The 1990s have been designated as the Decade of the Brain (Subcommittee on Brain and Behavioral Sciences, 1991). While scientists are striving to understand the neurophysiologic processes underlying dementia, clinicians are striving to understand the therapeutic processes underlying effective, humane care of persons living with dementia.
In order to meet the needs of clients with dementia, there has been a tremendous growth in long-term care settings that specialize in dementia care. This growth is evident in the proliferation of special care units (SCUs) in nursing homes (Holmes, 1992). There has been smaller-scale - but parallel - growth in the number of adult day care programs specializing in dementia care. Despite this growth, there is no consensus on what constitutes special care, and the research literature has not clearly documented the benefits of SCUs (Berg, 1991; Read, 1992).
Single-site descriptive studies that evaluated the impact of SCUs reported positive outcomes, such as increased ability to perform activities of daily living, decreased agitation, weight stabilization, increased resident interaction, and increased family satisfaction (Benson, 1987; Geary, 1988; Hall, 1986). In contrast, only two of six studies that used control groups to evaluate changes in residents over time documented beneficial patient care outcomes in SCUs (Chafetz, 1991; Coleman, 1990; Holmes, 1990; Maas, 1990; Rovner, 1990; Wells, 1987).
Clearly, further research is required to test the effects of SCUs; however, it is not the purpose of this article to debate the benefits of SCUs. This article will describe elements of a therapeutic milieu that are basic to dementia care - whether that care is provided in SCUs or in integrated patient care settings.
Although much has been written about designing environments for dementia care, the focus has remained on the physical environment - the social context has received little attention. Experienced clinicians understand that staff approaches are as critical as architecture. So much attention has been focused on environmental design that we have lost sight of the critical role of the staff in building a relationship and creating a culture that supports, involves, and validates the human being with the disease. A blueprint that identifies and articulates the full spectrum of interventions used to create a therapeutic milieu is necessary.
Gunderson (1978) developed a model that provides the basis for a blueprint of the therapeutic processes in psychiatric milieus. In this model, Gunderson described five elements that can constructively affect the therapeutic environment: safety, structure, support, involvement, and validation. Gunderson (1983) emphasized the importance of fit between the application of these therapeutic processes and the needs of different patient groups, including groups outside of the traditional psychiatric setting.
The five elements in Gunderson's (1978) model are described in this article as separate building blocks in creating a therapeutic milieu for dementia care. In reality, these elements interact and blend to form a whole that is greater than the sum of its parts. The Table summarizes how Gunderson's model is applied in dementia care and suggests relevant outcome criteria.
Because of the necessity to compensate for cognitive impairments, a safe environment is the most basic requirement in dementia care. Gunderson named this element containment and described its purpose as preventing dangerous and selfdestructive actions, and sustaining physical well-being. Renaming this element safety emphasizes the need that is served by a variety of staff approaches.
Application of Gunderson's Model of Therapeutic Processes in Dementia Care
The challenge for the staff is to maintain safety in the least-restrictive environment. Operating a safe environment for clients with dementia requires that the staff carefully weighs safety requirements with issues of autonomy. In a therapeutic milieu, the staff ascribes to a philosophy of care that values autonomy, and intervenes to help clients maintain independence and self-determination. This requires an assessment of strengths and abilities in order to help clients maintain optimal functioning but avoid the experience of failure (Weiner, 1991).
The need to pace or wander is a common behavioral characteristic in many clients with dementia. When this need is coupled with memory loss and disorientation, the potential for wandering away and getting lost becomes a focal safety issue in dementia care. One approach to maintain safety is to lock doors and limit access. The staff is again faced with the dilemma of balancing safety and autonomy needs, though locked doors may represent the least restrictive safe environment for clients with dementia. Limiting access protects clients and frees staff time and energy for other more therapeutic tasks than attendance checks.
The environment can safely accommodate wandering by providing paths or by enclosing outdoor areas (Calkins, 1988). Designing walkways as continuous loops with activity alcoves and rest areas allows for wandering without getting lost. The rest areas divert the client's attention away from exhaustive, repetitious wandering and invite the client to engage in other activities.
Safety is important not only because of the cognitive impairments of dementia, but also because of simultaneous physical disabilities of an aging population. For example, visual and perceptual impairments are common, and the staff meets safety needs by compensating for sensory losses. Compensation is achieved by increasing lighting, eliminating glare, and providing visual contrast between objects and background. For example, the edges of steps can be painted with a bright color to aid in depth perception.
Many clients also have significant motor impairments due to arthritis or problems with coordination. Grabbars, handrails, and sturdy, simple furniture with rounded edges are examples of modifications that increase the individual's ability to negotiate safely in the environment. Experienced staff members have trained their eyes to quickly identify hazards and provide a safe environment - this includes many of the same modifications used to make a house childproof.
Safety needs also are met by the ability of the staff to recognize and intervene when agitated behavior is escalating. The staff must be able to examine the environment, recognize stimuli that are distressing to the client, and remain calm while intervening to interrupt the behavior. For example, a client may interpret a loud noise as a threat and respond by shouting to protect himself. A skilled staff member might defuse the situation by calmly asking, "Did you hear that noise? It startled me too." The staff member reinterprets the stimuli to reduce the threat and communicates that "I know what is going on, and I will take care of it."
In Gunderson's model, the first element requires interventions that provide for physical safety. Because disorientation produces anxiety in clients with dementia, psychologic safety also is important. Interventions to meet psychologic safety needs are determined by the remaining elements of Gunderson's model.
Gunderson defined structure as the predictable organization of person, time, and place. He described examples of imposing structure on a treatment milieu by using contracts, hierarchical privilege systems, or token economies. Such behavioral strategies are inappropriate in dementia care because of clients' compromised ability to remember the contract or learn the set of rules.
In dementia care, structure is provided by the schedule of activities, which provide rhythm and predictability to the client's day, and focus energy into meaningful activities. As clients become familiar with routines, a predictable schedule of activities reduces disorientation and anxiety, and provides social stability (Roberts, 1988). The goal is to provide temporal landmarks by maintaining a regular daily schedule.
Providing such temporal landmarks is an appropriate goal in dementia care, and yet the art of caregiving requires something more. Routine must be tempered with ftexibility. Experienced staff members recognize the value of familiar routines, and then learn to be flexible and take the client's lead. For example, staff members recognize when an activity is not working and make adjustments to meet the needs of the clients. When personal or situational variables mandate a change, the schedule of activities is changed - or the staff makes a change (Chavin, 1991).
Structure also is provided by the physical environment, which provides boundaries and mediates environmental stimuli. Despite the recent interest of architects in environmental design for dementia care, architecture also can be a barrier when the staff must adapt to pre-existing structures (Calkins, 1988; Cohen, 1991). For example, in many nursing homes, large activity rooms and dining areas are overstimulating and lead to client responses such as anxiety, agitation, or withdrawal. Despite such environmental constraints, staff creativity can change the structure of the environment. Partitions or even furniture can be used as a barrier to divide a large space into two or more self-contained activity areas. Architects state that form follows function. In dementia care, the staff determines what functions will occur in what spaces and designs the physical environment accordingly.
By making changes in the physical environment, the staff is able to manipulate the level of stimulation (Maas, 1988). Clients with dementia have difficulty filtering sensory stimuli. They easily become confused by competing stimuli and have difficulty distinguishing on which stimuli to focus. Clients who are easily overstimulated need a space that limits the number of people and limits visual and auditory stimuli.
Group size is determined by the clients' tolerance of environmental stimuli and by their ability to interact socially. The optimal size of client groups also varies according to the activity but generally does not exceed 12 to 15 people in higher functioning groups, and 6 to 8 people in lower functioning groups.
From a macroenvironmental perspective, the structure is determined by the design of the building and the way the space within the building is divided. From a microenvironmental perspective, the interior design structures the environment by providing orienting cues, by simplification, and by maintaining homelike associations.
Orienting strategies include wayfinding cues, such as clear paths to destinations with arrows or lines on the floor, or physical landmarks, such as signs and pictures. Orienting strategies help to maintain independence and compensate for perceptual changes that occur in dementia.
Simplification also supports the functional abilities of the client by introducing tasks in simple steps and reducing the number and complexity of environmental demands (Mace, 1981). In an issue of the American Journal of Alzheimer's Care and Research devoted to the topic of environmental design, Zgola (1990) provided a graphic example of how to simplify the environment and maintain function:
Many of the common errors and distressing behaviors that may be exhibited by the person with Alzheimer's disease, such as urinating in inappropriate places or misusing objects, result from impaired perception and judgment. The best response to such problems is to simplify the environment and remove the confusing or misguiding articles.
Pictures illustrate how an open wastebasket next to a closed toilet seat might prompt someone with dementia to urinate in the wastebasket. Removing the wastebasket and opening the toilet seat provides a clear unambiguous cue to the appropriate behavior.
Maintaining homelike associations is another mechanism to avoid disorientation. For example, an activity room used for discussion groups is referred to as the living room rather than using the institutional terminology of day room or lounge. Designers of environments for dementia care frequently stress the importance of creating homelike environments, including comfortable furnishings and personalization. The domestic qualities of a home environment can be fostered by variations in color schemes, types of furniture, and by photographs and memorabilia.
However, homelike means more than comfortable furniture and pictures on the wall. Staff member's attitudes also are an important dimension in creating homelike environments. Staff members convey a "lived-in" quality when the structure is relaxed and clients are invited to join a group where "the coffee is on."
Structure is provided by the physical setting and the activity schedule. If the structure does not fit the needs of the client, an increase in anxiety results. This anxiety is often expressed in restlessness and verbal agitation. Because clients sense the anxiety of others, the anxiety may become contagious. Timely staff intervention can often avoid its spread by providing a less stimulating environment with more individual attention for a group member who requires it. The relationship between the response of the client and the structure of the environment is complex. However, the experienced staff creates a therapeutic milieu by assessing individual and environmental variables and manipulating the structure to meet the needs of both the individual and the group.
Gunderson (1978) defined support as conscious efforts to help clients to feel better and to enhance their selfesteem. The role of the staff is to build a supportive relationship in which the client feels cared for and understood. The goals of the supportive relationship are to relieve anxiety and maintain a sense of trust, security, and self-worth. In dementia care, when these psychosocial needs are not met, agitated behavior may result. In contrast, when these needs are met, clients exhibit both attempts to be helpful and increased sociability.
Support is provided by reinforcing each person's identity through strategies, such as enhancing personal choice, reminiscing about past accomplishments, and validating feelings. Support also is provided through the relationships the staff builds with clients. Communication is at the heart of relationships, and the staff uses communication skills and assumes supportive roles so that clients experience being cared for and understood.
Enhancing Personal Choice
Enhancing personal choice is a supportive intervention that is offered in a milieu in which autonomy and independence are valued. Seman (1990) studied the subjective experience of individuals with Alzheimer's disease and found that clients continued to experience the effects of their illness and were able to convey in interviews the discomfort that the disease produced in their lives. One hundred percent of the individuals interviewed spoke of anger and frustration at the loss of independence and autonomy.
By enhancing personal choice, caregivers are giving back a little bit of what the clients have lost. One way that this is done is by maintaining a milieu that is flexible enough to invite clients to engage in activities, but allow them to choose not to participate. Complex choices may overwhelm the client's cognitive reasoning powers, but experienced staff members are capable of following the client's lead and allowing choices that reinforce personal control.
Enhancing personal choice is a supportive intervention leading to a variety of positive outcomes. In a field study in a nursing home, several interventions were used to encourage choice and personal responsibility (Langer, 1976). In the experimental group where self-determination was fostered, there were significant improvements in alertness, active participation, and general well-being.
In another study, interventions were designed to enhance the control that nursing home residents maintained over their environment, despite impairments in cognitive functioning (Beck, 1982). Results of the study supported the benefits of maximizing control over certain aspects of the environment. The assumption, supported by experience and research, is that caregivers can promote optimal functioning in persons with dementia by enhancing selfdetermination (Lyman, 1989).
Reminiscence helps the client to experience being cared for and understood as a unique individual. Reminiscing about accomplishments helps to acknowledge the person the client was, and continues to be, despite the disease process. For many clients with dementia, reminiscence allows them to maintain continuity of self despite the impact of the disease.
Although short-term memory is severely impaired in dementia, longterm memory remains more intact, particularly in the early stages of the disease. Reminiscence builds on clients' abilities by capitalizing on longterm memory. Even in the later stages of the disease, the use of visual, auditory, and olfactory cues help to unlock memories. Reminiscence stimulates discussion of experiences, but reminiscence is not limited to discussion. The use of music, familiar objects, or familiar activities provides a mechanism to help clients access memories. Reminiscence is a supportive intervention that fosters continuity of self, enhances selfesteem, and promotes socialization.
Staff members also provide support by maintaining communication. As the disease progresses, most clients experience word-finding problems and use substitute words and repetitive phrases. Communication is further impaired by the loss of syntax. Clients become trapped by the disease, and the challenge for the staff is to maintain communication and forge relationships.
Although the understanding of language changes in dementia is still in its infancy, experienced staff members rely - to an increasing extent - on the identification of themes in the client's verbal communication and on the use of nonverbal communication strategies (Beck, 1988; Lubinski, 1991).
Feil (1982, 1985) described a supportive communication approach for interacting with disoriented elderly individuals in which staff members focused on accepting a person's emotional reality and validating feelings rather than insisting on the accuracy of facts and orientation to present reality. Staff members listen to the feelings expressed by the words and use their knowledge of the client to interpret the meaning.
For example, when a client insists that "I must go home," he may be expressing a physical need, such as the need to urinate/defecate - or he may be expressing a psychosocial need, such as the need to experience the security of familiar surroundings. Supportive communication relies heavily on a combination of empathy, touch, eye contact, mirroring body movements, matching voice and rhythms, picking up cues about feelings and putting them into words, accepting without judging, and genuine total listening (Hoffman, 1990).
A number of communication strategies are useful to convey support to clients. One supportive intervention is to redirect the client's attention away from distressing stimuli through distraction. The memory impairment promotes the success of this intervention, because the client may forget an upsetting incident and respond positively to distracting activities or changes in the topic of conversation.
Another supportive strategy is to provide reassurance. When individuals experience anxiety resulting from disorientation and memory loss, they benefit from reassurance that the caregiver knows what is happening and understands the anxiety. This understanding is communicated by an attitude and sense of calmness. Reassurance that "we will do it together" helps clients feel more secure in doing what they can for themselves because they know they have someone they can depend on.
Techniques such as distraction and reassurance are sometimes conceptualized as behavior modification techniques. However, it is more useful to consider them as supportive roles. The shift from behavior management to support is a philosophical one. This philosophical shift occurs when we stop asking how to manage behaviors and start asking how to understand and meet needs.
In addition to the support that the staff offers to the clients, the staff has an equally important role in supporting the family members. Families who attempt to care for the patient at home struggle with an endless array of caregiving issues and often become exhausted; those who make a decision to institutionalize the loved one often experience feelings of guilt. Families require the support of staff members and other families facing similar situations. The staff provides this support by being available to family members, organizing education and support groups, and balancing respite needs with desires to continue to be involved in caregiving.
Maintaining supportive relationships requires an attitude of empathy and consistent caring on the part of the staff. In order to maintain this level of caring, the staff also must be supported; this happens when staff members support one another and engage in shared problem-solving.
The administration provides leadership in defining and mamtaining a value system that directs clinical practice. Administration demonstrates a commitment to quality care by creating an expectation of respect for both clients and staff members. Administration also plays a vital role and demonstrates caring by providing adequate staffing and meeting individual scheduling needs.
Unit leadership demonstrates caring by supporting the staff when the milieu becomes stressful, by active listening to staff concerns, and by enthusiasm for staff interventions. Supportive leadership recognizes what is unique about a staff member's approach and fosters that uniqueness as a means of professional growth.
In Gunderson's model, interventions that provide empathy and caring serve the therapeutic function of the support variable. Some supportive interventions such as reminiscence also may be useful in application of the variable of involvement. Support differs from involvement because support tends to be unidirectional while involvement requires a two-way relationship.
Gunderson (1978) defined involvement as "those processes that cause patients to attend actively to their social environment and interact with it." According to Gunderson (1978), positive change occurs through a process of social learning. In dementia care, learning is not a realistic goal because the reinforcement must be consistent and ongoing. However, with consistent supportive approaches by staff members who encourage continued involvement, many persons with dementia are able to attend actively to their social environment and interact with it.
In dementia care, experienced staff members promote involvement by reconnecting clients with their ability to function in social roles when dementia and the aging process rob them of previous roles. In Seman's (1990) research on the subjective experience of dementia, two dominant themes were expressed unanimously by those interviewed. As previously mentioned, one theme was the anger and frustration at the loss of independence and autonomy. The other unanimously pressed theme was a desire to remain active and useful. The staff promotes involvement by maintaining relationships and meaningful activities in people's lives.
The staff builds connections among residents by role modeling and by building group support. One technique to build group support is the use of reframing techniques. Reframing is defined as "changing the frame in which a person perceives events in order to change the meaning. When the meaning changes, the person's responses and behaviors also change" (Bandler, 1982).
When clients perceive actions or events as threatening, reframing is used to build understanding and empathy. For example, one client resisted another client's attempt to touch his hand. Staff intervention prevented the misinterpretation of touch by explaining, "She misses her husband who died many years ago. Sometimes she gets confused and thinks of you as her husband." The client responded with attempts to be soothing and attentive.
It is important that the staff does not underestimate the ability of clients to engage in interpersonal communication and maintain relationships. In group discussions, when an atmosphere of trust exists, many clients are able to share concerns about their illness, tell jokes, or offer suggestions. Groups provide an opportunity for expressing feelings and for building mutual interdependence. A caring community that fosters the expression of feelings diminishes the clients' sense of anonymity and isolation.
In dementia care, activities become a vehicle that supports roles and relationships. The loss of tasks and roles occurring in Alzheimer's disease leads to a loss of identity. Although it is often difficult for individuals with dementia to plan and initiate activities, they may participate in activities initiated by someone else. Client-initiated activities also may be generated in an environment that provides a rich variety of materials and props that build on old interests and abilities.
Goals of the activity program include validation of past roles, purposeful use of time, social interaction, physical activity, and cognitive stimulation. Programs designed to meet these goals include an endless range of activities described in recent publications on therapeutic activity programs in dementia care (Beisgen, 1989; Chavin, 1991; Hellen, 1992; Sheridan, 1987; Zgola, 1987). Activities vary in both complexity and type, and include music, exercise, discussion, crafts, and/ or games.
Unfortunately, establishing an activity program is meaningless unless the staff understands how to promote active participation in activities. Visitors to nursing homes often see large groups of clients who, although present, are passive and uninvolved in activities. The therapeutic dimensions of the activity program do not merely happen. The challenge for the staff is to assess clients' needs, abilities, and interests and then match activities to those same needs, abilities, and interests.
In addition, the focus within the activity program is on the process or effort exerted - not on the results. In groups where clients are physically active and need to pace, activity programs minimize restrictive, negative feedback and allow clients to wander. Props are provided to invite clients to engage in meaningful activities. For example, by providing a pacing client with a sweeper, pacing can be transformed into a purposeful task. Clients generally enjoy social activities, and daily snacks or "coffee breaks" build on lifelong patterns and provide a focal point for social interaction. Normalization activities meet psychosocial needs by compensating for the loss of tasks and roles (Hellen, 1992). These activities are meaningful tasks that individuals would be participating in if they were well - such as cooking, gardening, cleaning, or folding laundry.
The activity program is individualized, and placement in groups requires careful selection to minimize conflicts and promote a caring community. For some clients, activities focus primarily on one-to-one interactions or solitary activities that are based on the person's interests. For example, one client worked for many years as a check-out clerk at a grocery store. Looking at grocery advertisements in the newspaper was a meaningful activity that she enjoyed.
Involvement is reinforcing for both clients and staff members. A staff member described involvement as one of the gratifications of caregiving and as a means of avoiding burnout. If the criteria of support and involvement can be met, then it is possible to create a culture in which clients respond as one did on a field trip: In a moment of clarity, he tapped a staff member on the shoulder and said, "I don't know where we are going. I don't have any money, and I don't know how I am getting home - but Tm going to have a good time."
Gunderson (1978) described validation as a therapeutic process that affirms the patient's individuality and leads to individualized treatment programs. Goals must be matched to the client's abilities when the staff plans targeted interventions to meet the needs of a specific client. In dementia care, the staff designs individualized care plans that specify desired outcomes such as the ability to meet selfcare needs and participate in activities, or the need to reduce anxiety and rninimize agitated behavior.
For example, Teri and GallagherThompson (1991) reported the successful treatment of depression in individuals with Alzheimer's disease by using cognitive interventions that challenged negative thoughts or behavioral strategies that modified the environment and increased pleasant activities. Choice of intervention strategy was based on the client's level of cognitive functioning and the response of the client. Declines in scores on depression scales occurred in both groups after treatment. Cognitive therapy proved more successful in clients with mild dementia and behavioral interventions were more appropriate for individuals with moderate or severe dementia. Controlled clinical trials of both intervention strategies are currently underway.
Individualized treatment plans also include the family. Interventions are shared between the family caregivers and the staff to provide for mutual problem-solving and continuity of care.
Targeted interventions to meet specific needs also include strategies to treat or prevent excess disabilities. Excess disability has been defined as a reversible deficit that is more disabling than the disease alone (Dawson, 1986). Sensory deficits, overstimulation, fatigue, minor illnesses, medication reactions, and the use of restraints are sources of excess disability. Knowledgeable assessment and intervention can reduce the presence of excess disability and allow individuals with dementia to function at their highest potential.
Because dementia is inevitably a deteriorating disease, a therapeutic milieu in dementia care is one that emphasizes process as well as outcomes. A social model of dementia views persons with dementia eis individuals who continue to interact with others and maintain relationships despite their illness (Lyman, 1989). The staff validates the human being trapped within the disease by affirming the individual and building tolerance.
It is important to recognize that in dementia, brain damage due to the disease may make individuals behave differently from the way they would wish. Gunderson (1978) described building tolerance as a validating role in which the staff creates a milieu in which clients may be sick and unpunished for it. In many institutional long-term care settings, behaviors are framed as "problems." In such settings, the staff operates on the basis of routines and rules; when rules are broken, patients are scolded or even restrained.
In contrast, therapeutic approaches reframe behavior in ways that build tolerance and acceptance. Gunderson (1983) explained that when clients are validated, their symptoms are interpreted as meaningful expressions of the person's inner-self - expressions that should not be terminated or ignored, but rather understood and accommodated.
The Gunderson model is prescriptive and defines the potential of staff members and environmental approaches to create a therapeutic milieu. Concern for and care of older adults with dementia has come to the forefront of elder care issues in the 1990s, and the health care community has come a long way in understanding the special needs of clients with dementia. And yet, implementation of the therapeutic processes described in this article requires a philosophic shift based on the following assumptions:
* The biomedical model offers a limited view of dementing illness based on neuropathology. In contrast, a social model provides a conceptual framework for creating a therapeutic milieu that treats the whole person by working within the social context and the caregiving relationship (Lyman, 1989).
* It is the relationships within the social environment - rather than the architecture and interior design of the physical environment - that create a therapeutic milieu.
* A therapeutic milieu reframes "problem behaviors" as meaningful expressions representing unmet needs and responding to supportive interventions.
* Little can be done to halt the progressive cognitive decline associated with dementia. Even so, the functioning of persons with dementia has the potential to improve in an environment where autonomy and independence are fostered within the abilities of the individual and the limitations of their illness.
There are no panaceas for nurses to apply in dementia care, but the philosophic assumptions and the therapeutic processes described in this article provide a blueprint that organizes the full spectrum of therapeutic interventions. These interventions are approaches that nurses use to meet clients' needs for both physical and psychologic safety. The outcome criteria may be helpful in clinical practice and in research to evaluate the effectiveness of this model in meeting the needs of clients.
In creating a therapeutic environment, the nurse's role includes meeting the needs of the group as a whole - as well as responding to the needs of individual clients. Nurses maintain a 24-hour presence in longterm care settings and provide leadership in rnamtaining a therapeutic milieu. Within the therapeutic milieu, nurses have a responsibility to provide a physical environment that maintains safety and structure, and fosters a sense of belonging. Nurses also have a responsibility to provide a social environment that creates a culture of caring that supports, involves, and validates individuals with dementia.
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Application of Gunderson's Model of Therapeutic Processes in Dementia Care