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An 'Old Sea Dog' Reflects ...

Daniel Byrne

I've been thinking about writing something like this for a while, having had time to reflect on our young onset CST friendship groups and virtual groups, which have been up and running now for more than a decade.

I remember back in the day (early 1980s) we were told about the benefits of 'Reality Orientation' and all became involved in focusing people on the 'here and now', or rather 'our here and now'. This was all well and good, but it focused on the memory lapses and mistakes people with cognitive impairment would inevitably make.

What this amounted to was 'I (as a facilitator) am the knowledgable one. I have all the right answers. You did very well (patronising!), but got this, this and this wrong!'.

So what? Did it really matter where we were, what the weather was like, what our next meal was, or how far off Halloween was? Not a jot.

So what really did matter? How our clients, friends, equals, respected elders FELT. Belittled most of the time, I would imagine.

Then came 'Reminiscence Therapy', or as some would call it, a lovely jaunt down memory lane. Lovely that is, unless your life has been a 'bit shit'! The focus of these sessions was clearly on the past, or what has gone before. Hopefully, sessions would be focused on the person's life and THEIR timeline, rather than an older age cohort's experiences of major events such as the coronation or the dreaded war years.

I love a good old fashioned bit of personal reminiscence and reflection. I really enjoy story telling and getting the old photos out. But really, it does seem like another lifetime ago. Days gone by and all that. I really do feel like and I AM a very different person now as I approach my 60th than I felt in my 20s and 30s. And thank goodness for that!

Looking back I now think reminiscence really is a bit Passé, which as the dictionary definition goes "something that's out of style" or "so yesterday!" Being that age now, I really am more interested in TODAY.

I then very much 'got into' 'Validation Therapy', which as I see it is an attempt to enter into the person with more severe cognitive impairment's reality, rather than dragging them back into ours. At its most extreme, it is NOT saying 'Ah, but you're 80 now so of course your mother has gone!' (so don't bother looking for her!!), but rather entering into meaningful dialogue about life at home with mother (when things were better) as a means to reassure and divert from current distress.

Validating a person's feelings is essential ("Thank you. You do get it!), developing empathy for their reality is crucial ("You really do understand where I am coming from!") and entering into meaningful dialogue based on life review is critical ("You seem to know a little about me. I think I can trust you!"). But isn't this all something we should be doing everyday within ALL our relationships both inside and outside the work place? Isn't this just BEING KIND - something that we should all aspire to be?

So what about 'Cognitive Stimulation Therapy' (CST), or my take on it at least? In a nutshell, I think it embraces the best bits of all the three above approaches and adds in some 'Multi-Sensory Therapy' to complete the approach.

But what is DIFFERENT about it?

Well, I think it respects the person living with cognitive impairment as they are NOW. It focuses on inclusion and enjoyment and values differences - different levels of impairment, different lifestyles, different experiences, different skills.

What I LOVE about it?

... is that, if done well, it can result in fun and laughter, story-telling, singing and dancing and creative activities. Rather than focusing solely on the past, it relates the past to the present and celebrates here and now participation and achievement, that is to say PRESERVED AND NEW SKILLS. It is NOT about competition, but rather 'having a go'.


I think people (sometimes) get 'hung up on' having a group of similar skills (or impairment). In my view, this is a mistake. Feeling excluded from a group because you have progressed in your illness is yet another 'kick in the teeth'. Rather, your facilitator (multiple skilled persons required) should aim to provide 1:1 support if SOME of the group stuff is not enjoyed by an individual.

The skill of the CST facilitator is to 'read the group'. What is working well? What is not connecting? Are any members disengaging? Adjusting session content, by reducing or simplifying it is often necessary. And the great art of the facilitator is to make EVERYONE feel as if they have participated and achieved by the end of the session. This can involve reaching out to quieter (or more communication impaired) members and giving clues, prompts and nudges that help engagement.

Here is an example.

Q. What is this Hollywood movie star's name?

What was she famous for?

What films did she star in?

Who did she sing 'Happy Birthday' to in 1964?

Okay, give a clue - Do you recognise this movie star? Her first name was Marilyn?

Simplify it - This Hollywood movie star's name will be on the tip of your tongue. It's Marliyn ... Mon...?

Nudge it - Let's have a look at this video clip of her singing 'Diamonds Are A Girl's Best Friend' and 'Happy Birthday Mr President'.

My next KEY is Music, Music, Music. Okay, we all love music, or at least SOME music. Personalised Playlists have a MASSIVE place in dementia care and can really enhance well-being, especially if there is meaningful engagement with another and multi-sensory approaches such as video, gesture, movement, singing and dance running alongside it.

But beyond this, it is a PROVEN FACT that musical memory can be better preserved than semantic memory and there are lots of videos out there showing people with more advanced cognitive impairment engaging with tune, rhythm and even lyrics whilst connecting with spoken words is more difficult. THUS making CST activities MUSIC INCLUSIVE is vital.

Another important final clue is making CST sessions have SOMETHING FOR EVERYONE. Some members might engage better with the quiz type approach. Others may value story-telling more. Some people might rely more on gesture and enjoy music clips more. Others may be more creative individuals and enjoy getting stuck into painting, baking or gardening.

PLANNING YOUR SESSION based on what has previously worked well can really help.

As you will know from my CST Blog, having a weekly theme to hang everything on can help avoid repetition and add an important aspect of orientation.

My FINAL CLUE is BE CAREFUL not to fall into the trap of me = knowledgeable helper (parentlike role), you = memory impaired and differently abled other (childlike role). AVOID US AND THEM. We are all adults in the room. We all have our own strengths and vulnerabilities. People can get caught up in over simplification of content, but cognitive impairment DOES NOT have anything to do with intelligence or lived experience. AIM HIGH with content, but be prepared to adjust according to engagement and enjoyment, as above.

And my FINAL FINAL KEY is EVALUATE (well, sort of!). Check how people are feeling at the end of your session. Ask for immediate feedback. If people leave your session feeling uplifted then that is EVERYTHING.

As Maya Angelou once said "I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."

And this is a VERY important lesson for us all. MOMENTS OF PLEASURE can add up to A BETTER DAY.



I would welcome feedback on this short article. Let's keep the conversation going.


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