Post on 27-Apr-2015
Aging Matters
Aging Matters: Humanistic and Transpersonal Approaches to Psychotherapy
with Elders with Dementia
Matt Spalding, PsyD, EdM and Puran Khalsa, PsyD
Key Words: existential, process-work, humanistic, transpersonal, therapy, elder care,
dementia.
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Authors Note
Matt Spalding’s clinical and research work with elders with dementia focuses
upon the therapeutic potential of non-ordinary states of consciousness and the invitations
of enhanced freedom, relaxation, and wisdom in progressive states of not knowing. His
evolving experiences as a psychotherapist, teacher, and dog owner continue to remind
him of the importance of trust and how little he really knows about anything at all.
For more than ten years now, Puran Khalsa has been working/training in the field
of psychology. During recent work with clients suffering from numerous forms of
dementia, he had the unique opportunity to witness existential theory effectively put in
practice. Working with a broad spectrum of clients from children to elders, Puran
believes that there are many points along each person’s journey that offer potential
meaning specific to their stage of development.
Correspondence concerning this article should be addressed to both Matt
Spalding, 166 Gates Street, San Francisco, CA 94110, and Puran Khalsa, 172 Ivy Street,
San Francisco, CA 94110. E-mails: spaldingmatthew@gmail.com;
purankhalsa@gmail.com.
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Abstract
The purpose of this study is to discern the relevant and effective components of the Existential and Process-work psychotherapeutic approaches to the clinical treatment of elderly clients with dementia. This study explores how these specific humanistic and transpersonal approaches to this population’s presenting concerns represent unique alternatives to the mainstream medical model of dementia treatment that frames dementia as a mental illness. 10 therapist interns at two of Pacific Institute’s assisted living facilities in San Francisco, CA were interviewed using open-ended questions designed to elicit detailed accounts of their clinical work using these two therapeutic modalities. The interview transcripts were coded using a qualitative thematic analysis methodology and computer software assistance to identify prominent factors that influenced the therapy, including therapist attitudes, embodiments, clinical conceptualizations, interventions, and impediments to effective treatment. These research results systematically thematize the prominent aspects of Existential and Process-work approaches in the effective treatment of the elderly with mild to advanced symptoms of dementia. It is hoped that this study will inform further exploration of these effective therapeutic modalities in diverse clinical populations and settings.
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I. INTRODUCTION
Literally meaning “loss of mind,” the vague and pejorative term dementia refers
to a progressive course of mental and physical decline due to a variety of known and
unknown causes. This pattern of deterioration tends to be most evident in significant
cognitive impairment in the realms of memory, language, orientation, and attention,
accompanied by an increased agitation and lack of ability to care for one’s basic physical
needs. One in eight, or 13% of people over the age of 65 in America are estimated to
have Alzheimer’s disease, a ratio that is predicted to double by 2050. By this same year
more than 100 million people world-wide will have some form of dementia, while many
more will struggle with age-related memory impairment (Herbert et al., 2003).
The standard medical model of care views dementia as pathological in nature and
relies chiefly upon medication and dismissive behavioral interventions to ameliorate its
symptoms. In a recent meta-study of diverse therapeutic approaches to dementia, Hogan,
et al. (2008) concluded that, “Although the available therapies for dementia can help with
the management of symptoms, there is a need to develop more effective interventions”
(p. 788) This present study investigates the core components of the Existential and
Process-work approaches to psychotherapy with mild to advanced symptoms of
dementia, in the hopes that these representative traditions of the humanistic and
transpersonal perspectives may contribute to such enhanced treatment efficacy.
The term “humanistic” in this study refers to the conviction that each individual’s
subjective experience of meaning-making has an intrinsic value. This core worth must be
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taken into consideration in the ethical and effective treatment of dementia so as to affirm
the dignity and fullness of the human experience. The term “transpersonal” refers to the
validation of psychological categories that transcend the normal features of ego-
functioning. Such altered, or non-ordinary, states of consciousness often accompany the
experience of dementia, calling into question the hegemony of the dominant culture’s
‘consensus reality.’ Both of these perspectives allow for a view of advancing
‘forgetfulness’ as potentially imbued with meaning and relevance to the human journey, a
transitional experience that may entail novelty and benefit as well as loss.
There has been little research to date analyzing the relevance of humanistic and
transpersonal approaches to treating elderly clients experiencing dementia. These
modalities call into question the central tenet of the medical model, which frames
forgetfulness as a condition to be prevented or corrected. Indeed, the choice of diagnostic
lens in large part determines whether a client is regressing or working through,
dissociating or revisiting, decompensating or integrating. What is typically diagnosed as
pathology may in fact be an individual’s need to process, prepare, rehearse, or repair,
emphasizing healing and growth over maintenance and comfort. Such organic unfolding
of symptoms is likely to be inhibited by excessive medication, often the prescribed norm
for clinical patients. Well-intentioned attempts to behaviorally control and minimize
symptoms can similarly antagonize and undermine both clients’ and therapists’ potential
recognition of an underlying coherence and meaning to the various psychological,
emotional, physical, and perhaps spiritual signals that comprise “dementia.”
This study examines the foundational notions of two humanistic and transpersonal
approaches to therapy in light of newly generated interview data, serving as an initial
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inquiry rather than a definitive test of a particular hypothesis or set of theoretical
assumptions. It seeks to identify the essential components of the Existential and Process-
work modalities of psychotherapy, both of which may effectively complement the current
mainstream model of treatment. The study authors interviewed 10 Pacific Institute
therapist interns, reviewing the transcripts using a computer-assisted qualitative thematic
analysis methodology to identify prominent therapeutic factors influencing the treatment
of geriatric patients with mild to advanced memory impairment. These factors were then
assigned to categories, giving rise to an initial “codebook” of successful Existential and
Process-work approaches and obstacles to treatment.
Pacific Institute’s Gerontology Wellness Program is an assisted living facility of
100 residents and 20 interns in San Francisco, CA. It makes available a variety of
therapeutic offerings for elders with mild to advanced symptoms of dementia, who
comprise most of the client population. Pacific Institute seeks to model a new way of
working “elders with forgetfulness,” prioritizing holistic and irreducible humanistic
values over symptom checklists as the chief criteria by which to assess the subjective
experience of a person’s meaning-making. The treatment clinic endorses Existential and
Process-work approaches to psychotherapy as uniquely relevant to addressing both the
personal and transpersonal values and concerns of this client population. The intern
training program also includes expressive arts and somatic interventions, providing
activity enrichment, sense stimulation, and attempted rehabilitation of clients’ behaviors
and functions.
These research results make data accessible for further assessment of the
appropriateness and efficacy of Existential and Process-work approaches to
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psychotherapy with the geriatric population. This study also illuminates the need for
further exploration of the relevance and implementation of humanistic and transpersonal
approaches to dementia in diverse therapeutic settings. It is hoped that information from
this study will help to stimulate greater general interest in alternative modalities to
working with individuals with dementia, with the overall aim of offering more
comprehensive and integrative services to this client population.
II. RESEARCH QUESTION
This study’s main inquiry is, “What do effective Existential and Process-work
approaches to psychotherapy look like with elders with dementia in a residential
treatment facility?”
III. LITERATURE REVIEW
Alzheimer’s disease represents the most common type of dementia, accounting
for 60 to 80 percent of all documented U.S. cases, followed by vascular dementia, which
is also known as post-stroke dementia. Less frequently cited, but equally impactful types
include dementia with Lewy bodies, dementia precipitated by Parkinson’s disease,
frontotemporal dementia, Creutzfeldt-Jakob disease, and normal pressure hydrocephalus
(Plassman et al., 2007). Although it is not yet fully understood what processes are
responsible for the accelerated deterioration of neurons that leads to dementia-related
symptoms, it is theorized that rapidly forming ‘plaques’ and ‘tangles’ of various proteins
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in the brain lead to a pronounced shrinkage of vital brain mass due to cell loss and debris
from accumulated dead neurons. Prominent risk factors for dementia are also imprecisely
known, although advancing age clearly accounts for the vast majority of its occurrences.
Enhancing opportunities for novelty, creativity, exercise, group activity,
processing end of life issues, and grief and bereavement support have all proven to be
moderately effective in working with dementia. Together with a consistent exercise
regimen, a low-fat diet rich in vegetables and fruits, and properly prescribed medication,
such treatment strategies can dramatically help to stimulate intellectual curiosity, creative
engagement, social interaction, and meaning-making processes that mitigate encroaching
forgetfulness (Grasel et al., 2002).
The extensive available literature on dementia reveals that each of the bio-psycho-
social aspects of an individual’s experience must be taken into account for an effective
and ethical course of treatment, addressing the patients’ physical, cognitive, emotional
and relational concerns (Slumasy, 2002). The biological component of this triumvirate
approach includes pharmacological medication, nutrition, and exercise. The social
component of dementia treatment includes family involvement, a purposeful role or
identity in one’s residential community, and potential participation in larger societal
spheres of influence. The psychological component, which is the focus of this study,
involve four chief categories of emphasis: activity enrichment and sense stimulation,
rehabilitation of behavior and function, emotional exploration, and cognitive processes
and function. These psychological approaches emphasize person-centered individual
counseling, support groups, and cognitive-affective enrichment activities. They also rely
upon codified environmental modifications paired with strict routines, behavioral
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interventions that can help reduce the patient’s experience of disorientation and stress
levels (Grasel et al., 2002; Rayner, 2006; Slumasy, 2002).
Psychological care has increasingly adopted ‘person-centered’ therapies tailored
specifically towards the patient’s immediate emotional, behavioral, and environmental
needs. (Rayner, 2006) The central tenets of the person-centered approach to dementia are
consistent with the humanistic vision and include, “1) Valuing people with dementia and
those who care for them; 2) Treating people as individuals; 3) Looking at the world from
the perspective of the person with dementia; 4) A positive social environment in which
the person living with dementia can experience relative well-being” (Brooker, 2004, p.
216).
The humanistic and transpersonal paradigms, known respectively as the ‘third and
fourth forces’ of psychology (following upon the behavioral and psychoanalytic schools
of thought), support caregivers’ deepening empathy for their patients by reorienting them
towards a more curious, investigative, community-oriented, and anti-discriminatory view
of dementia. They also honor a client’s unique subjective experience and validate ‘trans-
egoic’ states of mind, which may not be available to empirical or clinical observation.
Rather than attempting to halt the inevitable progression of an illness, both the humanistic
and transpersonal lenses focus upon the internal lives and perspectives of affected
patients and their social network of family and caregivers.
A. Overview Of the Medical Model
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Pharmacological interventions are typically aimed at treating memory and
learning impairment by reducing the breakdown of acetylcholine in the brain (Hogan,
2008). This treatment at best slows the progression of dementia, though there remains no
known cure for the associated cognitive decline. The most common class of drugs
prescribed to this population are central nervous system suppressants with the associated
side effects of sedation and potential cognitive impairment (Ganjavi, 2007). In the case of
pharmacological interventions for behavioral disturbances, antipsychotic medications are
typically used. However, in a recent meta-analysis of 13 studies, Yury and Fisher (2007)
found that the use of atypical antipsychotic medication “is not very effective for the
management of neuropsychiatric symptoms of dementia, and the effects are modest.” (p.
216)
The many risks involved with medication and geriatric populations (Hogan et al.,
2008) strengthen the consideration that non-pharmacological interventions be considered
prior to pharmacotherapy for psychic and behavioral disturbances. Several drugs can
temporarily slow advancing symptoms for up to a year in half of those who take them,
while no reliable medical treatment is available to prevent or even significantly delay the
deterioration of brain cells responsible for this complex of symptoms. It should, however,
be kept in mind that many of the non-pharmacological interventions that draw upon
traditional behavioral models have also demonstrated limited short-term efficacy in the
general population. Antipsychotic medications have in fact been shown to be the most
effective treatment for severe behavioral problems associated with dementia, though
unfortunately tend to be disproportionately prescribed to elderly communities (Hogan et
al., 2008; Yury & Fisher, 2007).
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B. Overview of the Humanistic and Transpersonal Frameworks
This study is situated within a transpersonal framework, which includes the
humanistic world-view while viewing psychology and spirituality as complementary in
awakening the psyche to newfound dimensions of freedom (Cortright, 1997; Walsh,
1993; Washburn, 1994, 1995). According to transpersonal scholar Brant Cortright (1997),
“Transpersonal psychology in this sense affords a wider perspective for all the learning of
conventional psychology; it includes and exceeds traditional psychology” (p. 10).
“Trans-”personal psychology, which literally means an understanding of mind as
existing “across and beyond” the ego identity, seeks to address both the personal and
transcendent, or spiritual, realms of human experience. Building upon the central tenets
of humanistic psychology, which affirm each person’s effort to make meaning of his or
her life and to receive the freedom and support to live this meaning, the transpersonal
framework also acknowledges that humanity's range of experience includes ‘trans-egoic’
states of consciousness. While psychology seeks to intervene on the level of thoughts,
emotions, and behaviors, spirituality can be seen to address the source and foundation of
these bio-psycho-social activities that sustain our illusionary sense of separation from one
another.
Existential psychotherapy in this study represents the humanistic polarity of the
psychospiritual spectrum. It engages the client in personal issues that address the
concerns of the psyche. Process-work is understood here to more overtly support the
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transpersonal dimensions of the psyche. It emphasizes expanded awareness and deep
states of consciousness, including non-dual awareness, which may be more suitably
interpreted as spiritual in nature.
Clearly the ‘personal’ and ‘transpersonal’ poles of human consciousness are
artificial categorizations of experience that in reality lie on a vast and subtle continuum.
Indeed, the differences between Existential and Process-work psychologies are often
semantic, as both share a generous philosophical and clinical terrain. Such conceptual
divides are nonetheless helpful in highlighting the respective dimensions of the human
condition and the most suitable therapeutic approach to working with them.
C. Overview of Existential Psychotherapy
The diverse existential schools of therapy, referred to collectively in this study as
‘Existential psychotherapy,’ have their roots in existential philosophy. The origins of
existential philosophy are often attributed to the 19-century writings of Kierkegaard,
Nietzsche, and Dostoyevsky, and later enriched by the 20th century reflections of
Heidegger, Sartre, and Camus. While the term ‘existential’ connotes a wide variety of
associations, most existential writing emphasizes experience over abstraction, the dangers
of isolation and depersonalization, and the invitations of authenticity, responsibility, and
freedom. It also reminds us that human beings are not static objects, but processes of
becoming; our infinite potential is either a blessing or a curse, depending upon our ability
to affirm the vital experience of being alive.
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Prominent tenets implicit to the existential vision might be summed up as: a) an
emphasis on the concrete here-and-now “existence” of the individual (in contrast to
theoretical assumptions or abstract speculations about one’s “essential” nature), which
takes into account the immediacy of one’s intra- and inter-personal context; b) the
framing of such existence in light of one’s inevitable impending mortality, which
necessarily entails “dread” or anxiety in the face of one’s finitude and an intrinsic guilt in
response to the recognition that each life choice necessitates the elimination of infinite
other potential “right” choices; c) the subjective meaning of participation in the world
from “within” one’s engaged lived experience (in contrast to a fictional idealization of a
detached, disinterested, or objective perspective upon one’s being in the world); and
finally, d) the ultimate responsibility of the individual to steer his or her fate, each choice
demanding a “leap” of faith into a new moment, a process inherently devoid of certitude
(D. Stewart & A. Mickunas, 1990, p. 63; M. Freidman, 1964, pp. 3-9)
Existential psychotherapies can be seen to seek to instill in the client a growing
appreciation of the opportunity to live one’s life with increasing awareness and
responsiveness to these foundational philosophies. In practice, this is likely to entail an
emphasis upon the intrinsic values of freedom, presence, participation, and responsibility,
encouraging and affirming one’s authentic being in the world, and prioritizing concrete
choices over abstract premises. Contemporary existential approaches to therapy owe
much to Kierkegaard’s “absolute paradox,” which views the human condition as a
dynamic oscillation between ‘finitude’ (limitation) and ‘infinitude’ (freedom).
Existential-humanistic psychologist Kirk Schneider reformulates this continuum
in his Existential-Integrative approach to psychotherapy as that of ‘constriction’ and
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‘expansion.’ Working with such a model, the therapist assists the client in recognizing
where he or she might be adopting extreme or static stances on this continuum,
supporting their efforts to relate to their experience with greater fluidity, acceptance of
paradox, and an increasing ability to embody and identify with what had once been
feared or denied (Schneider, 2008, pp. 62-80).
Schneider is aware, however, that any theoretical model is as potentially
restricting as it is liberating. Indeed, as noted by Basset-Short & Hammel, “students too
often apply their techniques and knowledge to clients instead of working with them in
shared endeavors… theory can obscure one’s clients if one applies it around them like
scaffolding… one of the most formidable challenges for beginning therapists, then, is to
draw structure from a particular orientation without letting theory obscure the complex,
unique individual in front of them.” (Schneider, 2007, pp. 24-25)
D. Overview of Process-work Psychotherapy
Process-work, also known as “process-oriented psychology,” is a modern
therapeutic modality developed in the 1970’s by Arny Mindell, which seeks to increase a
client’s awareness of psychological and physical processes on several planes of
consciousness in service of clarifying and resolving personal and collective issues. Such
healing and resolution work entails three levels of investigation, that of a) “consensus
reality,” or of concrete and observable personal and collective experience; b)
“dreamland,” which includes the seemingly invisible realms of dreams, deep imaginings,
synchronicities, subtle feelings, proprioception (inner body sensation), and phantom
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presences or “ghosts”; and c) “essence,” the non-dualistic realm of source awareness that
manifests as tendencies or forces that prefigure and transcend manifestation.
Process-work is especially relevant in working with extreme states of
consciousness, death and dying, somatic symptoms, problematic relationship issues, and
clarification of inner conflict. Its intervention strategies seek to utilize psychological and
physical agitation as gateways through which to explore ordinarily unknown and
potentially frightening domains of experience. Such exploration entails amplifying and
unfolding initial psychological and emotional signals to assist in revealing more subtle
experiential insights in service of psychospiritual integration. The therapist in turn attunes
to and trusts his or her own psycho-somatic experience, either as information for what the
client is experiencing or for guidance on how best to proceed in a course of therapy. In
this sense, the traditional empirical method of attempted objectivity is dismissed, as the
therapist recognizes the greater richness of data in simultaneously observing external and
internal sources of information.
In the words of Mindell, through Process-work “one can begin to change one's
relationship to oneself, to others, and to the world, enlivening an awareness process that
enriches life to re-emerge with new knowledge and awareness” (Mindell, 2000, p. 509).
Process-work is cited as a transpersonal approach in this study due to its validation of
non-ordinary states of consciousness, which may themselves be arenas of letting go,
working through, or preparing for unknown and potentially frightening experiences to
come. As noted, the transpersonal paradigm frames consensus reality as just one
legitimate perspective among many, allowing for multiple concurrent dimensions of
consciousness. While Existential psychotherapies clearly allow for non-consensual
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realities, Process-work approaches speak more directly to the existence of different levels
of reality formation, often of prominent relevance in the experience of dementia.
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Clinical Training Philosophy and Psychotherapeutic Emphasis of the Pacific Institute General Wellness Program
(As outlined in the light gray boxes below)
Biological Pharmacology Rehabilitation Nutrition Exercise
Psychological Cognitive
• Mental Processing • Meaning-Making
Affective • Emotional Exploration
Behavioral • Activity Enrichment • Sense Stimulation
•
Social Family Community Societal Role
Spiritual Hospice Pastoral Services Rose Petal Ceremony
Medical Model Heavy reliance upon psychopharmacology “Dementia”-Symptoms Evidence of Pathology Empirically-Validated & Manual-Driven “Distract & Redirect”
Alternative Humanistic & Transpersonal emphases “Not Knowing” May Have Psychospiritual Meaning Intuitive and Empathic “Mirror and Join”
Existential Psychotherapy (Humanistic Psychology)
Existence Precedes Essence
• Experience over Theory • Tangibility over Abstraction
“Thrown into the World”
• Freedom of Self-Determination • Responsibility of Meaning-Making
“Being-Towards-Death”
• Recognition of Finitude • Acceptance of Anxiety and Despair
Process-work Psychotherapy (Transpersonal Psychology)
Consensus reality
• Facts • Relationships
Dreamland • Felt Sense • Intuition • “Ghosts”
Essence • Tao • Quantum tendencies • Dynamic Ground
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The above diagram situates the clinical philosophy of the Pacific Institute General
Wellness Program within the bio-psycho-social framework of both contemporary
mainstream and alternative treatment paradigms. The contemporary mainstream “medical
model” approach to treating dementia-related symptoms favors pharmacological over
psychotherapeutic interventions. Pacific Institute, while acknowledging in appropriate
circumstances the clinical relevance of medication and manualized care strategies, chiefly
advocates humanistic and transpersonal approaches to working with distressing
psychological issues associated with memory impairment. These alternative treatment
perspectives assume there to be an inherent meaning underlying “dementia”-labeled
symptoms, which can be effectively assisted through the Existential and Process-work
therapies.
IV. METHODS
A. Design, Materials, and Procedure
This study uses Boyatzis' qualitative thematic analysis method to code the 10
interview transcripts, developing and organizing themes based upon one of Boyatzis’
specific procedures (Boyatzis, 1998). This design is well-suited to address the paucity of
qualitative research related to dementia, which is essential to understanding the variety
and nuances of the lived experience of this multi-faceted condition. As this is the first
empirical study to systematically explore the influence of Existential and Process-work
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psychotherapies with elders with dementia, a qualitative research design is appropriate to
further illuminate the efficacy of these two unique treatment modalities (Creswell, 1994).
The phenomenologically-informed research method of thematic analysis locates
themes based upon the number of times they occur in the transcripts, rather than upon any
pre-established treatment philosophy (Miles, 1994). Semi-structured interviews with the
study participants were designed to elicit unrehearsed accounts of therapeutic styles and
interventions with an emphasis on what does and does not work in treatment (Rubin &
Rubin, 1995). An inter-rater reliability protocol, detailed below, was meanwhile
established to help mitigate the inevitably biased and value-laden vulnerabilities of
thematic analysis.
B. Procedures for Subject Recruitment, Timeline, Informed Consent, and
Qualitative Interviewing
The interview subjects included 10 current pre-doctoral and postdoctoral interns
at Pacific Institute’s Gerontological Wellness Program who had been working with their
clients for at least 6 months. This study utilized an open-ended interview format to
guarantee that participants were able to answer all the questions given their time
restrictions and limited accessibility (Patton, 1990). At the outset of the interview
participants were given an Invitation to Participate in Research form, a Bill of Rights for
Participants in Psychological Research, and a Confidentiality Statement, all of which
detailed and safeguarded the prospective participants’ rights of participation. Interviews
were then conducted in person with both of the study authors in a comfortable private
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office setting at Pacific Institute. Any questions about the nature and purpose of the study
were answered at this time. As suggested by Rubin and Rubin (1995), all interviews were
recorded in digital format for later transcription so that the researchers could give their
full attention to the sensitive interview process. The interviews lasted an hour on average
and the data collection took a total of 1 month.
C. Interview Questions
The interview questions were designed to reveal nuanced details of intern
assumptions, states of being, and interventions employed when working with clients with
dementia. Questions also focused upon contextual factors that either facilitated or
impeded effective treatment, in addition to interns’ reflections on their training at Pacific
Institute. The interview questions were designed to generate a natural flow of
conversation and not asked in any specific order. Such flexibility allowed participants to
speak about their experiences in the spontaneous and organic way in which they were
recalled (Mason, 2003).
D. Instrumentation/Materials
QSR NVivo 7 software is a qualitative research tool used for sophisticated
analysis and management of text data, which was employed during this study’s coding
process for its unique capacity to help manage the extensive text-based material derived
from the 10 interviews. Key phrases were highlighted in the text and assigned to specific
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codes so as to be efficiently located when later searching for common themes. NVivo
provided the ability to search all texts for key words and phrases, thus allowing easy
cross-sample comparison of major identified themes without having to remove them from
their original source documents. Coding in NVivo 7 allowed for specific pieces of text to
be labeled for later analysis by category (themes) or by source (specific interns), while
also revealing quantitative data such as the number of times each word or phrase was
used. These codes provided an essential link between identified themes and supportive
textual data from the interns’ accounts, while preserving subtle distinctions in language
usage between participants that could not alone be detected from the coding process.
The identified codes with supportive text were then organized into hierarchical
‘tree code’ structures. Tree code structures organized the large number of codes into
categories based on their relationship to newly emerging themes. When text references
were applicable to more than one code, a new parent code was created to include the
closely related child codes. These more encompassing parent codes eventually became
the foundation for more complex theoretical conceptualization of the data, representing
themes that consistently presented across narratives.
E. Thematic Analysis and Coding
For the purposes of this study a “code” is a mnemonic device or abstract
representation of an identified theme (Boyatzis, 1998). In thematic analysis, codes refer
to distilled words or phrases from shared text entries. Creating highly defined codes both
enhances the qualitative richness of the data and increases the later likelihood of inter-
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rater reliability. The process of defining themes itself increases the visibility of patterns,
encouraging increasingly subtle refinements of distilled themes.
Phase 1: Inductive / Data-driven coding.
‘Tree structure’ of coding is the first movement toward making sense and finding
order in the large amount of data that resulted from the ten interviews. During this phase
codes were assigned specific definitions according to Boyatzis’ (1998) five elements of a
good thematic code:
1. A label (i.e., a name), 2. A definition of what the theme concerns (i.e., the characteristic of issue
constituting the theme), 3. A description of how to know when the theme occurs (i.e., indicators on how
to “flag” the theme), 4. A description of any qualifications or exclusions to the identification of the
theme), and 5. Examples, both positive and negative, to eliminate possible confusion when
looking for the theme.
The researchers read all ten transcripts straight through to get an overall “feel” for
the participants’ narratives. Three interviews were then coded from beginning to end,
after which those codes were entered into the tree code structure. Key phrases that
applied to more than one code suggested a potential relationship between codes,
revealing further macro or ‘parent’ codes that stemmed from several micro or ‘child’
codes branching out from them. Each child code contained more specific information
than its parent code. Bazeley (2007) suggests a two- or three-layered code structure of
classifying and differentiating nuance in codes, which this study adopted.
Phase 2: Initial test of validity.
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Three new transcripts were then coded with the newly established tree codes,
which allowed for a quick review of all other codes and an even more sensitive and
thorough coding process. Emerging themes were then checked against all new codes
resulting in a new theory infused code.
Phase 3: Reliability and the interrater.
Five of the most prominent codes were used to re-code three transcripts picked
randomly by the interrater until a 95% accuracy was reached. Reliability of this code was
determined by two factors: (a) consistency of judgment based on two separate coders, and
(b) consistency over the span of 10 different interviews. Having multiple coders was
deemed the best way to control for the potential biases of the researcher. The second test
brought the code to a level of “data saturation,” in which no new themes are generated
and all of the transcripts can be accounted for in the final coding structure (Boyatzis,
1998).
Phase 4: Validity–the final code.
The final four interviews were coded with the established reliable code, validating
the identified themes across the entire sample. This refined coding structure was viewed
as sufficiently representative of the transcripts after the final transcripts could be coded
with only minor additional changes needed to the coding structure. With all the transcript
data divided into the respective codes, queries were used to search for specific key words
or phrases by again assembling the pieces of fragmented text. This final review of key
concepts while viewing their coding classification revealed interrelationships between
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themes with supportive quotations. Queries also revealed associations between large
concepts that could not be displayed by the tree codes in a hierarchical structure.
V. RESULTS
The research findings, presented in the charts below, confirm that Existential and
Process-work approaches to psychotherapy are largely effective in treating elders with
mild to advanced symptoms of dementia in a residential treatment setting. These results
were consistent across all ages and genders of the interviewed therapist interns, validating
the suitability and efficacy of these alternative therapeutic approaches for this sample
therapist population.
Upon analyzing the emergent patterns of the therapists’ perceived successes with
their clients, it became apparent through emergent and distilled themes that therapeutic
efficacy could be classified into two main categories: A) Therapist qualities (“Being”);
and B) Therapist behaviors (“Doing”). The “Being” category in turn encapsulates both
“Attitudes,” which refer to the therapists’ conceptions of their adopted clinical frames
and roles that were most conducive for successful treatment, and “Embodiments,”
describing the stances and qualities deemed by the study participants to be most effective.
The “Doing” category includes both “Strategies,” which refer to conceptualizations of
effective therapeutic practices, and “Interventions,” which detail the actual enactments of
such practices. It is of note that the categories of Being and Doing were often difficult to
tease apart in the coding process, testifying to the subtle experiential distinctions between
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quality of presence and active expression when working in the humanistic and
transpersonal modes of clinical engagement.
The Being category emphasizes the quality of presence of a therapist over their
enactment of behaviors. Prominent Attitudes (a subset of Being) that emerged from the
thematic analysis of the interview data included a stance of basic trust towards both the
client and the efficacy or sufficiency therapeutic process, emphasizing the significance of
the relationship over interventions, an openness to not knowing what the moment will
bring (such as the outcome of any intervention), an investment in empowering the client,
an empathic attunement to the uniqueness of the client, an appreciation of the present
moment, an increasing acceptance of one’s unfolding experience, a non-pathologizing
perspective, and a humility and willingness to learn in the face of one’s experienced
elder. Embodiments (the other subset of Being) meanwhile included patience, the
willingness to be authentic and increasingly transparent when deemed clinically
appropriate, relaxation, loving kindness, play and humor, equanimity and groundedness,
and the increasing ability to tolerate discomfort.
The Doing category emphasizes the therapists’ activity or framing of action, and
includes both Strategies and Interventions. The specific strategies, or conceptual frames,
most frequently cited were rapport-building, acknowledging another’s boundaries and
right to set limits, tailoring therapy sessions to each client’s unique capacities, creativity
and imagination, utilizing all five senses in the course of treatment, creative
improvisation, and honing one’s unique therapeutic style through observation of and
consultation with co-workers in a milieu treatment setting.
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The most popular interventions included the simultaneous affirmation of non-
consensus and consensus perspectives upon reality, acknowledging and mirroring verbal
and non-verbal signals, active listening and reflection, following the client’s lead in their
experience of meaning-making, affirming the client’s basic health underlying their
potentially distressing experience, using touch and encouraging embodied self-
expression, and teaching clients skills and tools to enhance their well-being.
All of the study participants commented upon challenging aspects of their clinical
work that impeded upon their ability to deliver effective therapeutic services. These
responses were classified into a third category of Inhibiting Factors (“Interfering”), which
fell into two the main groupings of “Personal” and “Environmental” obstacles to
treatment. These challenges included doubt and self-criticism, an attachment to
preconceived notions or outcomes, the risk of burnout or compassion fatigue when
overextending one’s clinical role into the personal domain, the inability to tolerate
distressful experiences and circumstances, and rigid notions of therapeutic dynamics that
inhibit the ability to spontaneously respond to unpredictable arising needs of the moment.
Environmental challenges meanwhile included seeking to reconcile Existential and
Process-work intervention approaches with medical-model documentation, the
pharmacological and behavioral suppression of disruptive client behaviors that can
eclipse unique opportunities to process difficult experiences, the progressive nature of
dementia, and distractions unique to the milieu setting.
In the below bar graphs, “therapist response density” refers to the frequency of
theme occurrence in the interview trasncripts. The themes in the corresponding tables are
similarly numbered in accordance with their frequency of mention by study participants.
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I. BEING: Therapist Qualities
ATTITUDES: Conceptualizations of the therapeutic frame and the therapist’s role conducive for effective treatment
1. Trusting the Process: Assuming client’s and therapist’s inherent movement towards health will reveal itself in relational unfolding
2. Prizing the Relationship: Prioritizing interpersonal attunement over interventions
3. Openness to Not Knowing: Letting go of preconceived notions and
receptivity to newly arising experience 4. Client Empowerment: Affirming dignity and autonomy of client as a
whole person instead of an amalgam of symptoms
5. Person-Centered: Affirming that each client deserves a unique and empathic therapeutic approach that reveals and supports their unique meaning-making system
6. Strength-Based Emphasis: Non-pathologizing perspective
7. Receptivity to Being Taught: Facilitating client’s desire to impart
wisdom of accumulated life experience EMBODIMENTS: Therapist stances and qualities conducive for effective treatment
1. Patience: Mindful acceptance of need to tolerate unsettling encounters 2. Radical Authenticity: Veracity and transparency, emphasis of
personhood over clinical role, and generous self-disclosure when deemed clinically appropriate
3. Relaxation: Embodiment of ease and confidence
4. Compassion: Communicating both loving-kindness and a sensitive
awareness of another’s suffering with the wish to alleviate it
5. Humor and Play: Appreciation of levity and laughter to initiate and strengthen rapport building
6. Equanimity: Embodying a neutral stance of objectivity, balance,
groundedness, and ease with arising experience
7. Distress Tolerance: Ability to withstand or abide in unpleasant experiences of cognitive, affective, or somatic sensations
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II. DOING: Therapist Behaviors
INTERVENTIONS: Enactments of effective therapeutic practices
1. Essential Validation: Simultaneous affirmation of client’s non-consensus and therapist’s consensus perspectives upon reality
2. Joining and Mirroring: Energetic attunement to and reflection of a client’s
conscious and unconscious, verbal and non-verbal cues and signals
3. Active Listening: Acknowledging and encouraging client’s need to tell their story
4. Co-Authoring Therapy: Following the client’s lead in their experience of
meaning-making
5. Normalizing: Affirming basic health underlying client’s potentially distressing experience
6. Somatic Engagement: Use of touch and encouragement of embodied self-
expression
7. Psychoeducation: Teaching clients skills and tools
STRATEGIES: Conceptualizations of effective therapeutic practices
1. Rapport-Building: Establishing a foundational trusting relational bond
2. Respecting Boundaries: Acknowledging and supporting the client’s defenses and limit-setting
3. Accommodating Constraints: Tailoring therapy session frequency, duration, and environment to client’s unique capacities
4. Creative Improvisation: Present-centered emphasis on fluidity,
improvisation, and imagination over rigid and linear goals and expectations
5. Multiple Sense Modalities: Acknowledging importance of having an extensive repertoire of clinical tools and perspectives that accommodate all five senses
6. Collegial Collaboration: Honing unique therapeutic style through
observation of and consultation with co-workers in milieu treatment setting
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III. INTERFERING: Inhibiting Factors
ENVIRONMENTAL: Conceptualizations of unique challenges of and impediments to the clinical setting
1. Clinical Paradigm Dissonance: Reconciling Existential and Process-work intervention approaches with medical-model documentation
2. Obstacles to Shadow Work: Pharmacological and behavioral
suppression of disruptive client behaviors hinders valuable opportunities to process ego-dystonic experiences
3. Progressive Nature of Forgetfulness: Client’s advancing
symptoms of dementia result in inevitable loss of capacities and limited possibilities of treatment
4. Milieu Setting Challenges: Distractions endemic to a clinical
residential environment
PERSONAL: Conceptualizations of unique challenges of and impediments to the therapist’s internal experience
1. Doubt: Self-critical internal monologue heightens anxiety and fear of inadequacy, inhibiting ability to be present to relational attunement
2. Attachment to Outcomes: Having conclusions in mind that
interfere with evolving goal-setting
3. Overextension of Therapist Role: Temptation to blur therapeutic boundaries by assuming caseworker or conservator domains of influence
4. Distress Intolerance: Inability to withstand or abide in unpleasant experiences of cognitive, affective, or somatic sensations
5. Functional Fixedness: Rigid notions of therapeutic dynamics that
inhibit ability to be spontaneous to arising needs of the moment
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VI. DISCUSSION
Thematic patterns became increasingly evident to the coding inter-raters during
the course of the interview, transcription, and coding processes. These emergent codes
represented the intern therapists’ essential criteria of both what “worked on the floor”
with their clients in the residential treatment setting and what impeded such efficacy.
While the interviewers did not prompt the participants to speak directly to the Existential
and Process-work modalities, the distilled themes clearly reflect the basic tenets of these
psychotherapeutic approaches, confirming the applicability of these alternative treatment
modalities to effective dementia treatment.
Although the therapist interns were trained in these specific therapeutic
paradigms, rarely did any of the therapists speak explicitly of utilizing Existential or
Process-work approaches; rather, all of the participants spoke about trusting themselves
over the training material as their ultimate refuge of discernment. 1 This finding is clearly
reflected in the code named “Trusting the Process,” ranking among the highest in
significance to participants. These factors lend an aspect of spontaneity to the
participants’ response of treatment choices, safeguarded from theory-driven recitation,
and a nod towards the natural fit of Existential and Process-work therapies with the
unique needs of this population.
The study participants all shared the belief that there is a possible, indeed likely,
subjective meaning and intrinsic value to the experience of dementia apart from
deterioration and loss. Most reported that this meaning can be “held” by the therapist
1 Pacific Institute interns were also trained in expressive arts, somatic awareness, and psychopharmacology.
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even as the client experiences increasingly intermittent gaps of “consensus-reality”
cognition and memory, which Process-work might label “ghosts” or “dreaming.” Indeed,
many of the interviewees claimed that simply positing an inherent value to the
progressive condition of dementia can inspire a more effective co-investigation of a
client’s experience.
The study results also testify to many of the participants’ shared conviction that a
deeper form of knowing can emerge from their own and their clients’ increasing
acceptance of not knowing. This openness to not knowing, paired with a growing trust in
the unfolding process of therapy, served as a cornerstone conviction for many of the
study participants. It was similarly reported that preoccupation with a client’s history and
diagnosis did more to interfere than assist with understanding their client. Such a present-
centered emphasis freed the therapists from imposing a restrictive therapeutic agenda
upon the client, reflecting a prioritization of fluidity that is discouraged with manualized
treatment approaches.
The majority of therapists emphasized the importance of empowering their clients
by supporting their freedom of choice and independence within the restricted freedoms of
the institutional context. Many cited the importance of focusing upon the clients’ strength
and abilities rather than their symptoms of pathology. The therapists also recognized their
clients as being the ultimate experts in making meaning of their own experience of
progressive forgetfulness and loss. Regardless of their level of functioning, all of the
clients represented in this study were perceived by their therapists as striving to clearly
communicate their will and perspective. Such communication often included resisting
and rejecting the invitation of relationship extended by a therapist. Indeed, several
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interviewees reported that simply acknowledging and accepting a client’s rejection can
serve as a powerful foundation for future connection.
In regards to relationship, most interviewees emphasized the importance of a
steady empathic companion on the painful path of grief, loss, and forgetting. One
participant referred to a recurring sense of paradox in the work that simply by sharing
one’s experience of ultimate aloneness and alienation with an empathic other can make
one feel more at home in the world. Several study participants also spoke towards the
delicate balance of validating a client’s unique experience while maintaining one foot
planted firmly in the ground of consensus reality, neither negating nor colluding in a
client’s apparent fantasy.
All of the participants reported that an enhanced receptivity to a meaning and
value underlying “dementia” symptoms consistently emerged in the course of their
sustained empathic connections with their clients. By attuning with compassion to both
the shared humanity of a client and his or her unique individuality, often aided by humor,
imagination, and a willingness to put one’s worldly impatience aside, therapists described
a growing appreciation of potentially latent meanings underlying many of their clients’
apparently meaningless behaviors. Indeed, many participants stated their belief that a
client’s sustained reverie or agitation is often rooted in a need to work through an
unresolved trauma or fantasy in another time or realm.
The unique combination of working with forgetting and dying in a humanistic and
transpersonal framework presents a powerful crucible for maturation as a person-centered
therapist. An unexpected finding of this study was that most of the interns reported their
style of working with the elders as generalizable to a wide variety of therapeutic
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populations. Several participants offered freely, without prompting, that deepening one’s
skills as a therapist using these particular modalities with this population’s presenting
symptoms would likely translate to most clinical settings. Among the unique effects of
working with clients enduring the loss of both memory and life seems to be that one
comes to naturally take on humanistic and transpersonal values. It is possible, of course,
that the clients in this study also ‘pulled’ for Existential and Process-work attitudes,
embodiments, strategies and interventions from their therapists, essentially coaching their
therapists to take into account their imminent encounters with loss.
Because the majority of research conducted on the treatment of dementia is
pharmacologically-based, there is limited related research with to compare these study
findings. Previous studies reviewing the literature on psychotherapeutic work with
dementia by Richard Cheston (1998) inquired into the environmental and personal
limitations that emerge when treating dementia patients in a residential treatment facility.
Cheston’s research revealed that the states embodied by therapists are particularly
influential in how well received they are received by their patients. The study also found
that particular adaptations often need to be made to a therapeutic setting to accommodate
the progressive cognitive limitations specific to dementia patients.
The fact that all of the participants worked at the same treatment facility
undoubtedly influenced the therapist responses to the interview questions and thus limits
the generalizability of this study’s findings. Considering that the 10 participants in this
study were colleagues, we could expect to see the participants’ views to be relatively
similar. This study does not, however, confirm such a unilateral bias expected from this
relatively homogeneous sample. The participants’ actual therapeutic work often differed
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significantly both from each other and the theoretically effective clinical interventions
taught in the clinic trainings. For example, one of the major training emphases cited by
the study participants was a classic Process-work technique called “amplifying.” In this
specific intervention, the therapist seeks to locate the predominant “signal” being
expressed by a client and reflect it back to him or her in an exaggerated way in order to
help them “unfold” it in service of its ultimate release. It was notable, however, that not
one of the participants in this study talked about successfully using this intervention.
On the other hand, most participants in this study agreed that some form of
“essential validation” is among the most effective interventions when working with
dementia patients. The code of “essential validation” as defined by this study is the
“simultaneous affirmation of client’s non-consensus and therapist’s consensus
perspectives of reality.” Because dementia patients at times perceive their inner and outer
worlds differently from one moment to the next, it becomes critical to recognize the equal
validity, if not reliability, of their altered state of consciousness. This validating process
was often reported as being a powerful method of building rapport and establishing trust,
helping to relieve the client’s frequent feelings of alienation from themselves and others.
As this study is a one-sided account of the therapist-client exchange and draws its
participant sample from a single professional context, future research may wish to focus
upon the effectiveness of treatment from the perspective of the dementia patients, clinical
supervisors, interview caregivers, and/or family members in diverse clinical or domestic
environments. Another of the design limitations of this method is the sustained time,
energy, and concentration needed to carry out a thematic analysis. Testing the
assumptions of Existential and Process-work theoretical approaches cannot be achieved
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by a simple questionnaire. In the course of the lengthy coding process, ten hour-long
interviews were transcribed and reviewed several times, each interview coded separately
to insure inter-rater reliability. Without the help of coding software like NVivo and ample
time for the inter-raters to meet, such a detailed analysis would not likely be available to
a study of this scale.
The categories presented in the results section represent an initial step in the
empirical validation of two effective non-pharmacological therapeutic approaches with
elders (Gatz et al., 1999). While it is hoped that these results may be used to inform better
practices, they are not intended to contribute to the rigid calcification of a standardized
treatment manual, which would be largely antithetical to the open-ended nature of
humanistic and transpersonal exploration. Professionals from both the academic and
clinical domains who might wish to expand upon this research are encouraged to gauge
the effectiveness of these results findings with diverse clinical populations.
VII. CONCLUSION
The research findings suggest that Existential and Process-work psychotherapies
are uniquely effective in the treatment of elders experiencing mild to advanced symptoms
of dementia. This study proposes advances in both clinical research and therapy with this
population by categorizing successful experience-tested, non-pharmacological
approaches reported by therapist interns. This research can be considered an initial step
towards establishing Existential and Process-work therapies as empirically validated
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treatments for working with progressive memory-impairment and its accompanying
symptoms.
The research results, in the form of a thematic codebook, convey effective ways
of responding to diverse behavioral problems and psychic disturbances associated with
dementia that do not rely upon medication or invalidating behavioral interventions. In so
doing, this research presents what is essentially a humanistic and transpersonally-oriented
toolkit for working with dementia as an adjunct to or substitute for the medical model of
treatment. While this study’s findings emerged from the specific context of providing
therapeutic treatment to a geriatric community with varying degrees of loss and
forgetfulness, it is hoped that the generalizable nature of the research results may help to
inform person-centered therapeutic work with diverse clinical populations.
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