Clarifying
Ensuring understanding
Exploring
Information gathering
Moderating
Maintaining flow of conversation
Validating
Recognising feelings
Rescuing
Seeking relevance in (isolated/non-connected) statements
Discourse markers
Social conventions (ok, I see, thank-you, uh-huh, etc.)
Connecting
Drawing on personal information to extend links/bonds
Positive communication entails understanding the individual’s view of the world without necessarily entering or colluding with it. Note in the above section how validating, for instance, focuses on the patient’s emotional and affective state. It does not encompass their view of the world. Similarly, in the above model, moderation is intended to keep the flow of the discussion going rather than shutting it down, which may be the case if we simply try to reorient the individual to ‘reality’. Positive communication disregards, to some degree, the words said, and instead, and seeks to find the underlying need behind the words. Returning to our previous example of the married couple, using positive communication as a tool, we would consider the need of the individual as they become anxious about their children. The underlying need, in this example, might be a need for comfort and reassurance. Reassuring the individual their children are safe and well might relieve their anxiety and prevent further agitation. It might require interaction from the caregiver in terms of reassuring words and physical comfort, or it might require distraction first, but once the underlying need is met, the individual is more likely to settle.
The basic communication tools of exploring and clarifying are now coupled with validating and connecting. Validation, or acknowledging the individual’s feelings, is an important part of reassuring them that their concerns are being taken seriously. Drawing upon our knowledge of the individual, we can then connect on a very personal level to understand their need. To do this, we neither have to agree with their reality nor disagree. We only have to try to understand it. Once we have recognised the underlying need, we can acknowledge that the individual is anxious and can provide encouragement and support without either reinforcing or challenging their view of the world. For example:
‘Peggy Smith’ has been living with dementia for 4 years. She is 89 years of age and becoming anxious for her son. She believes him to be in school and that she needs to collect him. It is 10 o’clock at night, and it is cold, raining and dark outside. She is dressed lightly and was preparing for bed before becoming distracted about her son’s welfare. For her own safety, she needs to stay indoors.
If we deceive Mrs Smith by suggesting that her son has been collected by someone else, we are not necessarily meeting her underlying need, as she has no evidence for this, or his safety, and may not therefore be reassured. If we attempt reorientation by explaining that her son is now himself retired, we might fail to convince her and still not meet her needs.
By recognising and meeting her needs, we stand a better chance of reducing the risk to Peggy. In this example, acknowledging her concerns would be a good first step. A distraction technique might then be employed, allowing time in which to provide the reassurance and comfort she actually needs.
Therefore, we can ask the following questions:
What does the individual need?
What is their reality at the moment?
These questions can be answered by exploring and clarifying the communication. Once we understand these, we can then validate the communication by acknowledging the person’s need and connect with them using what we know about them and their needs.
For ‘Peggy Smith’, the interaction might look something like this:
Individual | Communication | Interpretation |
|---|---|---|
Mrs Smith | I have to pick up my son from school | I am anxious and concerned |
Caregiver | Why is that? | Exploring the need |
Mrs Smith | It’s getting late and he’ll be worried! | Clarification of the need |
Caregiver | I understand – I have children too | Validating (acknowledging) the concern |
Mrs Smith | He needs me, he’ll be worried! | Clarification of the need |
Caregiver | It is cold and wet outside. Why don’t we have a nice cup of tea before we go? | Distraction creating time to connect |
Mrs Smith | Maybe just a quick one | Trust in the relationship |
Caregiver | <Sits down next to Mrs Smith with cup of tea> Why don’t you tell me a bit about your son? | Connecting to meet Mrs Smith’s need: finding time to reassure and comfort |
Mrs Smith | Well… |
During the course of the conversation, Mrs Smith might recall other events of her and her son’s lives, perhaps his graduation or wedding, minimising her natural concern for the safety of her ‘school boy’ son. Clearly, this is a contrived example. Real-life situations have many more variables and often take place over longer timescales, but it demonstrates the concept that in communication, we should consider not just what is said, but seek a deeper understanding of what needs the words express. This calls for a high degree of patience and attentiveness, or, in other words, effective listening.
9.7 Effective Listening
Effective listening is an essential communication technique that requires skills in listening, empathy and trust. Effective listening includes ideas of ‘active’ listening, understanding and interpreting the needs of another person correctly, and responding appropriately and effectively to that need (Shipley 2010; Doas 2015). Active listening is therefore a planned and deliberate act which demands the full attention of the listener (Stickley and Freshwater 2006). It requires them to be alert to what is said and how it is said, without necessarily forming judgements. Key to active listening is allowing the individual to speak in their own terms, at their own pace. This may require discourse markers such as ‘uh-huh’ or ‘I see’ in order to show attentiveness and enable the speaker to continue, but should avoid potentially judgemental terms such as ‘don’t worry’ or ‘it’ll be alright’ that might appear to discount the value of what is said. To ensure understanding, the communication needs to be reflected back to the individual. The conversation might be paraphrased or summarised; but the basis of the individual’s need and their feelings should be included in this summary. By restating the content, both the individual and the carer can be reassured that the communication has been understood clearly (Shipley 2010). It also allows for modification of understanding where required. Clearly, this needs to be done in such a way as to not appear patronising, and part of the skill in effective listening is in achieving a ‘natural flow’ to the conversation. There are ways in which we can demonstrate active listening, and caregivers should be well rehearsed in both verbal and non-verbal skills:
Verbal
− Open-ended questions
− Exploring problems rather than ‘leaping’ in to solve them
− Reflecting communication back to the individual
− Non-judgemental
− Tone of voice
Non-verbal
− Eye contact
− Adopting a mirrored position
− Open gestures
− Close proximity
(Stickley and Freshwater 2006)
Non-verbal skills are an essential component in achieving rapport. Good non-verbal skills demonstrate to the individual that they are being listened to (Bryant 2009) and that they have your full attention. As with reflecting, non-verbal communication that is forced may appear patronising, so care needs to be taken to find the ‘gentle attentiveness’ that signals attention. For example, mirroring the individual’s position can seem artificial or pretentious if followed too rigidly resulting in a lack of trust. Performed mindfully, mirroring can reinforce conscientious attentiveness and help build trust.
Similarly, the non-verbal cues that can be picked up from the individual are significant when trying to find the underlying need in their communication (Jootun and McGhee 2011). Facial expressions, body language and the emotional context of the communication may all provide indication of need. The difficulty when communicating with a person affected by dementia, however, is in interpreting non-verbal cues correctly when the verbal content of the conversation may be confusing or misleading. One way to achieve this is to ensure that an overall picture is considered rather than any specific cue. A grimace in itself may not present a need, but may, with other signs, provide a guide to further exploration. In this way, using both verbal and non-verbal indicators, effective listening allows us to respond appropriately to the individual’s needs.
9.8 Person-Centred Communication
Person-centred communication is an approach in which the abilities of the individual, rather than their impairment, are considered before and during communication (Downs and Collins 2015). Communication difficulties are likely to increase as the disease progresses, and it is therefore important to understand the context of the communication in order to support the individual. This is achieved by having as full an understanding of the individual as possible in order to respond appropriately, allowing them time in which to respond and enabling them to make choices about their communication.
9.8.1 Know the Person
People communicate using different terms, a variety in language and using a wide range of non-verbal indicators. They may have different understandings of the world based on completely different experiences in life to ours. Of critical importance, in any communication with a person affected by dementia, is to know the individual you are communicating with as fully as possible (Lindholm 2015). Whilst this is not always possible, the better informed you are, the more likely you are to understand their underlying need. In some cases, it may be possible to access detailed information (e.g. a life history album), or it may be the case that the individual is the only source of information and all information is new or incomplete. Gaining insight to their needs will be more likely however, the more you find out about them (Downs and Collins 2015).
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