The Silent Epidemic

Some of you may have heard a recent visitor from the UK – Graham Stokes, a Neurologist. He spoke to many groups about the huge increase world wide in dementia that is going to happen oveer the next 40 years.

He cited many factors amongst them an increasingly long lived population, the “Baby Boomers” population bulge and better methods of diagnosis. It is not that rates of incodence of the condition are increasing, just that there will be a larger group from which people will develop the disease.

He made it very clear that this is not a psychiatric condition but a neuorolgical condition, something that we are not always clear about even now.

The points he made were very clear. There will not be enough beds to cope with the level of need.

There will need to be better supports for families and carers in the community. It will not be possible to rely on “The Family” to automatically take on the very real burden of care because our society is changing so much. Women tend to marry men older than themselves and if a marriage is not providing what they want many are now divorcing in their 50's and 60's. Second relationships do not have the same level of establishment so if a partner becomes ill there is not the same commitment to taking on caring for them.

We have another change in that children are economically dependent on their families for much longer. A combination of student debt, economic conditions in general and a much later date for settling down compared to previous generations.

We are already seeing calls for the retirement age to be raised. A result from this will be that in some cases people who might have taken on care will still be at work.

None of this paints a pretty picture but there are things that can be done. And we need to start now before the full force of this epidemic hits.

Dramatherapy can help both the person diagnosed and their families and care givers. It is much easier to cope with the memory loss if the person is not depressed withdrawn or angry, if they communicate although not from the past. Using this therapuetic approach benefits the individuals,and their families and enables them to stay in their community for longer whether it be home or the retirement village they have chosen.

We can do something that is positive in all directions, personally, socially and economically.

But we need to act before we get overwhelmed.

All those people who paid for the infrastructure we have now deserve better.

Today's teenagers will not be thinking about this yet but when they do get old – and they are likely to live even longer, they might just be grateful for having good standards of care well established.

Speaking the same language

One of the most important challenges any therapist faces is communicating effectively with their client.. We work hard to understand their context, their philosophy, their world view so that our interaction is effective. This is important when people are from similar settings, sharing the same cultural context. It pays not to make any assumptions as always. Oscar Wilde commented that England and The United States of America were two countries divided by a single language.

What makes dramatherapy so effective is that it isn't tied to language or complex cultural norms.

It's about being creative, working with the clients' imagination, working with them through the way they play. Play and fun a pretty much universal. Imagination is not a cultural specific although true respect for anyone mandates respect for their culture.

We saw this today wonderfully illustarted by two Samoan ladies who do not speak a lot of English. We were greatly helped by having someone to go over what we were discussing with the group in Samoan but the actions that followed were a tonic for every one.

The story created was about a trip to Samoa on a Sunday - so off to church for a blessing and then to the picnic. One lady stood and danced a beautiful slow hula and then the other sang. Everyone in the group loved it.

In another story, a Maori lady who has severe cognitive impairment and only uses a few words of Te Reo dressed up, followed all the movements, and sat with a beaming smile.

Of course culture is enormously important and we look forward to a time when we have enough drama therapists who are fluent in Te Reo, Samoan or whatever languages we need but until then it is so heartening to know that we can connect through creative thinking and action.

A few thoughts...

I just got back from our first session with a new group, using drama therapy for people living with dementia.

It was incredible. When you practice drama therapy, you have your own expectations and goals but you can never exactly predict what will happen.

Today was beyond my expectations ... to see someone with very limited motor skills (this person had two carers stabilising her when she arrived), be able to get out of her chair and cross the room by herself, to be part of a story being acted out was inspiring. The power and persistence that was shown was simply amazing.

Roll on next week to be blown away again! If there was ever a need at times to motivate us to do what we do, sessions like today’s was all the reason necessary.

Gibberish or Double Dutch?

Communication is the key to working through personal issues and interacting with society.

If we no longer can communicate, we become depressed and isolated. But often our feelings are misunderstood or unacknowledged. Are we simply speaking gibberish? Do we expect too much of others in requiring them to read between the lines?

The difficulties with communication are compounded where a person has a disability (eg Autism, ID) or an illness (eg Dementia). In these instances, difficulties arise as a result of some type of barrier (intellectual or physical) between the person trying to communicate, and the person on the receiving end trying to understand the message being given.

Drama therapy helps remove barriers and allows people to express (or communicate) their issues and feelings, and give them form - often indirectly. A drama therapist is trained to read between those lines and help the client interpret what they express in therapy.

A person might create a story about an angry boss, firing an employee. This could represent a feeling of needing control, or being allowed to vent frustration and anger.

For those that are non-verbal, drama therapy provides the opportunity to use mime and gesture to convey their needs. The therapist’s response validates those actions and empowers the person. A growling lion will scare the duck (representing in a different way the same feelings as the angry boss firing an employee in the example above). Purring noises being an indication of needing to be accepted and loved.

Through positive reinforcement (e.g. responding to the person’s particular way of communicating (and teaching others how to similarly respond)), a person will start to become more interested in trying to communicate. For example, those with Dementia come out of their state of isolation, and start to get interested once again in the world around them - starting with forming sounds, they move on to seeking to initiate contact, and often begin to use words again.

By making an effort to understand apparent gibberish (in some cases, be it growling, shushing, or tapping) and seeking to remove barriers to communication, we might open up a whole new and rewarding world for all involved.

Happy Families

This is a quick reflection on how families cope when a beloved member gets dementia. It takes a while to work out what is happening. When we are close to people we often don't notice changes for a long time. Eventually we realise that things are not as they should be. Diagnosis is not always easy or clear cut. We can get aggravated by behaviours that we think are unnecessary or could be controlled with a little effort. It is all too easy to get into a pattern of being irritated, angry and resentful. We forget who the person was for most of their life and see them only as how they are now.

Sometimes when someone has a terminal illness people feel it is almost easier to behave as though that person was already dead and gone from their lives. This can also happen with dementia.

And yet how much time and pleasure in that person's company is stolen from families if this happens?

We need to be supporting families who struggle to care for a dementia sufferer. At least in a hopsital setting, staff work in shifts, have a life outside and however poorly paid at times have the choice of being there. Likewise the amazing community groups who offer respite care at day centres. They still have the opportunity to be elsewhere.

Families have no such choice. Regardless of the relationships that existed before – good, bad or indifferent, there is an expectation that the family will provide.

It is much more likely that a family will find the energy and willpower to do this if they can interact with their relative with dementia in a meaningful way, a way that gives them something positive not just frustration and grief.

Dramatherapy can give that positive contact. Of course it isn't going to bring back the original person but they will see someone interesting with something to say, original ideas and thoughts and a person in their own right.

We hope that in time this method will be available to family members to enhance their relationship or even build a new one.

Everyone deserves the right to make the best of a really tough situation, not just have to keep coping with what must seem a hopeless situation.

There is a better way.

The ripple effect

As with any therapy form, drama therapy also has a ripple effect. You treat the person, and automatically family, school, work, and the wider community will benefit from the effects drama therapy offers.

System theory explains it all. Change one element, and the rest automatically has to change as well.

It is great to hear the stories from families, and the people involved in their lives, of the benefits that drama therapy has brought for all of them.

A while back, Linda and I ran a drama therapy program at a dementia day centre. The effects of the therapy were not only noted in relation to the clients. We also received feedback of the changes for the caregivers and the clients’ families. As a result of breaking the isolation felt by the clients, they started to re-engage with the people around them - newly established communication skills (expression, empathy and in some cases, speech) allowed for positive communication and reciprocity. Families got to see and reconnect with their loved ones again, aggressive behaviours diminished and mobility skills improved, allowing for meaningful participation in the community.

By way of another example, a previous client with Autism diagnosis, through drama therapy was able to become engaged in meaningful employment. The client went from being unable to participate in the community, due to fear and depression, to being a productive member of society.

Sometimes it is possible to become so focussed with a client that you tend to forget (or not realise) the changes that drama therapy makes to many people lives, over and above the client that you are directly working with. Whenever a difficulty is encountered in a client’s progress, it is often inspiring to look at the bigger picture and recognise this ripple effect, to appreciate that any short term challenges are just a step on the way to bringing changes for the better in many people’s lives.

Live in the moment

Following on from thinking about saying “Yes” more and taking more risks, I started to think about how dementia sufferes have to live in the moment. Memory loss ensures this. We seem to interpret this as a huge negative – and for others it may well be. But for the person concerned, if we can learn to value this and respond positively to it, how much better would their lives be?

Most of us are mindful of consequences – it's a good way to ensure survival – but have we moved past this to letting ourselves be inhibited in the present by always thinking ahead?

I was told possibly the most positive thing I have ever heard around dementia from the son of a lady with considerable memory loss. He said that, at first, visiting her in the safe home had been a huge trial. He and his wife had cared for mum for as long as they could but work and young children made this an impossibility. They felt guilty at “Giving up” but exhaustion was damaging them, their children and their relationship. The first visits were a nightmare of trying to talk, trying to keep a mother and son relationship alive. Then he realised, that was gone. It hurt but the next time he saw his Mum he just went with whatever she said. She was so much more relaxed and he began to see a lovely woman, not his Mum but a lovely person. A couple of visits later she told him it was great to talk to him because he was a good listener. She said that another man used to come but he was always thinking about other things and was never really interested in her. He did check with the carers but as he guessed, he was the only man visiting.

He said that learning from his Mum to stay with what is in front of you was a huge gift. It works for him as a father and as a manager.

We have to analyse and plan ahead but unless that is the purpose of our being with others, let's stay focused on the real people.

It all comes down to being with the living person you are with rather than the imaginary outcomes in your head.  

Taking a chance

I’m a cautious person by nature and experience. Much of my my training is about making progress slowly and carefully although it is also about going with the moment, working with “now” but sometimes that can get overlooked.
People living with dementia don’t have a lot of time to make slow, ordered progress. They can’t take time to build trust. Their world is immediate and often short lived in terms of memory. yet they are a shining example of willingness to take risks when there is some fun attached. I am continually amazed and impressed by their willingness to try anything imaginative with little knowledge of where it may go or what it might involve. There is some initial caution from some - quite right too -but all of them quickly get involved, share ideas and get stuck in. They embrace play in a way most of us take time to get to.
We can argue that their sense of self is different, they are less embarrassed by others’ potential opinion, but that is not always so.They say yes when they could say no.
This week the news featured an item on those whose memory it total. They forget nothing and have complete and instant recall. The impressive thing about them was that they approached every day thinking “I must make this count because it will always be with me.
At both ends of the memory spectrum there are people willing to take chances because that is where the true quality of their life is for them.
The action methods we use are such fun. The impact on me that working with people with dementia has had is totally positive. They have taught me that saying yes and taking a chance is so much more rewarding than standing in my own way. I haven’t seen the Jim Carey movie about saying yes yet but can I encourage all of us to say yes rather than no if at all possible?
Of course we shouldn’t take foolish risks. Most of us learn to assess risks once we make it through adolescence and realise we aren’t invincible. But then we stop a lot of our play.
using Improv, puppets and drama takes a long time with other groups because they have to get past their inner fogey saying “Don’t make a fool of yourself”.
The most fun I’ve had at work has come from doing just that. And when we do get groups past that barrier they grow and progress so fast.
So, don’t start climbing mountains, bungy jumping or going on the stage- unless you want to, but say yes to as many things as you can and see where it takes you.

Marching to the same beat

This week was hugely exciting. Research undertaken with people with Parkinson’s Disease was published showing that with active methods, improvements to their lives in several areas can be made. The researchers at Roehampton University in the UK showed that when dancers worked with those having Parkinson’s, they grew in confidence, in their actual ability to move more and with more control over those movements. The dancers worked with the group to teach them ballet steps and movement to music. The fact that the dancers were from the English National Ballet was the icing on the cake.
There is much to be considered here. Even moving more and in positions that allow the lungs better movement will always help. More oxygen to our bodies can only be a plus when we make that increase through our own efforts. But this work goes a long way past this. The rhythm, the music and the imagination that goes into dance is stimulating many different parts of the brain.
The results that have been found here bear a close resemblance to those achieved using dramatherapy with the disabled, autism and those with dementia. The increase in confidence, in feeling less anxious and in the ability to interact are rapid and make a huge difference to the lives of those affected by such conditions - not to mention their families and friends.
One of my many happy memories is of a man who started out re-enacting gangster or cowboy movies. He ended by doing the haka for us. For non kiwis that’s the challenge given to important guests as they arrive, a mark of respect but intimidating. To see someone who had only sat in a chair do this, unable to walk except with a stick very slowly, on his feet unaided at full volume was uplifting. And he told us after that this was his gift to us.
We have the opportunity to do that research here, before the arrival of, what the current Minister of Health, Tony Ryall, has described as, the next major threat to our health system. That is the huge increase in those diagnosed with Alzheimers and dementia that will come with our aging population. It is already starting and in a small country like ours we do not have the resources to deal with this.
Let’s invest in some work that does offer positive results. So many people who are affected directly or have family or friends affected by illness that affects memory ,movement or interaction have indicated that they give up in despair because they lost hope. Here is a way that is safe, fun and rapidly beneficial and we haven’t even begun to explore its’ full potential.
Whoever you are, dance, sing, make up stories this week. Do it for yourself, for fun and take a moment to reflect on how much it could help so many.

The Past is Another Country

One of the hardest things any person or family faces when someone they love has dementia is that the person they love is physically there but the personality is gone. Many struggle with this. They believe “If only” the person tried hard enough or was reminded enough memories would return. It can become an agonising struggle for all. There is no chance of any outcome other than frustration on both sides and increased anxiety for all.
It is understandable that often people walk away or find contact very difficult.
One of the most positive aspects of drama therapy in these circumstances is that it offers a relaxed, fun way to reconnect. Often we base our knowledge of older people on who they are right now, forgetting that they have lived long, full lives. The recent upsurge in interest in genealogy shows that many of us are interested in the past yet how many of us really know our parents and older relations? We may think we do because they may well have repeated many stories but it is often amazing to find out just what they have achieved.
Last year the community based group we worked with had a huge and varied history. Fortunately the people working with the group knew them well and had recorded their individual histories.
It is these earlier memories that are clear and thus accessible. These are the memories that people share when we are developing stories with them. It is so much more powerful if we know what these memories relate to.
It is almost miraculous to watch someone engage who has been totally detached and uncommunicative. When we enter their world, even if it is one from many years ago, we are there with them. It is familiar to them so not a source of worry. It puts them in control at a time when the world may feel very confusing and scary. I loved the quiet man who got asked to do a song in one of the plays and produced not just a pop song but a stunning operatic aria. His family knew of this but felt it might be painful for him to remember as he now no longer sang. The smile on his face as we all applauded said this was an area to talk about with joy. Each person had huge talents and their own fascinating experiences.
An additional bonus is that when families get involved they can continue a relationship that is positive and not a burden. They sometimes learn new things about a person they thought held no surprises. They get to enjoy being with the person again. Being relaxed and happy is something we all benefit from.
Making it easier for them to stay at home for as long as possible can only be an advantage. A more positive relationship is good for the individual but think what it could do for loving but currently exhausted care-giving families.
This is one of the areas we are keen to do more research in. This method is non invasive, does no harm and is fun. And it improves daily life for all using it.
There is nothing to lose for any of us and everything to gain.
We hope to offer a programme for people and their families in the community soon so keep watching – get to know your family and have as much fun as you can.

Expressing Emotion – Clients with an ASD, ID, Alzheimer’s Diagnosis

Expressing emotions in therapy is one of the hardest things to do for many people. We are taught from a young age to keep our emotions in check. This is certainly true in New Zealand. We have the attitude that we can fix it all ourselves (the No.8 wire mentality). Allowing clients to act out their feelings in play using characters, helps them express pent up emotions. Using the hierarchy of needs method – allowing people to express what is on top, allows them to explore what is underneath.

Often conventional therapies (like classic CBT, psycho-analysis, etc) are not suitable for our client group, as you need a certain level of cognitive ability to participate in these therapies. The clients we work with often can’t describe the feelings they have, process the information the therapist/counsellor gives them, or integrate this and form meaningful responses. Using drama therapy, people can show what they feel, experiment and adjust feelings they have, and reflect upon those feelings from a safe distance. (After all it is the police officer that is angry, not me...) It is internationally proven that drama therapeutic methods are successful when working with people having cognitive disabilities (ASD, ID, Dementia, Alzheimer’s, and head injuries).

Autism, Asperger’s & ID

I found that people with an ASD or ID diagnosis are often confused by the emotions they see in others. It is difficult for them to understand what other people feel because they are confused by the emotions they feel themselves. What often happens is that they categorise feelings into good and bad ones. This might look like this:

Good feelings	Bad feelings
Happy Feeling in love Excitement	Angry Sad Jealous Nervous

They then respond with a planned response. These planned responses are a safety mechanism which happens automatically. A planned response for bad feelings might be putting your hands over your ears and rocking, swearing, punching someone/something, isolating yourself. A good feeling might be to hug a person.

As feeling annoyed is a negative feeling, it will have the same response as being scared. This is very confusing for the community they live in, as it is for them.

In drama therapy, I use many games to practise different emotions, and different intensities of emotion. For example, anger ranges from slightly annoyed to extremely aggressive. Practising these different levels of anger helps people understand the feeling. It also makes it a valid and useful emotion and is no longer just bad. Practising different emotions also allows the client to practice different outcomes. Having alternative responses will help people be more appropriate in their responses.

Dementia & Alzheimer’s

When Linda and I worked with people suffering dementia, we noticed that expressing emotions was difficult for many of the participants - however, it was very important for those clients to let their emotions out. By validating every emotion/action expressed by the participants in drama and giving an immediate response, people came out of their state of isolation. Once the participants allowed themselves to express emotions, it often had a very strong and profound effect. Some people expressed their fear of dying, others found closure of previous experiences. For example, one person revealed the abuse and fear he suffered. Finding peace with his past allowed him to relax more and be less anxious.

We look forward to hearing your experiences in working on emotions with clients with cognitive disabilities in your practices.

Using puppets in drama therapy.

We sometimes use puppets when we work with our client groups. As the photograph shows, our
puppets are quite big, and very human-like.

Linda having a serious get together with some of the puppets...

Dementia
When working with a lady who suffered from dementia, and had lost her speech, using the puppets,
allowed her to re-engage with her environment. I put the puppets on the floor, and looked away
from the lady, pretending to be busy doing something else. With her walking stick she brought
the puppet closer to her. Casually I put the puppet in her lap. She started cradling the puppet, and
when she discovered how to operate the mouth, she started singing to the puppet. Everyone was in
awe, as this lady had not spoken for quite some time, only making grunting noises. As the sessions
progressed the lady started to use her voice more and more. The puppets allowed her to re-engage
with her environment.

Autism – Aspergers
I found that people with an ASD diagnosis sometimes have difficulties understanding the world
they live in. They are often frustrated, as they miss social cues, and unwritten rules. They feel often
isolated. Using puppets they can create social situations in which they can let the puppets practice
different social reactions to problems. For example, what can a puppet do if it wants to play with
another puppet? How do you ask? How do you react when they say no, or do not want to play what
you want to? Having experienced different responses and outcomes, people with ASD diagnosis
can recall these memories when they come into similar situations. Having already practised how to
interact will help them connect with their environment.

Cognitive Impairments (e.g. intellectual disabilities, brain injuries, Cerebral Palsy)
Being able to show people what happened to them, without having to rely on oral language allows
people to look at their issues from a safe distance and express their feelings in a safe environment (it
is the puppet who is frightened...not me...). To see people finding closure to traumatic experiences
using puppets is very rewarding.

Introducing Drama Therapy

Welcome to our new weekly updated blog about drama therapy.

As drama therapy is relatively unknown in New Zealand we decided to make our blog , so drama therapists and people with an interest in using its techniques in New Zealand, and overseas can contribute and share ideas.

As a quick introduction: We are from Wellington, New Zealand, where we work as drama therapists.

We have experience in a diversity of fields, using drama therapeutic and action methods. They include the disability sector (intellectual disabilities, physical disabilities, Aspergers, Autism, brain injury), elderly sector (Alzheimer’s, Dementia, Age Care), mental health sector (post traumatic stress, Depression, Psychosis and Neurosis) and we also use our skills in clinical supervision, management training and team building.

In our weekly updates we will talk about different techniques we use in the different settings/sectors. For example, projective techniques (like masks and puppets) psychodrama with people who have cognitive difficulties, slowing down the deterioration in people suffering dementia, and which techniques we found most successful.

We would also love to hear about your experiences in using drama processes when working with your client-base.

Drama Therapy and Dementia

Hi anyone reading this. Drama Therapy was something I'd used a little – and enjoyed hugely but it wasn't until I had the chance last year to work with Bas that I saw the enormous potential it has in the care of those with dementia.

We worked with a group of elderly – and not so elderly -people with varying degrees of dementia and Alzheimers. When I first met them, some were completely withdrawn or very limited in their communication. It was truly wonderful to see them respond, gain in confidence and start taking a keen interest in what was going on. Those working with them were doing a great job. They really got involved and valued the positive changes. Participants started to remember the sessions and interact more. Aggression decreased considerably.

This all happened just as a report from the Minister of Health was published. This showed the

impact of an ageing population and increased rates of dementia were going to pose an enormous

challenge to the Health sector over the next years.

There is little detailed research in NZ on using Drama Therapy but some very useful information

from the USA on the positive impact on behaviour and the potential reduced need for drugs.

We'll keep you posted as we try to introduce these methods, find some funding for research and

training.

This is one problem we all face potentially as we live longer. I'd like to think there was some fun

ahead for me, whatever the state of my memory. How about you?