The challenge of sharing meaning in reminiscence

Memory and language skills are often compromised in people with dementia, yet reminiscence sessions rely on both. Carol Thorne considers the challenges of sharing meaning in reminiscence work and how to overcome them

People living with dementia may have difficulty with memory and communication, yet reminiscence relies precisely on those two factors.
My question is: how can we square this circle?

Ten years ago, I joined a small-scale reminiscence project. We were a group of enthusiastic but inexperienced people whose shared and largely unspoken objectives were to encourage lively and fun sessions for some people living with dementia in our local care homes.

We used to meet every few months for support and to discuss topics that had been well received by the people we worked with. We were so intent on the challenge posed by which activities to offer that we largely failed to consider how sessions were presented or reflect on any benefits for the people themselves. Indeed, the training we received focused mainly on the types of activities we might use.

These days, support for practitioners delivering reminiscence sessions is becoming far easier to access. Research on the subject has developed and analysis of the potential benefits of reminiscence is taking place as researchers delve into the variety of activities included under this umbrella term. Helpful language and communication strategies are being studied.

Even so, we as reminiscence workers continue to focus much of our attention on the practical aspects of what we share with people with dementia. We believe that memory is awakened by sensory experiences, touching, tasting, smelling and sound and the joy of music. This is fundamental to the “what” aspect of reminiscence. It is the concrete part of what we bring to each group and at least part of the reason why we might take a bucket of seashells and gritty sand to our seaside topic or a leaky hot water bottle to aid recall of the cold, dark days of winter.

But we need to shift our focus from the “what” to the “how”. We should move the agenda on so that the process of reminiscence and the ways we seek to overcome the major difficulties faced by people with dementia take a much higher priority in our discourse. Resources to support the “what shall we do” of reminiscence abound but the “how to do it” is not so easily accessible and becomes much more a question of personal intuition. I am suggesting that perhaps we might review this strategy and begin to pay more attention to how we present topics.

Communication is key

Effective communication should be at the very heart of reminiscence. The subtle aspects of communication which are so heavily embedded in our individuality but are so hard for each of us to appreciate, seem to me to be the core of the “how” part of reminiscence. Only skilful communication will enable people with dementia to truly participate in our sessions in a respectful and equal partnership.

We must recognise potential communicative limitations that are part of dementia, including, word-finding difficulties, disrupted communication leading to a mismatch in meaning between speaker and listener plus the confusions that can be inconsistent and may vary from day to day. We are required to collaboratively negotiate communication strategies in order to begin to overcome these difficulties.

Professor Alison Wray (2020) encourages us to think of dementia as a communication difficulty. Communication is a collaborative process, negotiated between speaker and listener, to secure and develop shared meaning. Mercer (2003) recognises the powerful integration of language and cognition which is required to share meaning in communication. Communication can become disjointed or confused and meaning may struggle to cross boundaries so that it may be frustratingly difficult to share meaning in reminiscence sessions.

A model for reflection

How should we think about this vital interaction between language and cognition? The matrix (see diagram) is an attempt to provide a model for reflection on the communicative interaction of language and that aspect of cognition which we recognise as memory. This model is solely concerned with features of language and memory and as such it must be viewed as artificially simple.

Interactions are also subject to the influences of emotional and social contexts, which I make no attempt to integrate into this model but are equally important.

From person to person, over time and in differing contexts our communicative competences fluctuate. It would, therefore, never be appropriate to equate a particular quadrant of this matrix with a static set of communication skills which either frustrate or facilitate reminiscence. This matrix is intended as a guide to one way of thinking about communication and how we may either support or challenge our potential aim for shared meaning.

Quadrants B and C are perhaps easiest to unpick as they demonstrate the extremes of communicative competences. Quadrant B can be viewed as a zone where language skills and memory are soundly established. Here shared meaning is relatively easy to achieve between individuals or groups. Abstract concepts can be explored through discussion that bounces backwards and forwards aided by questions and explanations, for example a delightful exploration of the changing roles of women in society between a lady with early-stage dementia and her carer.

Quadrant C, in contrast, is the zone where both language and memory require profound and sensitive support. Here shared meaning can be much more difficult to achieve. However, supported by immediate experiences, sounds, tastes, smells or concrete objects, it is possible to enable people with dementia to experience personal recollections. Often there is no need for language as objects or experiences speak for themselves. For example, the dawning appreciation of a dancehall tune which illuminates someone’s face as they appear to recall teenage years.

Quadrants A and D are more challenging to interpret. Indeed, language and memory are so tightly entwined that on occasions it is impossible to be sure where major difficulties lie. Consider the confusions that frequently arise in naming family relationships. The utterance “mother is waiting for me” may be a memory lapse in which the actual person “mother” is confused with the person who is waiting, “daughter”. Equally it could be a word-finding difficulty where a word denoting another female family member is substituted for “daughter”. Quadrants A and D do, however, provide opportunities for us to reassess how we are supporting the process of communication.

Quadrant D is the zone where language skills are relatively high but memory is greatly impaired. For example, Marjorie, carefully examining a pinecone, says, “this is so beautiful, where did you get it?” She does not recall finding the cone in the garden a few moments before, but she confidently expresses her reaction to the pinecone. Her language skills remain more robust than her memory.

Questions are not always helpful

We once took sports equipment, including a leather football, into a care home where Charlie was immediately able to recount details of a professional footballer who came from the same small town where he was brought up. We were told about trips to away matches, details of scores and so on, a really colourful description of a special time in this man’s life.

When I interrupted to ask where this happened, he was at a loss. Further discussion was destroyed as the disheartened man softly recited his stock phrase, “I don’t know, I can’t remember”. Wray’s work suggests that questions are not always helpful when talking to people with dementia and yet, for those of us presenting reminiscence activities, questions can be an almost automatic response as we strive to gain insights into other people’s worlds.

It might be salutary to consider the purpose of quizzes for people with significant cognitive recall difficulties. I remember a quiz that was held at a Christmas party; it was enjoyed by carers and relatives but hardly any of the people living with dementia participated. One lady told me, “I don’t know any of this stuff”.

Quadrant A is the zone where language impairment appears greater than cognitive impairment. People may have disrupted vocabulary but retain some grammatical and pragmatic features.

Patience pays dividends

Vera’s tale springs to mind. She was sitting outside our reminiscence group as we played with marbles and the string of cats’ cradles, while also talking about children building dens in “wild” places.

Suddenly our eavesdropper joined in. She was unable to tell us explicitly about playing with her brother in the vicarage garden. The words escaped her, she confused nouns and called her brother a man, but it was absolutely clear from her limited vocabulary that she wanted to communicate the joy of being under a big tree with her brother. With long pauses it took some time for her to relive her tale and for us to share in her meaning, but our attention and encouragement paid dividends.

Wray’s notion of formulaic utterances that are repeated, but carry minimal meaning – for example, “that’s nice”, “I don’t know.” “I’m nearly 100 you know” – are the indicators that the people we are sharing reminiscence sessions with may have a veneer of language competence but could really struggle to share meaning. In this context there may well be a mismatch between the speaker’s and listeners’ access to meaning, but short and simple utterances with extended pauses and delays may help to resolve the problem.

Activities to suit all participants

Within any reminiscence session we draw on features from most of these quadrants and need to provide activities which can be developed to suit all participants. My favourites among these activities include passing an object, perhaps a rolling pin or sponge, concealed in a soft bag around the group. With support most participants are able to hold and feel the weight and texture of the object. Some people will comment on these features, “it’s heavy,” while others may be encouraged to talk about their experiences of baking or the Sunday car wash routine.

Home made board games can also be adapted to the needs of all members of a group. A small selection of objects associated with a particular topic, the seaside, sport, food, cleaning and so on, can be picked up and handled by members of the group. Gradually the objects are named. To turn this activity into a game, images of the objects suggested by members of the group are drawn on postcards and secured to the table with blue tac.

Then a counter, perhaps a small wooden block, is moved from one postcard to the next. At each stop a recollection is shared, initially by the reminiscence worker, but gradually the other members of the group begin to make contributions. Tales of wasps in the windfall apples, the journey home on market day with heavy bags, favourite recipes, helping in the garden or the agony of eating greens as a child. As each card is discussed it can be turned over so that the visual impact is slowly reduced.

The key to effective reminiscence

To stand back from myself and adjust both language and communication is something that I certainly find difficult and fail at over and over again. However, I would suggest that this may be the key to effective reminiscence experiences for people with dementia. Considering language and communication in the light of enabling shared meaning should be a focus in our roles as both speaker and listener.

In this respect I have found Wray’s work especially helpful. Her focus on the normal frustrations and inadequacies that we may feel as we attempt to ascribe meaning to all the utterances of our partners who are living with dementia is balanced by sensitive reflection on those aspects of communication which can help us in this process. The joy of reminiscence is revealed as we reflect on interactions in our attempts to meet perceived needs.

Key points
  • Reminiscence relies on language and memory, but these can be compromised by dementia
  • More attention should be paid to “how to do” reminiscence as opposed to “what shall we do?”
  • Skilful communication is the heart of the matter, recognising the potential for a “mismatch in meaning” between speaker and listener
  • Modelling the interaction of language and memory can help our thinking about communication and how shared meaning in reminiscence sessions can best be achieved.

References

Wray A (2020) Dementia communicaton across language boundaries: developing language awareness. YouTube video, search title at www.youtube.com.

Mercer N (2003) Words and Minds: How we use language to think together. London: Routledge.