Can people with dementia benefit from therapy?

While dementia is a disease of the physical body, it can have a significant and devastating impact on the emotional health of the patient and family. I am often asked if psychotherapy is helpful, or even possible, for a person diagnosed with dementia. Research has borne out what we may instinctively know: having a trained, supportive therapist can help alleviate the emotional and sometimes behavioral symptoms associated with dementia.1 2

Therapy for Early-stage Dementia

A diagnosis of dementia brings a flood of emotions: fear, anger, anxiety, depression, and even guilt. In early-stage dementia, the ability to be insightful, to generate and execute a plan, and to communicate one’s emotional state may be intact. Therapy can provide the opportunity to sort through the barrage of emotions and to create interventions to address them. Goals of therapy during this stage may include:

• Identifying losses
• Reconciling the grief between the expected life and the actual life
• Managing fears about disease progression
• Coping with depression
• Future-planning and communicating care wishes with loved ones
• Expressing all emotions in a non-judgmental space

Therapy for Middle-stage Dementia

Clients with middle-stage dementia may have more difficulty recalling recent events or using verbal language. Loved ones may become concerned about behavioral changes such as withdrawal, argumentativeness, or sudden bursts of tearfulness or anger. This may be the time that the client is no longer able to live independently, and the resulting changes in environment or caregiving arrangements could add to the confusion and feelings of loss. Therapy during this stage is marked by:

• Greater involvement of a family member to help identify areas of concern (e.g. Mom gets upset or accusatory when she can’t find her glasses) for clients with poor recall. Family needn’t attend sessions, but are helpful in providing background information
• More active role of the therapist in guiding content of sessions
• Use of prompting and cues to encourage verbal communication
• Working through issues of loss and change
• Assisting client in rebuilding positive self-image
• Helping client maintain autonomy whenever possible

Therapy for Late-Stage Dementia

Even some clients with late-stage dementia can benefit from psychotherapy. Clients who are oriented to self (know who they are) and have some ability to converse are able to engage in the therapeutic process. Treatment at this stage is generally aimed at preserving and maintaining, rather than improving, emotional health and functioning. Involvement from caregivers is very important to provide feedback to the therapist, such as monitoring the client’s mood or behavioral changes between sessions. Therapy at this stage may include:

•  Supportive psychotherapy to affirm client’s sense of self-worth
• Reminiscence therapy
• Conversation and interaction to maintain social engagement
• Use of sensory objects to address anxiety
• Engaging family members/caregivers to explore possible antecedents of emotional or behavioral disturbance
• Modeling interactions for caregiver or family member that will support client’s emotional health

The Specialized Therapist

Given the complexities and changing needs of dementia-affected clients, I strongly encourage finding a clinician with experience and specialized training in serving this population. Here are some ways in which working with dementia-affected clients is different than working with the general population:

• The standard 50-minute session may not be the best fit. Some clients will need a longer session due to needing additional time to tell a story, or because they tend to repeat themselves. Some will need a shorter session due to limited tolerance or shorter attention span.
• In-office sessions may be difficult. Clients may not drive, or have physical disabilities that make it difficult to go outside of the home. Having home visits or telehealth could be a good option.
• An expanded understanding of consent. It is standard practice within the industry that “the client must call to make an appointment.” For dementia-affected clients in middle or late stages, this may not be possible. A clinician with experience in this field will understand a client’s limitations and have flexibility with making initial contact, completing forms, and scheduling appointments. An experienced clinician will work with the client at the client’s level of understanding to gain consent for therapy, regardless of who is ultimately responsible for signing the forms.
• The ability to manage confidentiality. At the core of therapy is a relationship built on trust. The client must trust that the therapist has the client’s best interests and privacy at the forefront. A family member must trust that the therapist will be skilled enough to address any potential safety or family conflict concerns. A dementia-trained therapist will be able to navigate the intersections of confidentiality, right to self-determination, and safety.
• A solid understanding of the disease process. Clinicians experienced in working with dementia-affected clients and families will be attuned to nuanced changes in mood, behavior, speech, and ability. Understanding the disease and assessing a client’s level of functioning are critical to the success of therapy. This will inform so much of the process, and its importance cannot be overstated. For example, a clinician may decide to use more closed-ended questions if a client seems to struggle with responding. It’s not uncommon that I need to re-introduce myself as a clinician, and provide a summary of what we’re working on at the start of each session, to assist with orientation.
• A willingness to work within a team. Clients may request a clinician to communicate with family, hired caregivers, assisted living staff, community programs, or other medical professionals. A dementia-specialist therapist knows that the client is at the hub of a many-spoked wheel, and sees value in participating in the team-approach to treatment.

• Perhaps most importantly, the clinician must seem like a good “fit” in terms of personality and demeanor. Look for a clinician who is patient and addresses the client directly rather than relying on caregivers for information. The right clinician will be empathetic and respectful, and never talk down to or patronize a client with dementia.

Finding a therapist

Once you, or your loved one, has decided to see a therapist, you may not know where to start. Here are some ways to find a dementia-trained therapist:

• Ask your primary care physician, gerontologist, or neurologist for referrals • Contact your local chapter of the Alzheimer’s Association
• Contact your local Area Agency on Aging

Once you find a therapist who provides the specialized care you are seeking, you can begin to work towards improved coping and emotional well-being.

Sources: 1 Hepple, J. (2004). Psychotherapies with older people: an overview. Advances in Psychiatric Treatment, 10(5), 371-377. 2 Cheston R, Ivanecka A. (2017) Individual and group psychotherapy with people diagnosed with dementia: a systematic review of the literature. International Journal of Geriatric Psychiatry, 32(1), 3-31.