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Therapeutic Use of Self: How to Facilitate Positive Behaviors in Someone With Dementia

therapeutic use of self
Never underestimate the powerful impact you can have on others—particularly those you provide care for. Understanding your potential to influence the emotional experiences, and, in turn, the behavior expressions of your residents is an essential step to providing quality dementia care.


Earning trust


A key approach for facilitating positive interactions in the nursing home is gaining each resident’s agreement to participate in his or her care experience—a feat that can only be accomplished if care partners are able to develop a trusting relationship with all of the individuals they serve—including those with conditions that are known to produce challenging symptoms.

I have been specializing in dementia care as an occupational therapist for a while now, and my appreciation and understanding of the impact we have on patients and their behavior responses grows exponentially every year.

During my time in the industry, I’ve heard many variations of, “Mrs. Jones will do this activity for you, but not for me.”

The reason behind such preferences is often quite simple: A particular staff member might not have gained the resident’s trust, or has failed to alleviate a negative behavior expression by not addressing its source.

We must all recognize and take responsibility for the profound impact we have on residents and their behaviors. As a care partner, YOU are the most important tool or modality to facilitate a positive care experience, and you have many responsibilities that impact a resident’s outcome. For example, you must clearly demonstrate respect for residents. In addition, you must:
 
  • Maintain their dignity and privacy
  • Avoid taking control or choice away
  • Work to maintain comfort
  • Show sincere concern for their well-being and appreciation for their company

Essentially, you must be a chameleon, adapting your approach to providing care based on what an individual resident needs from you at a given time to feel safe, supported, and successful. Glean specific cues and strategies from those who know each resident best and by taking notes on your own experiences and observations. Integrate all that you’ve learned into each care interaction.


Recognizing behavior triggers


People with chronic, progressive dementias such as Alzheimer’s disease often demonstrate negative behavior symptoms such as agitation, aggression, resistance to care, sundowning (i.e., worsening symptoms as the day wears on), and anxiety.

While these symptoms may be common, they are often caused by a certain trigger and can therefore be mitigated. To alleviate a resident’s negative expression, you must figure out why it occurred in the first place.
 
To alleviate a negative behavior, figure out why it occurred in the first place.

Research suggests that up to 90% of dementia-related behaviors have a specific trigger. Oftentimes, they are a response to something the staff member is or isn’t doing, something in the environment that is bothersome, or something internal that is annoying to the individual.

Therefore, it's important to ask yourself, “What want, need, or problem is this person trying to convey?”
 

Potential Causes of Common Behaviors Among Residents With Dementia

Behavior Potential Causes
Agitation • Undetected or unmanaged pain
• Unmet needs (e.g., boredom, the need to use the bathroom, feeling cold)
• Feeling helpless or hopeless due to declines in control or autonomy
Anxiety • Lack of knowledge about what’s going to happen or where to go
• Feeling unsafe in the environment or with a care partner
Resistance to care • Feeling frightened, violated, or out of control
Sundowning • Exceeded stress threshold (e.g., due to exhaustion or overstimulation)

In addition to these general triggers, there's also a significant amount of research that suggests a direct cause-and-effect relationship between negative behaviors and a caregiver’s approach to providing services.

For example, in a 2005 article in BMC Geriatrics titled Prevalence of Physical and Verbal Aggressive Behaviors and Associated Factors Among Older Adults in Long-Term Care Facilities, researchers describe care processes and practices that can contribute to aggressive behavior and/or resistance to care—most notably physical and chemical restraint usage.

In addition, the authors cite research that posits that aggressive behavior most often occurs when nursing staff are helping with ADLs, which can cause residents to feel threatened if they perceive their personal space or privacy is being violated.
 
People with #dementia feel threatened if they perceive their privacy is being violated.

Based on these findings, aggressive behavior appears to be a defensive reaction. However, when staff members don’t understand this rationale, they can react inappropriately, fueling additional expressions of verbal or physical aggression, and ultimately causing the cycle to repeat.
 

Therapeutic use of self


After identifying what is causing a resident to express a negative behavior, a staff member must explore what he or she can do to help the individual feel better.

Whether the adverse behavior is triggered by a resident’s personal characteristics, the environment, or the caregiver’s own actions, the objective remains the same: to remove the trigger, thereby alleviating the negative expression and improving the individual’s well-being.

This concept of using one’s own actions to effect positive change for a resident is known as the “therapeutic use of self,” and has long been described in occupational therapy literature.

In her 1986 book, Psychosocial Components of Occupational Therapy, Ann Cronin Mosey writes that the conscious use of self enables someone to become “an effective tool in the evaluation and intervention process” by initiating “a planned interaction with another person in order to alleviate fear or anxiety, provide reassurance, obtain necessary information, provide information, give advice, and assist the other individual to gain more appreciation of, more expression of, and more functional use of his or her latent inner resources.”

Because of this striking ability to foster positive experiences, caregivers must never push through a care task just to get it done. Instead, they should be cognizant of the fact that they are caring for another human being—an activity that, if approached strategically, can enhance the individual’s self-esteem, improve his or her level of independence, and as a byproduct, facilitate better health.
 
Don't push thru a care task just to get it done. Remember you're caring 4 a human being.

In this way, the success of a resident’s outcome often lies in the hands of his or her care partners and the long-term care facility’s leadership. Without a strong commitment to promoting comfort, privacy, respect, and trust for all residents, the care provided can be detrimental—a fact that will often be reflected in the individual’s behavior expressions.

Therefore, it is imperative that we strive to create a care experience that enables each resident to feel safe, valued, and successful. This strategy can also minimize the negative feelings that underlie so many of the adverse behaviors we regularly encounter.

What can be more rewarding?

Editor’s note: This article originally appeared in Dementia-Capable Care Insights, a column by Kim Warchol, OTR/L, DCCT, featured in HCPro’s PPS Alert for Long-Term Care. Reprinted with permission from HCPro, Volume 18, Issue 4, April 2015. Download a PDF of the article.  

More Resources:
Therapeutic Use of Self: The Concept of Action and Reaction in Dementia Care
How to Manage Combative Alzheimer's Behavior Without Drugs
How to Establish Dementia Care Best Practices and Why They Matter
Dementia Care Training
 
 
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