open heart, thus conveying a sense of listening with one’s whole being which is required for the Music Therapist to be with the dying person. Describing her clinical approach, Freeman highlights the importance of watching and waiting, attuning to very small gestures and giving the person time to respond. Signs of response may be a tiny as a change in breathing or eyes tracking an instrument as it moves. Towards the very end of life the person may be unconscious, but Freeman emphasises that unconsciousness does not necessarily mean unawareness, and that hearing is the sense which usually functions until the end of life. With attunement, sensitivity and by drawing on case history and contact with the family, the Music Therapist can accompany the person with dementia as they negotiate the threshold of the end of life.
Throughout the book, case studies illustrate clinical practice. These are at the heart of the book; some chapters are based around a single case study, while others contain short vignettes to elucidate certain examples. The examples are a vital way to explain and demonstrate complex theoretical ideas which may otherwise seem abstract. Broadly speaking the book is accessible to those who are not familiar with psychodynamic concepts and terms, although some chapters are more accessible than others. Hagger’s chapter about liaison psychiatry is a particularly useful starting point as it provides clear explanations of various terms from psychotherapy such as splitting, containment and counter-transference. A minor criticism is that we do not hear much directly from those living with dementia or their carers in this volume. Apart from a brief interview with two art therapy clients in Byer’s chapter, this is a book written from the point of view of experts, but not experts by lived experience.
As well as many useful and enlightening direct insights into clinical psychodynamic practice, this book is a valuable resource for understanding how dementia can shape and affect responses to the world, both for the person living with dementia and for their partners, friends and family. Dementia is a progressive disease with no cure; it causes loss and the anticipatory fear of future losses. As Evans points out in Chapter 5, denial of their condition by the person with dementia may result from this fear: ‘the ego hides the unwanted knowledge from the self repressively’ (p. 59). Family members may collude in the denial. Evans believes that people with dementia can overcome denial but need time to learn and understand their diagnosis. It may not always be clear whether lack of awareness of their condition in a person with dementia is caused by psychological or organic factors, but in any case carers may feel isolated while mourning the loss of the person they knew. Evan’s conclusion is that giving people with dementia time to know and understand their condition allows them to have ‘a genuine voice in their own future and plans for care’ (p. 67).
Also on the topic of dementia’s effects on existing relationships, Balfour’s chapter explores the experience of living as a couple with dementia, highlighting how changing cognition can activate different attachment needs in the person with dementia. They may require someone else’s mind to go on thinking for them and holding their mental state: ‘increasingly the carer partner becomes the witness, whose mind can register and think about what is happening to the person with dementia whose own capacities are progressively diminished’ (p. 122). Naturally, the carer will also require their own containment to perform this role.
The impact of dementia on professional carers and institutions is not neglected. In the first chapter, Renwick describes an observational project which he conducted in a short-stay hospital, from the perspective of both patients and staff (p. 3). He noticed that it is common for nursing staff to be constantly engaged in tasks and rarely spend time with the people with dementia. Apart from the obvious explanation of lack of time and high workloads, Renwick suggests that this could be a social defence mechanism as working with people who have dementia is emotionally taxing and reminds carers of their own mortality. Renwick also identifies that ‘malignant positioning’ (Sabat, 2006) plays a role in his own and others interactions with people with dementia. In this framework, the person with dementia is seen primarily as a patient and their behaviours are attributed to disease process rather than meaningful attempts to communicate and be in the world. Renwick gives the example of his own assumption that a patient’s habit of walking up and down the ward at fifteen minute intervals is ‘some repetitive action explained by dementia’ (p. 10). However, a nurse explains that the man used to be a physiotherapist; he walks to keep fit. Unconscious processes may affect our attitudes towards people with dementia and we must be curious about this possibility. Working in institutions is especially difficult if one is visiting as an outsider. Maciver and colleagues present a case study involving short-term counselling for a care home resident (p. 133). They vividly describe the feeling of shock and disorientation experienced by client and therapist when a well-meaning member of care staff ignores the ‘Do not disturb’ sign on the door and bustles into the session offering tea. This feeling will be familiar to many of us who have attempted to create and hold space and boundaries for sessions in institutions which are not therapy-orientated. And yet Maciver et al. point out that despite its inherent difficulties, flexibility and willingness to work outside conventional spaces is vital for accessibility; without this flexibility, the client in their case study would not have been able to attend therapy.
Overall, this book provides many valuable insights into the experiences of people with dementia and those around them through a psychodynamic lens. The plentiful clinical examples bring often complex theoretical ideas to life, and the people described in the vignettes and case studies are always depicted with dignity and respect. Dementia is a disease which challenges our capacity to think, through the organic disease process itself and as a psychological defence against its frightening reality. This is a book which will help readers to keep thinking in the face of loss and pain, and has great potential to improve the care of people with dementia as a result.
