Developmental perspectives on dementia and geropsychiatric care

The STAGES Insider Issue 3, November 2021

I work in training and counseling of healthcare workers in geropsychiatric care homes inGermany, and for several years I was consulting the nursing management of a residential care home in assessing residents who are undergoing a process of cognitive changes, in which care unit they can best be cared for during the course of dementia - in regular residential care unit for both cognitive oriented and slightly disoriented residents, in a protected special care unit for active people with moderate dementia, or in care unit for immobile people with severe dementia.

In my work I combine an awareness of dementia as an entity in the gross, subtle as well as causal dimension, work with an AQAL approach to the bio-psycho-social-systemical understanding of dementia and integrate the findings of adult development research in my practical as well as theoretical research.

Dementia is - philosophically speaking - both noumenon and phenomenon, it is both what people think about dementia and what is currently consensualised as the visible about dementia - and already here a broadening of perspective is necessary, because it is also what is not consensualised, it raises the question of who is consensualising, and furthermore what about those things that are not professionally consensualised, but are nevertheless perceived by a certain group as part of the entity of dementia?

All other definitions and attributions that can be found in large numbers in the context of dementia were already briefly discussed in my master thesis (URL in references). Some years ago and I refer to the spectrum of attempted definitions presented there, which in my view is still valid, but in the meantime certainly needs to be expanded (unfortunately only available in German so far). The respective construct underlying the respective use of the word dementia (and also all other diagnostic terminology such as Frontotemporal Dementia, Alzheimer's disease, Lewy Bodies etc.) is born out of and at the same time always gives birth to the
perspective of the user as well as the re- or new-constructing power of the respective context.

An integral research perspective should therefore seek to reveal contexts as well as construct-consciousness.

From a meta-aware perspective, I follow a continuous research impulse that attempts to grasp the construct of dementia from both an evolutionary and an involutionary perspective, thereby striving to be and remain aware of myself as a researcher as well as the thing to be researched as part of the cosmic impulse for what appears as dementia through individual consciousness, always dissolving and re-creating (and failing anew every day in doing so, as a very real human being).

In the course of my professional practice over years I perceived that my knowledge of adult developmental stages enabled me to understand the needs of people with dementia better than a dementia test (like MMSE) could, so that I relied more and more on my intuitive scoring of the residents based on my knowledge about adult development, in addition to the usual testing procedures and medical diagnoses, and was thus able to perceive much more accurately how they could best be cared for within the framework of the given.

The knowledge of developmental stages was equally helpful in education and training of nurses as well as in case supervision; here too, my path of awareness corresponded with my own development and the increasing perspectives that were possible for me. Thus, coming from humanistic psychology and the person-centered approach, at the beginning I systematically overestimated the capacities of the caregivers to take on perspectives and therefore conveyed the approaches of person-centred care (which is state of the art in the care of people with dementia) in a way that could not be implemented by the staff as they were not yet able to take
on this perspective. I realized more and more that the center of gravity of most teams in elderly care is in the area of the expert and not in the area of the achiever and the pluralist/individualist, so a pluralistic person-centered approach is not accessible to many
healthcare workers in Germany (where healthcare is mostly non-academic), and teaching a person-centered approach without this awareness brings a lot of frustration and confusion so that I adapted my way of providing competences among the health care professionals. It was necessary to convey an approach that requires at least the level of the pluralist in such a way
that people with their center of gravity somewhere around expert and achiever also get starting points that enable them to understand.

So I had to grow in my perspective taking for developing a training and supervision model based on a person-centered approach but aligned with both, the need for clear rules (Conformist/Expert), the growing need for expertise and influence through performance
(Achiever), and it led to increasingly better dementia and depression diagnostics and therapy, more collaboration between the different care units for the benefit of residents, and more confidence of caregivers in communicating with people with dementia in challenging situations.

It was not distinctly person-centered care that emerged in this care facility during these years, but it opened up the possibility of enabling individual attitudes and techniques of person-centered care to those caregivers whose developmental center of gravity had not yet been able to realize the embodiment of behaviors of a pluralist consciousness. This seemed to bring about a shift in the center of consciousness of the whole care institution from a predominant diplomat/expert level to an expert/achiever level over the course of a few years, with increasing pluralist consciousness in quite a few caregivers.

Further questions arose from this work, for which I was looking for a suitable research environment: How can training and supervision better relate to the learning needs and understandings of dementia of healthcare workers on every stage of adult development? How
does the developmental perspective of a caregiver influence the developmental perspective of a person with dementia in need of care?

When I met Terri O'Fallon at the Integral European Conference in 2018, we got talking about my perspectives on dementia, and over time the Special Inventory on Dementia at Stages International emerged from that exchange, with initial data now available, based on a 36-stem Sentence completion test, with six newly created Dementia specialty stems:

• Dementia...
• We could make the world a better place for people with dementia if...
• I feel sorry for people with dementia...
• Someone could avoid getting dementia...
• If I had dementia...
• If I care for a person with dementia…

Following data are from a pretest for the Cronbach's Alpha; the chart shows the range of 132 sentence completions from 22 inventories:

From the sample, there is a clear focus of understanding (57 responses) on dementia on 3.5 - Achiever, with further, albeit smaller, focuses on 4.0 - Pluralist - (26 responses) and 4.5 - Strategist - (24 responses).

Despite the embeddedness of the participants in this pretest in a predominantly scientifically and integrally informed community, the pattern shown corresponded to my expectations about the perspectives on dementia, as I repeatedly perceive that in the personal discussion of the topic of dementia, even people with relatively high levels of consciousness tend towards a more individually-subtly oriented perspective, actively seeking solutions, and only in the course of a conversation also permeate to later, collectively oriented or even meta-aware perspectives.

• While the full analysis of the data is still waiting to complete its emergence, broader and deeper questions have already emerged:
• Is it possible to determine the center of gravity of the employees of a nursing home and consequently develop customized training programs?
• How does the center of gravity of a care facility develop as a result of these interventions? Does this have an impact on the quality of life of those in need of care, on the satisfaction of the caregivers in their job and on the retention of the caregivers in the facility - and thus on the expenses of the facility?
• What constructs of dementia/their own situation do people with dementia have over time, and to what extent can this be measured with a sentence completion test? What are alternative methods of measurement?
• What are the potential benefits for people with dementia from such research questions?

Overarching (and what I am particularly interested in) is the question of the involutionary connections between how dementia is expressed or experienced and the social construction of the environment. How does the reality of life of a person with dementia fold in, from which physical and psychological constitutions, from which causal entities in the individual as well as. collective field of consciousness, over which dimensions in and beyond time and space? Is it possible to become aware of this causal as well as the subtle implications of a dementia embodiment?

References

• Cook-Greuter, S. (2005). Ego development: Nine levels of increasing embrace. Retrieved from http://www.cook-greuter.com
• Murray, T., O‘Fallon, T. (2020). A Summary of Research on and with the STAGES Developmental Model. Integral Review, Vol. 16 No. 1, April 2020.
• Wichers, B. (2011). Entwurf eines integralen Demenz-Konzepts (Draft of an integral Dementia-Concept). Masterthesis in Gerontology, University of Erlangen-Nuremberg. https://www.socialnet.de/materialien/27590.php
• Levy, B. R., Ferrucci, L., Zonderman, A. B., Slade, M. D., Troncoso, J., & Resnick, S. M. (2016). A culture–brain link: Negative age stereotypes predict Alzheimer’s disease biomarkers. Psychology and Aging, 31(1), 82–88.