Table 6: Creating a Successful Therapeutic Environment and Relationship Optimal Characteristics and Tips for Success
References
The therapeutic relationship should be prioritized over the task.
• Establish an excellent rapport. • Understand client’s personal and family history (which requires investment in information gathering). • Use names of family members, pets, and friends in conversation. • Talk through a reminiscence. • Attend to emotional needs of client with reassurance, respect, and empathy. • Build on interests and cognitive strengths of the individual. • Reward successes. • Smile. • Consciously simplify interactions as needed (e.g., yes-or-no questions, choice of two activities). • Use pleasant but firm voice commands when trying to elicit a response (avoid elevating intonation at the end of an instruction – this implies that a question is being asked and can be confusing). • Instruct toward meaningful (functional) goals versus abstract (nonfunctional) actions. • Provide clear, objective, repetitive instructions. • Gestures, demonstrations, tactile cues, and reassuring touch can be useful communication strategies. • One-step commands (unless capable of more) • Direct, friendly eye contact and facial expression • Avoid asking, “Do you remember . . . ?” • Position self at eye level to communicate.
Fazio et al., 2018; Haak, 2002; Hauer et al., 2012; Heliker, 2009; Hernandez, Coelho, Gobbi, & Stella, 2010; Kovach & Henschel, 1996; Ries, 2018; Sadowsky & Galvin, 2012. Dawson, Gerhart, & Judge, 2017; Haak, 2002; Heliker, 2009; Kovach & Henschel, 1996; Ries, 2018; Small et al., 2003; Smith et al., 2011; Stinson, 2000.
The communication strategies should be simple and direct.
Note . From Western Schools, 2020. Progression of cues
5. Occasional physical guidance : Provide minimal physical guidance (only when the individual gets distracted or is not responding); individuals who require occasional guidance can often initiate movement, but they may need physical cues to restart or redirect movement for the task. 6. Physical guidance : Guide the individual through the task by assisting movements as necessary; individuals who require physical guidance may need help initiating movements, but they can sometimes complete the activity independently. 7. Complete physical guidance : Provide substantial assistance to the individual to perform the necessary body movements and guide him or her through the steps of the task. Generally, disease progression will require stepwise advancement in cueing. Rote functional tasks may need lower levels of cueing than more complex or unfamiliar tasks, so an individual may require occasional physical guidance to practice a new single-limb stance exercise in a balance program, but he or she may require only a verbal prompt to perform sit-to-stand in the context of a functional task. It is important not to “over- cue” or over-assist clients with dementia. Allowing individuals with AD to function at the minimal possible level of cueing requires patience and time, but it has the benefit of allowing the individual to process and respond to the instruction or cue, maximizing his or her functional independence. Individuals with AD will eventually lose this ability, but neglecting to encourage their engagement and independence may expedite this loss of function. assistance with tasks like walking to and getting into a car, or walking while carrying objects (e.g., a plate of food, a bag of groceries), most likely in an effort to be helpful and to be sure tasks are completed efficiently and safely. But with loss of the opportunity to practice these tasks, individuals lose their skill proficiency. Fortunately, excess disability is a somewhat reversible phenomenon (Rogers et al., 2000; Spector & Orrell, 2010), but it requires a commitment to allow the individual with AD to practice the desired skills. Therapists should provide pointed education to caregivers related to excess disability and encourage them to give individuals with AD opportunities to carry out functional tasks as independently as possible.
Therapists should be mindful of paced and consistent cueing progression. The therapist should begin with verbal instruction and a concurrent visual cue, followed by gesturing and/or demonstration, followed by tactile guidance, and finally physical assistance if needed. Individuals with AD often need extended response time to react to instructions – 10 seconds of silence and nonactivity can feel like an eternity to the therapist, but clients should be allowed at least this much time to process and respond to cues. It may be appropriate for the therapist to repeat the cue exactly as previously stated at the 5-second mark if it appears as though there is no response; however, the slowed processing may truly require 10 seconds or more for an individual to respond. Clinical judgment will determine when it is appropriate to repeat instruction versus progressing to the next level of cueing. Beck, Heacock, Rapp, & Mercer (1993) presented a structured framework of seven levels for cue progression with older adults who have cognitive impairment: 1. Stimulus control : Alter the environment to encourage action (e.g., close a door to decrease distractions). 2. Verbal prompt : Ask an individual to perform the action; verbally guide him or her through the task. 3. Modeling or gesturing : Demonstrate or act out the activity for the individual to imitate; use gestures to start or guide him or her through the task. 4. Physical prompt : Provide a tactile cue to attract attention or to indicate which body part to move. Excess disability in dementia The construct of excess disability (Brody, Kleban, Lawton, & Silverman, 1971) suggests that individuals with dementia often appear more functionally debilitated than they should, given their physical impairments. This is likely a function of both the individual and the caretaker. When it takes longer and is more tenuous for individuals with AD to perform a functional task without assistance, they often receive support and guidance from a caretaker, thus losing the opportunity to practice the specific task. Though the intention of the caregiver (enhancing safety and efficiency) is admirable, the unintended result may be a decline in functional independence because individuals will likely lose the ability to perform the skills they do not practice. For instance, caregivers are often quick to provide
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