Writer, broadcaster and former clinical child psychologist Oliver James explains the SPECAL approach to helping people with dementia (Specialised Early Care for Alzheimer’s). This was initially developed by his mother in law while working with older people at a local community hospital.
The starting point is the hypothesis that most problems for people with dementia are due to problems storing new information and that focusing on new information can be both confusing and emotionally threatening. The aim is therefore to find key elements from their long term memory to help people with dementia make sense of the present and, along the way, create what the author describes as ‘24 hour wrap around care’. The result may be what James describes as a ‘like a happy version of the film Groundhog Day’ – but at least he sees it as a happy version.
There are three golden rules within SPECAL ie:
Don’t ask questions (as this moves the person with dementia into dangerous ‘new information’ territory).
Learn from them, as the experts on their disability.
Always agree with them, never interrupting them(as dementia can leave people feeling confused and upset, so helping them feel they are still in control can help them retain emotional stability).
To make the most of the person’s long term memory, SPECAL recommends that three aspects are identified ie:
A Primary Theme (an area of significant interest and achievement from earlier in their lives, which they used to do a lot and talk about) as a focus for continued conversation and engagement.
A Health Theme (a former medical problem which was successfully treated) as an example of a time when they acknowledged relying on others, which may need to be drawn on to manage essential everyday activities, like eating and sleeping.
An Acceptable Explanation for people being present or absent (often rooted in past memories) to avoid unnecessary alarm.
James recognises that this approach may not be easy and provides a range of examples and case studies as to how this might work in practice, including how to build a ‘team’ of carers following the SPECAL approach, to maintain continuity of support.
He recognises that some people may find the SPECAL approach counterintuitive (not least health professionals used to asking questions) or be uncomfortable with aspects, seeing it, for instance, as deceitful. However, he draws a number of parallels with the way parents talk to young children, in order to nurture and protect them (and Shakespeare described old age as a second childhood).
The range of examples James provides is persuasive, although there is no reference to clinical trials, and on its publication Contented Dementia was well received in the national press. At the same time it has also received some critical responses. The Alzheimer’s Society for instance, recognises merit in the emphasis on the value of good communication and the need to evidence-base what works best. However, it also raises a number of serious reservations. The recommendation not to ask questions is seen as, ‘contrary to all that is enshrined within the Mental Capacity Act,’ because it takes away choice and control from people with dementia; and the review concludes, ‘It is just one psychosocial intervention in the therapeutic toolkit and, as with many interventions that have aspirations to be a 'model', it is flawed.’
Criticisms from other reviewers include that this is a simplistic, one size fits all approach whereas there are a number of different types of dementia; that the assertion that people with dementia are the experts in their disability is flawed; and that others (like the late Tom Kitwood in Dementia Reconsidered or Dawn Brooker in Person-Centred Dementia Care) have already provided more perceptive insights.
Conversely, quite a number of carers seem to have found the SPECAL approach effective and tend to view some of the criticisms of the approach as more to do with political correctness. One carer reviewing the book on Amazon wrote, ‘So what if it seems like "infantilising" the sufferer, who in our experience certainly did not feel we were doing this but who immediately brightened up and was much happier with our new approach.’
However, other carer responses, were more critical. One writing in Alzheimer's Weekly wrote: ‘When we try to avoid giving (my Mom) choices and asking questions, she gets so mentally lazy, wanting to blob-out and do nothing. When we engage her and ask questions and discuss options, she still gets into it much of the time. One can see the questions and choices work her mind, make her more alert and "with-it" and "exercise" her brain.’
Contented Dementia raises important questions – and it would be good to see rigorous research undertaken to clarify how effective it is relative to other approaches to helping people with dementia.
Contented Dementia: Oliver James - Random House Group ISBN 9780091901813