Abstract
Appreciative Inquiry is an approach to organisational change that has been effective and popular around the world for the past two decades. What could it have to offer us as an alternative to traditional ‘behaviour management’? Traditionally, in modern dementia care, we take a psychiatric approach to the range of actions that people engage in when stressed or traumatised by the cognitive, social and psychological losses associated with dementia. We call them symptoms of an illness – Behavioural and Psychological Symptoms of Dementia. Then, we medicate them away because if they are symptoms then medical solutions are called for. We may obtain a better outcome from a different direction. Appreciative Inquiry focuses on an organization as a ‘solution designed in its own time to meet a challenge or satisfy a need of society’. This approach focuses on what is working well and is effective in organisations rather than seeing the organisation as a problem to be solved. In this way, we may approach the individual person as a solution designed in its own time to meet a challenge or satisfy a need. Using the 4Ds of the Appreciative Inquiry approach, this article examines the process of Discovery, Dream, Design and Destiny, as it is applied to a case example of a care situation that usually ends with disruption and distress. By formulating affirmative topic choices, the staff group and individual carers may resolve issues with what people with dementia do or say in a way that is humane and hopeful.
Introduction
Appreciative Inquiry is an approach to organisational change that has been effective and popular around the world for the past two decades. What could it have to offer us as an alternative to traditional behaviour management?
Most ‘behaviour management’ is focused on what is wrong, the problem caused to others. By the time a professional is called in to ‘solve’ the problem, the person themselves is regarded as the problem. This loses sight of the person, and who they are often disappears under the weight of negativity, frustration and judgments about the person.
Traditionally, in modern dementia care, a psychiatric approach is taken to the range of actions that people engage in when threatened with cognitive, social and psychological change in dementia. This behaviour is referred to as ‘symptoms of dementia’ and these normal reactions are medicalised and perceived as abnormal signs of illness; and ‘disturbed’, ‘challenging’ ‘disruptive’, all of which says more about its effect on the participants and their perceptions than anything about the behaviour itself. Kate Swaffer has written eloquently asking the question of who’s behaviour is the problem (Swaffer, 2015).
Evidence of these ‘problems’ is gathered and labels applied including aggression, wandering, repetitive, vocalising, mood swings, agitation, attention seeking, manipulative or clinging. Then, following the logic of this approach, the symptoms are treated with medication which is a traditional medical solution to a medical problem. So psychotropics are used to modify the person so that they do not engage in these behaviours. The unfortunate side effects include sedation and confusion, dulled emotions and slowness. These have been cause for concern for many years and there are efforts internationally to reduce the use of psychotropic medication with people living with dementia (Bannerjee, 2009; Senate Community Affairs Committee Secretariat, 2014; Smith et al., 2013). Advocates such as Kate Swaffer (Swaffer, 2015) and Christine Bryden (Bryden, 2005, 2012; Bryden & MacKinlay, 2003) have called for more humane and reflective mutual engagement with people living with dementia. We may obtain such engagement from a different direction.
Appreciative Inquiry focuses on an organisation as a ‘solution designed in its own time to meet a challenge or satisfy a need of society’ (Cooperrider & Whitney, 2005). This approach focuses on what is working well and is effective in organisations rather than seeing the organisation as a problem to be solved. In this way, we may 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, 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 on to another human being. The desire to stay alive is phenomenally strong in the human being.
As the human being faces the changes that occur in dementia (loss of memory, perceptual changes, personality and functional change), the person becomes stressed. The survival response under threat is to seek attachments for security and affection, to fight, flee or freeze, behaving to ‘make sense’ of the confusing world and to simply survive (Miesen, 1997, 2010).
Appreciative Inquiry uses 4Ds as a process: Discovery, Dream, Design and Destiny. This organisational approach may 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? Let's ask what is working in this person's life right now that we want to maintain? What is going well? 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. Draw upon and magnify the positives about the person to realise this ideal relationship and situation with them.
Destiny
Strengthen the affirmative capability of the situation, organisation or family. This enables it to build a hopeful and sustainable momentum for positive change and high performance of excellent human relationship.
A crucial step in this process and the centre of the process is affirmative topic choice. This is what will define and direct the process. If we remain focused on the behaviour as a problem for everyone, we will ultimately see the person as a problem and not just ‘what they are doing’. If we can reframe the behaviour 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.
Fictitious case 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, persuade, and lie to 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.
Dream
We ask what we want. What is the desirable future state we want? We want the doorway 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, afraid and sad, where her emotions are acceptable and it is OK for her to want 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 train staff who have the personal capacities and motivation to achieve the 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 contentment.
Appreciative Inquiry may be a useful way to reframe the current medical model of ‘behaviour management’ and the symptomology of Behavioural and Psychological Symptoms of Dementia into a more humane and affirmative, healing and hopeful engagement with people who live with dementia.
Footnotes
Declaration of Conflicts of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.