Working with any form of dementia is a tough decision to make and equally hard work. This little essay helps to illuminate some of the areas you may need to know on your journey .... Blessings Alix Harrow The Self-Parenteur

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ALZHEIMER’S AND DRAMATHERAPY:
THE PERSONALITY OF A SYNDROME
In my experience it is the environment and politics of care spaces that often reflect the inner chaos
of the client with Alzheimer’s 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 the
environment 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 is
a stigma attached. It used to be the kind of job you have if you couldn’t do anything else. The kind of
job you have if you are a working mum. You get little reward. The client group is extreme and the
training very limited to public sector services. Anyone can set up a care home. These often reflect
bad pay conditions.
Because of the sometimes-poor working conditions staff morale can be low and consequently the
clients become marginalized and under-represented. The staff turnover is usually quite high because
of 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 because of
shortages and sickness. This interferes with continuity and the client already confused has to see
many different faces.
Clients in this environment have a profound loss of awareness of self. Often they don’t know where
they are or who brought them there. There is a significant level of anxiety juxtaposed with a high
level of frustration. This leads to an equally noticeable point of anger that can erupt very quickly, and
without warning. Because the intensity of the fragmentation being experienced by the client is
unknown, it is an unpredictable situation.
It is common for clients to lash out without warning, bite, and kick and verbally abuse people. This
can be caused by fear and may be a consequence of a person’s personality or a consequence of the
illness. It is often said that, “my mother has always been very quiet”. And then Mother is seen to be
exhibiting extreme behaviours. Life’s repressions can emerge very strongly here and sometimes it’s
as if permission to act out some of these is given by presumably being out of control. There is a deep
level of fear within this client group, coupled with the level of fragmentation of personality creates
and atmosphere of chaos. Within this chaos is mistrust and therefore it is very difficult for the clients
to have a sense of freedom within an environment that is supposedly safe. Clients often try and leave
raising 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 cause
greater distress. The reflection or projection of degeneration is very evident. Are we therefore trying

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to build an environment of stability out of the duplication of instability? This is very important as we
are 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 worker
that is probably demoralised in some form or other and a client that is fragmenting and is an
unknown 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 what
is happening is continual. The client can be extremely demanding which in turn creates greater
anxiety for him or her because he/she often cannot get what they want as it has become too abstract
a concept. For example the client may begin to ask questions about a simple matter. I.e. the
whereabouts 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. These
conversations are difficult to follow and if there are six or seven clients challenging workers with
these types of conversations, concentration becomes a strain. Anxiety increases and the worker
becomes distressed.
Politics
One of the day services that I worked in, the borough was re-secterising (this means that the
borough 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 would
be 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 see
each other again. Therefore in my thinking the clients were becoming destabilized even further. Little
compromise 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 to
be. Now there’s a wall, for example. Staff change can really affect the dynamics of atmosphere within
a 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 this
environment seemed to change regularly. I became to understand that the client group fluctuated in
attendance and the dynamic of the group changed dramatically. This was also the case if the staff
team 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 internal
chaos there was nothing that I could do but work within the confines of the presented work. For
example when we had to work in a cold room we would incorporate this into our drama that day and
create a cold story or what is it like when it is very cold. This reminded the clients about the war.

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There are a huge amount of other distractions going on whilst trying to contain a very difficult client
group.
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 a
respite unit). Caretaker about heating. Cook about load music coming from the kitchen, other staff
members who wanted to take part in sessions.
We are primarily dealing with clients that are being systematically de-skilled a) by the effects of
the disease and b) by the circumstances that progress despite these affects. We have by our
structuring of society devised certain schemes of support for various client groups. These by the
nature of their design can be de-constructive.
Dynamics of atmosphere
When we talk about the dynamics of atmosphere, we are moving into the realms of physics. We are
talking about energy and matter and the effects they have, one on the other. When we walk into an
establishment there is an atmosphere that needs attention. How we respond to this will depend on
how in touch we are with our senses. Initially the response should be one of openness to suggestion.
It is all too easy to feel or think that you/I as a Dramatherapist can “fix it”; the truth is we can’t fix
anything we can only draw attention to. So we feel initially helpless and out of control. The
atmosphere will be different each time we go there. Depending on a huge variety of factors. All we
can 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 environment
often requires one to work in the whole space as people wander about, this means the corridor
outside the room and maybe the toilets, people in this environment experience a lot of anxiety and
this 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. I
wait for the clients to come. Stillness is a very powerful tool in Dramatherapy and helps to settle
fluctuating energy. It’s what I might call ‘holding time’.
Energy and matter exist together in a time continuum and if the matter of the human body is held
still in time then it appears psychically to prevent the movement of energy. This enables the chaotic
energy of the clients and atmosphere to settle briefly and aids stability in time and space.
Dramatherapy.

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Alzheimer’s disease
The appearance and close examination of the Conscious/ego State maintained by an Alzheimer’s
sufferer reveals certain universal characteristic qualities. The mind goes through a slow
transformation becoming increasingly fragmented leaving the recipient increasingly more confused.
In thought process, the mind will always seek to establish meaning. Initial meaning must be found
within memory function, since this allows us to bring thought into consciousness. When the mind
can find no meaning within the short-term memory function, which is severely impaired in this
disease; 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 internal
dictionaries of our life experience). Our general understanding of logical meaning becomes
irreversible and chaotic. The short-term memory begins to breakdown, becoming seemingly
detached from consciousness.
The division or fragmentation transcends normal functioning to such an extent that the physical
and emotional capacities connected to the cognitive functioning become detached.
This might effect: spatial awareness, recognition of environment, recognition of objects and people
within that environment, language retrieval and most of all self and body-awareness, leaving the
person with symptoms such as anxiety, depression, frustration, anger. In some cases the
fragmentation 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 as
increasing apathy and inactiveness and eventual cessation of movement altogether, sometimes
over a very short period of time.
People with Alzheimer’s find communication very difficult and frustrating because of certain
fundamental problems associated with the disease.
Disintegration of speech, the collapse of concentration and Confusion related to the breakdown of
inner 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 place
all with the symptoms associated with this disease, we are looking at quite a profound level of
De- construction and confusion.

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Because of the effects of this condition, we can be looking at strange behaviour patterns. These
may cause added anxieties and fears for clients that are already suffering from acute symptoms.
There may be outbursts of extreme vocalisations, physical gesture, and abusive behaviour that is
unfamiliar 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 of
therapeutic intervention?
The use of Devised Stories
The reason that this type of story is so effective is that the structure of the story starts off in a very
fragmented way, which works as a parallel, alongside the diagnostic implications of Alzheimer’s
disease. The elements of the story slowly emerge as a foundation for the re-membering/connection
of the functions of the short-term memory in particular.
The contents of the stories that emerge often include details of past experiences that help the
client stabilise themselves through recognition of their own existence in the world. So the structure
develops and a story begins to appear, this is constantly repeated and re-affirmed and this is
accepted because of the nature of the story building technique. What appears in fact to be
understandably repetitive. What this achieves is a re-membering of the components of the story as
we are 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 a
connection in space and time, in relation to the set time, content, day, and surroundings at the
sessions.
Once they start to remember they automatically start to become conscious and present within the
space to different degrees. This together with regular input begins to alleviate the symptoms of this
debilitating disease.
However, we are dealing with a de-generative condition, so realistically we are not aiming for cure
or 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 arise
from those past experiences; which have a distinct relation to the present; this sometimes has an
astute 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 be
connected to the motor skills. The clients start to be able to recognise otherwise forgotten

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movement and regain the ability to manipulate limbs consciously, enabling better circulation, which
in turn, helps to oxygenate the blood and brain tissue. The client in effect is becoming more
conscious 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 of
client, method and therapist. These have to be balanced very carefully so as not to distress the
clients into thinking that they are unable to do the task. It can be a slow process and if the pacing
is not accurate the group can be lost to frustration and anxiety. These clients are extremely
vulnerable. Once the balance has been stabilized the process develops with ease. Client and
therapist feel secure. Within this condition the clients seem to have extremely high energy levels
juxtaposed with very inhibited movement and impaired co-ordination. This is mainly due to the fact
that 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 split
into 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 could
say that we are actualising a living, external representation of the internal thought process of our
client, as the realities of the internal workings are limited. By externalising it we are implementing
a method of control.
A Story created by six clients with severe impairment due to Alzheimer’s disease---------------------
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The Story of Charlie
Charlie lives in a tent in the forest. He grows his own vegetables and is quite self-sufficient. He
likes to hunt rabbits in the forest. One day when he was out walking, he spotted something in the
distance. He looked closer, and he saw that it was a dragon. He was frightened because he knew
that dragons breathe fire.
He first wondered how he could kill the dragon and couldn’t find the answer. The next day when he
was walking in the forest he stumbled across a long fingernail, he wondered why it was there as he
looked closer at it, his hand started to tingle and become warm, he thought of the dragon and
looked 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 the
dragon looked quite sleepy. Charlie moved closer and was less afraid of the dragon than before, he
decided that he would rather be a friend, than kill him.

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The dragon lives on a leaf in the forest but keeps being interrupted from what he is doing. Charlie
asked the dragon what he was doing and the dragon replied making cigars.
Charlie and the dragon very soon after that meeting decided that they would remain friends
together in the forest.
Construction
The whole story was constructed over a 10-week period. The sessions were constructed using
strong 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 of
different sizes, textures, colours, and shape. These were used primarily to focus motor skills. It
became evident that interest in the process deepened during this process. Psychologically and
cognitively, the use of different shapes, textures and colours encourages slightly different motor
skills and neurological progression. The way in which we hold a ball for example. This will be
different for every person because we all have a unique energy field which affects our relationship
to objects. For example if a person was forced to hold a ball every day for four years his/her
relationship to the ball would be different than if every time a person held a ball they were shown a
deep respect. We need to be aware of what might be triggered by objects we use and how we can
use objects to trigger.
We examined these objects and during the course of the development the clients equated them to
past, present or imaginary events although not particularly coherently. This encouraged and
enabled the clients to become more aware of themselves and each other. This would be defined as
the embodiment process.
Once the clients started to identify and become conscious within the space, the story making
began, this usually started as a consequence of the completion of the initial process. The story
included objects that were used at the different stages.
I deliberately chose objects that may have held some significance within the story and in actuality
at the same time juxtaposing fantasy and reality at the same time. The group ran in the autumn so
I used objects that were relevant to autumn. This had a significant impact and we were able to
realise more truthfully.
Once a suitable set of actions and objects had been established, these were kept in place to
maintain a balance within the process. This enabled the re-membering processes. Each consecutive
week the symbols were repeated and the story emerged concluding in a narrative both of fantasy
and a story within the reality of the group and the reality of the autumn.

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Method
A cloth or platform is laid in the centre of the group on the floor. Attention is drawn to the evolving
story, which is created by laying objects onto the cloth. This enables the group to have a focal
point. Because the story is an evolving idea, the repetition is normalised and accepted. We cannot
afford 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 of
our 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 because
the 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