2 ALZHEIMER’S AND DRAMATHERAPY: THE PERSONALITY OF A SYNDROMEIn my experience it is the environment and politics of care spaces that often reflect the inner chaosof the client with Alzheimers disease. The energy in the care spaces can be constantly electric,because of the amount of distress. Not only from the clients but also the staff. Often theenvironment that a client inhabits reflects their inner state.It has always been the case that caring for the elderly has been seen to be an ordinary job. There isa stigma attached. It used to be the kind of job you have if you couldn‟t do anything else. The kind ofjob you have if you are a working mum. You get little reward. The client group is extreme and thetraining very limited to public sector services. Anyone can set up a care home. These often reflectbad pay conditions.Because of the sometimes-poor working conditions staff morale can be low and consequently theclients become marginalized and under-represented. The staff turnover is usually quite high becauseof self-esteem issues, low pay and lack of support. We used to say this is not a good career move.Workers often get assaulted in this environment. Usually there is a number of agency staff becauseof shortages and sickness. This interferes with continuity and the client already confused has to seemany different faces.Clients in this environment have a profound loss of awareness of self. Often they don‟t know wherethey are or who brought them there. There is a significant level of anxiety juxtaposed with a highlevel of frustration. This leads to an equally noticeable point of anger that can erupt very quickly, andwithout warning. Because the intensity of the fragmentation being experienced by the client isunknown, it is an unpredictable situation.It is common for clients to lash out without warning, bite, and kick and verbally abuse people. Thiscan be caused by fear and may be a consequence of a person‟s personality or a consequence of theillness. It is often said that, “my mother has always been very quiet”. And then Mother is seen to beexhibiting extreme behaviours. Life‟s repressions can emerge very strongly here and sometimes it‟sas if permission to act out some of these is given by presumably being out of control. There is a deeplevel of fear within this client group, coupled with the level of fragmentation of personality createsand atmosphere of chaos. Within this chaos is mistrust and therefore it is very difficult for the clientsto have a sense of freedom within an environment that is supposedly safe. Clients often try and leaveraising the anxiety levels of the staff team. Usually there are between 8 – 15 clients at a day centre.Given the levels of distress of these individuals, grouping them together in this way can often causegreater distress. The reflection or projection of degeneration is very evident. Are we therefore trying
3to build an environment of stability out of the duplication of instability? This is very important as weare often thrown into chaos by this environment. So our structures have to be solid.So if we take one care worker and one client and we stand them together we are looking at a workerthat is probably demoralised in some form or other and a client that is fragmenting and is anunknown quantity, due to being unable to verbalise thoughts and feelings in a coherent way.The amount of commitment and effort that the worker requires to help the client to understand whatis happening is continual. The client can be extremely demanding which in turn creates greateranxiety for him or her because he/she often cannot get what they want as it has become too abstracta concept. For example the client may begin to ask questions about a simple matter. I.e. thewhereabouts of the keys to their house. By the end of the conversation, which started out as simple,the client may well have incorporated several different conversations all mixed up together. Theseconversations are difficult to follow and if there are six or seven clients challenging workers withthese types of conversations, concentration becomes a strain. Anxiety increases and the workerbecomes distressed.PoliticsOne of the day services that I worked in, the borough was re-secterising (this means that theborough gets split into bits). I was not told of the splitting in two of the Day Centre provision.Meaning that during my group at least half of my group who lived in the South of the borough wouldbe moving to a new Day Centre. I was not informed of this change until halfway through the process.For the clients this was catastrophic as this effectively meant that they would probably never seeeach other again. Therefore in my thinking the clients were becoming destabilized even further. Littlecompromise was made for the client in terms of the Centre being moved and the group being split;establishing a need to become aware of what was going to happen during the life span of a group.The structural changes of a building can also cause major problems for groups. Where a door used tobe. Now there‟s a wall, for example. Staff change can really affect the dynamics of atmosphere withina space. Room changes can seriously interfere with group safety.I was arriving 1hr early to nearly every session, to establish a connection. The chaotic nature of thisenvironment seemed to change regularly. I became to understand that the client group fluctuated inattendance and the dynamic of the group changed dramatically. This was also the case if the staffteam did not gel together and there were absences.Having to accept the reality of the situation is never an ideal and although I battled with my internalchaos there was nothing that I could do but work within the confines of the presented work. Forexample when we had to work in a cold room we would incorporate this into our drama that day andcreate a cold story or what is it like when it is very cold. This reminded the clients about the war.
4There are a huge amount of other distractions going on whilst trying to contain a very difficult clientgroup.Having to negotiate with: - Day centre managers about who would be the helpers in the group.Respite managers for use of room (two settings contained in one unit. Day centre service and arespite unit). Caretaker about heating. Cook about load music coming from the kitchen, other staffmembers who wanted to take part in sessions.We are primarily dealing with clients that are being systematically de-skilled a) by the effects ofthe disease and b) by the circumstances that progress despite these affects. We have by ourstructuring of society devised certain schemes of support for various client groups. These by thenature of there design can be de-constructive.Dynamics of atmosphereWhen we talk about the dynamics of atmosphere, we are moving into the realms of physics. We aretalking about energy and matter and the effects they have, one on the other. When we walk into anestablishment there is an atmosphere that needs attention. How we respond to this will depend onhow in touch we are with our senses. Initially the response should be one of openness to suggestion.It is all to easy to feel or think that you/I as a Dramatherapist can “fix it”; the truth is we can‟t fixanything we can only draw attention to. So we feel initially helpless and out of control. Theatmosphere will be different each time we go there. Depending on a huge variety of factors. All wecan hope to do is to find a balance for ourselves within the perceived chaos of the environment.My own way of doing this is to set up my „area of play‟ wherever I am to work (this environmentoften requires one to work in the whole space as people wander about, this means the corridoroutside the room and maybe the toilets, people in this environment experience a lot of anxiety andthis often makes them go to the toilet more often than normal). Then I put some music on.I introduce myself and then I sit very still in a strategic position in the space where I am to work. Iwait for the clients to come. Stillness is a very powerful tool in Dramatherapy and helps to settlefluctuating energy. Its what I might call „holding time‟.Energy and matter exist together in a time continuum and if the matter of the human body is heldstill in time then it appears psychically to prevent the movement of energy. This enables the chaoticenergy of the clients and atmosphere to settle briefly and aids stability in time and space.Dramatherapy.
5Alzheimer’s diseaseThe appearance and close examination of the Conscious/ego State maintained by an Alzheimer‟ssufferer reveals certain universal characteristic qualities. The mind goes through a slowtransformation becoming increasingly fragmented leaving the recipient increasingly more confused.In thought process, the mind will always seek to establish meaning. Initial meaning must be foundwithin memory function, since this allows us to bring thought into consciousness. When the mindcan find no meaning within the short-term memory function, which is severely impaired in thisdisease; it begins to fragment or branch, trying to find other channels of meaning.Because brain tissue is decaying, lexical access becomes damaged. (Lexicons are basically internaldictionaries of our life experience). Our general understanding of logical meaning becomesirreversible and chaotic. The short-term memory begins to breakdown, becoming seeminglydetached from consciousness.The division or fragmentation transcends normal functioning to such an extent that the physicaland emotional capacities connected to the cognitive functioning become detached.This might effect: spatial awareness, recognition of environment, recognition of objects and peoplewithin that environment, language retrieval and most of all self and body-awareness, leaving theperson with symptoms such as anxiety, depression, frustration, anger. In some cases thefragmentation is so extreme that the person appears to be detached from reality altogether.Because Alzheimer‟s is one of the forms of dementia, there are related symptoms such asincreasing apathy and inactiveness and eventual cessation of movement altogether, sometimesover a very short period of time.People with Alzheimer‟s find communication very difficult and frustrating because of certainfundamental problems associated with the disease.Disintegration of speech, the collapse of concentration and Confusion related to the breakdown ofinner functions, which are associated with space and time, as well as many other factors.If we imagine for a moment a group of people that have been grouped together in a strange placeall with the symptoms associated with this disease, we are looking at quite a profound level ofde- construction and confusion.
6Because of the affects of this condition, we can be looking at strange behaviour patterns. Thesemay cause added anxieties and fears for clients that are already suffering from acute symptoms.There maybe outbursts of extreme vocalisations, physical gesture, and abusive behaviour that isunfamiliar to other clients. All of these symptoms can be evident in the syndrome that we call"Alzheimer‟s Disease”. Can we sincerely predict a successful community, without some form oftherapeutic intervention?The use of Devised StoriesThe reason that this type of story is so effective is that the structure of the story starts off in a veryfragmented way, which works as a parallel, alongside the diagnostic implications of Alzheimer‟sdisease. The elements of the story slowly emerge as a foundation for the re-membering/connectionof the functions of the short-term memory in particular.The contents of the stories that emerge often include details of past experiences that help theclient stabilise themselves through recognition of their own existence in the world. So the structuredevelops and a story begins to appear, this is constantly repeated and re-affirmed and this isaccepted because of the nature of the story building technique. What appears understandably, tobe constant repetition. What this achieves is a re-membering of the components of the story as weare re-membering the cognitive functioning of the clients, paying particular attention to memory.After some time the clients start to remember parts of the story, this helps them to find aconnection in space and time, in relation to the set time, content, day, and surroundings at thesessions.Once they start to remember they automatically start to become conscious and present within thespace to different degrees. This together with regular input begins to alleviate the symptoms of thisdebilitating disease.However, we are dealing with a de-generative condition, so realistically we are not aiming for cureor prevention, but relief. This then requires a particular type of input.Within this work we begin also to acknowledge past experience and to look at issues that arisefrom those past experiences; which have a distinct relation to the present; this sometimes has anastute clarity, which is sometimes extremely surprising given the severity of this condition.We also observe that the re-membering triggers some other mechanisms that seem to beconnected to the motor skills. The clients start to be able to recognise otherwise forgottenmovement and regain the ability to manipulate limbs consciously, enabling better circulation, which
7in turn, helps to oxygenate the blood and brain tissue. The client in effect is becoming moreconscious of him/herself, helping to improve confidence and evidently, group awareness.In order for this method to be effective, we have to pay close attention to the juxtaposition ofclient, method and therapist. These have to be balanced very carefully so as not to distress theclients into thinking that they are unable to do the task. It can be a slow process and if the pacingis not accurate the group can be lost to frustration and anxiety. These clients are extremelyvulnerable. Once the balance has been stabilized the process develops with ease. Client andtherapist feel secure. Within this condition the clients seem to have extremely high energy levelsjuxtaposed with very inhibited movement and impaired co-ordination. This is mainly due to the factthat the movement of energy in and out of the body is severely affected.This then has to be contained. The way this might be achieved is to invent a structure that is splitinto many fragments or units. These units are structured individually and represent part of a whole.The units in general have to be completed individually, before they are brought together. We couldsay that we are actualising a living, external representation of the internal thought process of ourclient, as the realities of the internal workings are limited. By externalising it we are implementinga method of control.A Story created by six clients with severe impairment due to Alzheimer‟s disease----------------------------The Story of CharlieCharlie lives in a tent in the forest. He grows his own vegetables and is quite self-sufficient. Helikes to hunt rabbits in the forest. One day when he was out walking, he spotted something in thedistance. He looked closer, and he saw that it was a dragon. He was frightened because he knewthat dragons breathe fire.He first wondered how he could kill the dragon and couldn‟t find the answer. The next day when hewas walking in the forest he stumbled across a long fingernail, he wondered why it was there as helooked closer at it, his hand started to tingle and become warm, he thought of the dragon andlooked up; and there the dragon was looking at him.At that very moment his hand, with the fingernail in it, started to dance very rhythmically, and thedragon looked quite sleepy. Charlie moved closer and was less afraid of the dragon than before, hedecided that he would rather be a friend, than kill him.The dragon lives on a leaf in the forest but keeps being interrupted from what he is doing. Charlieasked the dragon what he was doing and the dragon replied making cigars.
8Charlie and the dragon very soon after that meeting decided that they would remain friendstogether in the forest.ConstructionThe whole story was constructed over a 10-week period. The sessions were constructed usingstrong groundwork. This consisted of stabilizing a set routine. A set warm-up was used each week,with the same movements in the same order, followed by more focused work using objects ofdifferent sizes, textures, colours, and shape. These were used primarily to focus motor skills. Itbecame evident that interest in the process deepened during this process. Psychologically andcognitively, the use of different shapes, textures and colours encourages slightly different motorskills and neurological progression. The way in which we hold a ball for example. This will bedifferent for every person because we all have a unique energy field which affects our relationshipto objects. For example if a person was forced to hold a ball every day for four years his/herrelationship to the ball would be different than if every time a person held a ball they were shown adeep respect. We need to be aware of what might be triggered by objects we use and how we canuse objects to trigger.We examined these objects and during the course of the development the clients equated them topast, present or imaginary events although not particularly coherently. This encouraged andenabled the clients to become more aware of themselves and each other. This would be defined asthe embodiment process.Once the clients started to identify and become conscious within the space, the story makingbegan, this usually started as a consequence of the completion of the initial process. The storyincluded objects that were used at the different stages.I deliberately chose objects that may have held some significance within the story and in actualityat the same time juxtaposing fantasy and reality at the same time. The group ran in the autumn soI used objects that were relevant to autumn. This had a significant impact and we were able torealise more truthfully.Once a suitable set of actions and objects had been established, these were kept in place tomaintain a balance within the process. This enabled the re-membering processes. Each consecutiveweek the symbols were repeated and the story emerged concluding in a narrative both of fantasyand a story within the reality of the group and the reality of the autumn.
9MethodA cloth or platform is laid in the centre of the group on the floor. Attention is drawn to the evolvingstory, which is created by laying objects onto the cloth. This enables the group to have a focalpoint. Because the story is an evolving idea, the repetition is normalised and accepted. We cannotafford to cheat our clients or infantilise them, as they are adults and need respect at all times.So we draw attention to a focal point, which is represented by the evolving story at the centre ofour circle. By repeatedly drawing our attention back to the focal point we are internalising focus.We are internalising group stability as the group becomes balanced. Our anxiety lessens becausethe focus is removed from internal processes and projected onto an external fixed point.Conclusions 1. Through this process the clients were more able to be together in a relaxed and efficacious way. 2. A very large man who caused a lot of distress at the day centre through being very tactile with everybody touched people less. During the process and by speaking with staff we decided to give him his briefcase from work. Charlie the main figure in the story turned out to be his wife‟s name. As he remembered her he became less agitated. He started to bring his briefcase to the centre and stopped touching people. 3. A lady who hadn‟t spoken for two years began to speak again and began to be accepted in the group in a healthier way. During one of the group sessions she got up to put a leaf into the story, it took her about three minutes to do this and I encouraged her. She bent down and put the leaf in the story and lost her balance and rolled on the floor. She was full of delight that she managed to do this task and it enabled her to have the confidence to speak. Because she spoke people weren‟t so afraid of her. 4. Other members of the group were more confident and relaxed. 5. The efficacy of this process proves that far from dismissing people as too ill, too mad or old we can improve the quality of life for people who are otherwise left in an extreme state of distress. 6. This process also helped the carers as the clients became easier to manage because their distress had decreased.Cc Alix Harrow 2012