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The Psychodynamics of Dementia (4/5): Bereavement

How does grief counselling differ when the client has dementia? In the fourth part of her blog series coinciding with Alzheimer’s Month, psychotherapist and author Dr Esther Ramsay-Jones explores the experience of bereavement through the lens of dementia, including working with hallucinations, metaphor and felt-absence.


A person with dementia, in the early or moderate stages of the condition, will experience a raft of feelings following the death of someone he loves. Contemporary thinking on grief suggests that, while the death of someone we love leaves a hole in our lives that is never filled, life gradually springs up around it, fresh and eventually invigorating. However, for a client with dementia, the future itself is a more worrying concept. Loss might stir up a profound level of anxiety linking to his own fears of mortality and disintegration.

It can be that a person who has been living independently in conjunction with the support of a spouse, for instance, may become noticeably less able following his/her death. Bereavement might also lead to other significant changes in someone’s life – ie, input from social services, help from professional carers, transitions into care homes. As well as the emotional pain of grief, the real social impact of the death, along with the possible anxiety of increasing dependence on unfamiliar others, will also need to be considered.

Though a client with dementia may struggle to think clearly about the factual details of someone’s death, he will be affected by a residual sense of absence. The intensity of grief is not obvious at times – the client with dementia might forget that there has been a death. But when the death is remembered, feelings of sadness, anger, regret and guilt are likely to emerge in the work.

People with dementia can feel isolated in their dementia. With the added dimension of grief, a double isolation can ensue if family members are too nervous to talk about the bereavement for fear of provoking the memory of the death as if it has just happened. As per any therapeutic encounter, it is important to follow the lead of the client with dementia, responding to the material he brings.

Occasionally, a therapist will be invited into a person’s home. In this context it is vital to notice, for instance, where you might be invited to sit – is it in front of an important photograph of the person now dead, or opposite their empty chair? These can be non-verbal ways in which the person with dementia is communicating their grief.

A client with dementia may also suggest that the person who has died is still alive. Denial can be a powerful feature of immediate grief in all of us, a way of defending ourselves against the searing pain of loss. However, a person with dementia will also engage in confabulation to make sense of someone’s disappearance, developing stories about where the person might be to fill in the gaps.

It is also possible that a person with dementia will see the person who has died in others or in objects, a sort of explanatory hallucination that enables them to believe that nothing has changed. We shouldn’t puncture that reality with the factual truth, but rather use such moments to discover what the client with dementia is seeing in the object/mistaken person. Sometimes this can allow us to understand what the felt-absence is about; for instance, a lamp might be given the name of the dead person but only when the light is on.

Therapists working with people with dementia, certainly as the condition progresses, will notice this entrance into the metaphorical. The translation of such tentatively symbolic expressions can help a client with dementia to understand their experience at a deep, and meaningful, level. Putting into words the underlying feeling can be a huge relief, but this must be done with caution. Therapists must continue to be sensitive to the client’s reality, and avoid orienting him to the external reality of a death if it has been forgotten in the immediate moment.


Esther Ramsay Jones

Dr Esther Ramsay-Jones is a specialist psychotherapist in palliative care. She has conducted psychoanalytically informed research, and observations, in the field of dementia care, and her grandmother died of Alzheimer’s disease. Her book, Holding Time: Human Need and Relationships in Dementia Care, will be published by Free Association Books on 30 September.

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