Dance therapy and communication in dementia

PREFACE :
Dance therapy came into being as a formal profession in the United States in the 1940s as one of the group therapies used with the huge numbers of traumatised returned serviceman. While the word "dance" tends to conjure up images of ballet or social dance, the dance of dance therapy has roots in a more historical/anthropological understanding. In the past, and indeed in some cultures today, people dance to celebrate, to grieve, to reinforce social mores, to teach and pass on culture, and so on. Dance is not something apart from life, reserved for those with athletic bodies and performing skills. Rather, it is an essentially human activity of expression and communication. "To dance is human". (Judith Hanna, 1979)

Accompanying this understanding of dance is a view which rejects Cartesian dualism and sees mind and body as inextricably linked. In working with the body and body movement, the dance therapist is working with the whole person. He or she uses the therapeutic qualities inherent in dance to meet particular needs and to promote growth and physical/emotional integration.

For the past 13 years I have worked as a dance therapist in the field of dementia and am presently pursuing doctoral studies on the maintenance of self in dementia. I therefore offer in this article insights gained through the practice of dance therapy, insights which have been more clearly articulated and illuminated through my studies on the self and dementia care.

Communication is fundamental to human being

Professor Stan van Hooft, an Australian philosopher, has pointed out that we not only happen to be creatures who communicate, but also that we are creatures who need to communicate. This need to communicate is present from the very beginning and throughout the life of individual human beings. Indeed we have a will to communicate. "Communication is much more than the mere imparting of information from one person to another. It should be understood broadly as the overcoming of human isolation. To communicate is the verb we use to describe the dynamic processes through which we express our being in relation to others." (van Hooft, 1995) Dementia with its attack on so many of the processes of communication is therefore extremely threatening to our very humanity - not only in terms of diminishing the personhood of the person with dementia in the eyes of other people, but also in terms of feelings of well being, self worth etc., on the part of the person with dementia. The issue of communication is clearly an important issue to address in dementia care planning.

Communication is both verbal and non-verbal

Verbal communication is often taken to be synonymous with communication. There is no doubt that verbal communication is important - it is certainly taken as a distinguishing characteristic of human beings. While most of us would recognise that much of human communication is non-verbal, we still place major emphasis on the verbal. However, as dementia advances such communication becomes more and more difficult and while there is valuable work being done to maintain this verbal aspect of communication, even this work has to depend more and more on non-verbal cues to help support or foster a verbal response. The non-verbal is the area of course in which dance therapists have particular expertise in terms of observational skills in human movement expression, sensitivity to touch as communication and ability to tap into energy levels, affective (emotional) and movement cues. This is not an either/or situation - in order to communicate one needs to call on the whole spectrum of human communication skills, verbal and non-verbal. However, it is fair to say that as dementia advances, the non-verbal becomes more and more important as a prime means of communication and expression.

Communication is a "dance" between two (or more) people

Hamilton (1994) has pointed out that communication is interaction and that there are at least two parties in any act of communicating. The focus in studies of communication has often been on the person with the disability rather than taking into account the missed cues, the misunderstandings, etc. of the so-called able person. Kitwood, in identifying "malignant social psychology", has demonstrated how carers may enhance or diminish interactions through their own behaviour.

In dance therapy, communication is very much an interaction, a dance between two people. This dance is characterised by its give and take quality - both participants contribute. The dance therapist of course must be the more adaptable in the partnership in order to facilitate communication with the person with dementia. In practical terms, this means that the therapist does not dominate the "conversation" by leading, or imposing his/her own particular qualities. Most important is to give the person with dementia some time and space to take in and to respond. The therapist encourages by meeting the person where that person is in terms of quality of movement, energy level etc. So first of all s/he must just be present to the person, but ever alert for some response. The therapist may have to take quite a leading role (but even here, his/her understanding of the person's quality of movement and energy will help him/her start with something which is likely to connect). However, often once a small response is observed, s/he can build on that by reflecting the movement or gesture back to the person. This is partly to create relationship (in dancing with you I accept you) but also to give the person back what they are "saying" writ LARGE. This is affirming of the person and intended also to encourage self awareness and response. In this dance the person comes to recognise him/herself as well as the partner.

We communicate when we care

Hamilton has also pointed out that people with dementia (or indeed without dementia !) will not be motivated to communicate about something which is not meaningful to them. The dance therapist is not engaged in teaching dance technique or even in giving a creative dance experience per se. S/he is mostly interested in dancing the dance of the person s/he's working with, responding to what is meaningful for the person with dementia.

The greater the disability the more important the quality of the communication process

While I have emphasised the need for the dance therapist in one sense to step back, to not impose, to give the person with dementia the floor as it were, in another way, it is hugely important that the dance therapist is a whole human being in this interaction. Marcel (quoted in Post, 1995) talks of the mystery of presence - the power of simply being with another. The dance therapist, ideally, is totally open and willing to be fully human with his/her partner - every pore, every nerve must be alert, attentive. For total involvement (physical and emotional) and attention are part of any dance and are even more important when one of the "dancers" is struggling with dementia.

Environments support communication

Apart from the actual interaction of two embodied persons, there are other aspects of dance therapy which assist and support the communication process -one is environment. Dance therapists try to create an environment, a space, which is safe, accepting and above all focussed. The use of music or simple body rhythm also helps to contain and at times bring the fragmented parts of the self together into a coherent whole (albeit temporarily). External interruptions distractions are kept to a minimum.

The dance itself, as an aesthetic activity, offers an environment which is playful, creative and life enhancing, an environment which invites the person with dementia to emerge and join the dance !

Communication in the context of dance therapy is grounded in a view of human beings which does not limit them to cognition nor split off mind, emotion and body. The best communication is equal, requires total presence and a sensitivity and readiness to adjust to each other. Obviously, in dementia, the dance therapist has to work hard to create an equal relationship, an environment and a meaningful context in which to interact. (We also should not underestimate the endeavours of the person with dementia to communicate). As a dance therapist I aim to tap into that will to communicate described by van Hooft by inviting the person to join the dance.
Finally, in thinking about communication with people with dementia, I am reminded of Alice who, in the first few minutes in Wonderland, grows and shrinks so many times that she becomes quite confused about who she is. Is she Ada - or Mabel ? Or ?
"I must be Mabel after all, and I shall have to go and live in that poky little house, and have next to no toys to play with, and oh, ever so many lessons to learn! No, I've made up my mind about it: If I'm Mabel, I'll stay down here ! It'll be no use their putting their heads down and saying, 'Come up again, dear!' I shall only look up and say, 'Who am I, then? Tell me that first, and then, if I like being that person, I'll come up: if not I'll stay down here till I'm somebody else' - but, oh dear!" cried Alice with a sudden burst of tears, "I do wish they would put their heads down! I am so very tired of being all alone here!"

contents article index
Magazine Article	Article published in Signpost May 1999
Dance therapy and communication in dementia	KEYWORDS : dementia dance therapy communication
PREFACE : Dance therapy came into being as a formal profession in the United States in the 1940s as one of the group therapies used with the huge numbers of traumatised returned serviceman. While the word "dance" tends to conjure up images of ballet or social dance, the dance of dance therapy has roots in a more historical/anthropological understanding. In the past, and indeed in some cultures today, people dance to celebrate, to grieve, to reinforce social mores, to teach and pass on culture, and so on. Dance is not something apart from life, reserved for those with athletic bodies and performing skills. Rather, it is an essentially human activity of expression and communication. "To dance is human". (Judith Hanna, 1979) Accompanying this understanding of dance is a view which rejects Cartesian dualism and sees mind and body as inextricably linked. In working with the body and body movement, the dance therapist is working with the whole person. He or she uses the therapeutic qualities inherent in dance to meet particular needs and to promote growth and physical/emotional integration. For the past 13 years I have worked as a dance therapist in the field of dementia and am presently pursuing doctoral studies on the maintenance of self in dementia. I therefore offer in this article insights gained through the practice of dance therapy, insights which have been more clearly articulated and illuminated through my studies on the self and dementia care. Communication is fundamental to human being Professor Stan van Hooft, an Australian philosopher, has pointed out that we not only happen to be creatures who communicate, but also that we are creatures who need to communicate. This need to communicate is present from the very beginning and throughout the life of individual human beings. Indeed we have a will to communicate. "Communication is much more than the mere imparting of information from one person to another. It should be understood broadly as the overcoming of human isolation. To communicate is the verb we use to describe the dynamic processes through which we express our being in relation to others." (van Hooft, 1995) Dementia with its attack on so many of the processes of communication is therefore extremely threatening to our very humanity - not only in terms of diminishing the personhood of the person with dementia in the eyes of other people, but also in terms of feelings of well being, self worth etc., on the part of the person with dementia. The issue of communication is clearly an important issue to address in dementia care planning. Communication is both verbal and non-verbal Verbal communication is often taken to be synonymous with communication. There is no doubt that verbal communication is important - it is certainly taken as a distinguishing characteristic of human beings. While most of us would recognise that much of human communication is non-verbal, we still place major emphasis on the verbal. However, as dementia advances such communication becomes more and more difficult and while there is valuable work being done to maintain this verbal aspect of communication, even this work has to depend more and more on non-verbal cues to help support or foster a verbal response. The non-verbal is the area of course in which dance therapists have particular expertise in terms of observational skills in human movement expression, sensitivity to touch as communication and ability to tap into energy levels, affective (emotional) and movement cues. This is not an either/or situation - in order to communicate one needs to call on the whole spectrum of human communication skills, verbal and non-verbal. However, it is fair to say that as dementia advances, the non-verbal becomes more and more important as a prime means of communication and expression. Communication is a "dance" between two (or more) people Hamilton (1994) has pointed out that communication is interaction and that there are at least two parties in any act of communicating. The focus in studies of communication has often been on the person with the disability rather than taking into account the missed cues, the misunderstandings, etc. of the so-called able person. Kitwood, in identifying "malignant social psychology", has demonstrated how carers may enhance or diminish interactions through their own behaviour. In dance therapy, communication is very much an interaction, a dance between two people. This dance is characterised by its give and take quality - both participants contribute. The dance therapist of course must be the more adaptable in the partnership in order to facilitate communication with the person with dementia. In practical terms, this means that the therapist does not dominate the "conversation" by leading, or imposing his/her own particular qualities. Most important is to give the person with dementia some time and space to take in and to respond. The therapist encourages by meeting the person where that person is in terms of quality of movement, energy level etc. So first of all s/he must just be present to the person, but ever alert for some response. The therapist may have to take quite a leading role (but even here, his/her understanding of the person's quality of movement and energy will help him/her start with something which is likely to connect). However, often once a small response is observed, s/he can build on that by reflecting the movement or gesture back to the person. This is partly to create relationship (in dancing with you I accept you) but also to give the person back what they are "saying" writ LARGE. This is affirming of the person and intended also to encourage self awareness and response. In this dance the person comes to recognise him/herself as well as the partner. We communicate when we care Hamilton has also pointed out that people with dementia (or indeed without dementia !) will not be motivated to communicate about something which is not meaningful to them. The dance therapist is not engaged in teaching dance technique or even in giving a creative dance experience per se. S/he is mostly interested in dancing the dance of the person s/he's working with, responding to what is meaningful for the person with dementia. The greater the disability the more important the quality of the communication process While I have emphasised the need for the dance therapist in one sense to step back, to not impose, to give the person with dementia the floor as it were, in another way, it is hugely important that the dance therapist is a whole human being in this interaction. Marcel (quoted in Post, 1995) talks of the mystery of presence - the power of simply being with another. The dance therapist, ideally, is totally open and willing to be fully human with his/her partner - every pore, every nerve must be alert, attentive. For total involvement (physical and emotional) and attention are part of any dance and are even more important when one of the "dancers" is struggling with dementia. Environments support communication Apart from the actual interaction of two embodied persons, there are other aspects of dance therapy which assist and support the communication process -one is environment. Dance therapists try to create an environment, a space, which is safe, accepting and above all focussed. The use of music or simple body rhythm also helps to contain and at times bring the fragmented parts of the self together into a coherent whole (albeit temporarily). External interruptions distractions are kept to a minimum. The dance itself, as an aesthetic activity, offers an environment which is playful, creative and life enhancing, an environment which invites the person with dementia to emerge and join the dance ! Communication in the context of dance therapy is grounded in a view of human beings which does not limit them to cognition nor split off mind, emotion and body. The best communication is equal, requires total presence and a sensitivity and readiness to adjust to each other. Obviously, in dementia, the dance therapist has to work hard to create an equal relationship, an environment and a meaningful context in which to interact. (We also should not underestimate the endeavours of the person with dementia to communicate). As a dance therapist I aim to tap into that will to communicate described by van Hooft by inviting the person to join the dance. Finally, in thinking about communication with people with dementia, I am reminded of Alice who, in the first few minutes in Wonderland, grows and shrinks so many times that she becomes quite confused about who she is. Is she Ada - or Mabel ? Or ? "I must be Mabel after all, and I shall have to go and live in that poky little house, and have next to no toys to play with, and oh, ever so many lessons to learn! No, I've made up my mind about it: If I'm Mabel, I'll stay down here ! It'll be no use their putting their heads down and saying, 'Come up again, dear!' I shall only look up and say, 'Who am I, then? Tell me that first, and then, if I like being that person, I'll come up: if not I'll stay down here till I'm somebody else' - but, oh dear!" cried Alice with a sudden burst of tears, "I do wish they would put their heads down! I am so very tired of being all alone here!" Heather Hill ( Australia ) BA M.Ed. Grad.Dip Movement and Dance Grad.Cert. Dance Therapy "Dance Therapy and Communication in Dementia" - Published in Signpost, Vol. 4, Number 1, May 1999. Produced by : Cardiff and District Community NHS Trust Reprinted with permission of Signpost Editor. REFERENCES : Hamilton, H. Ehrenberger, 1994, Conversations with an Alzheimers' patient. Cambridge: University Press. Hanna, J.L., 1979, To Dance is Human. Austin, Texas: University of Texas Press Kitwood, T., 1997, Dementia reconsidered: The person comes first. Open University Press. Post, S.G., 1995 The moral challenge of Alzheimer Disease. Baltimore, Maryland: Johns Hopkins University Press. van Hooft, S., 1995, Caring: An essay in the philosophy of ethics. Colorado: University Press of Colorado. [ Article Index ] [ Contents Page ] [ Top of Page ]

Article published in Signpost May 1999