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The Psychodynamics of Dementia (5/5): Transition to nursing or palliative care

What therapeutic challenges and opportunities arise when a client with dementia enters nursing or palliative care? In the concluding part of her blog series coinciding with Alzheimer’s Month, psychotherapist and author Dr Esther Ramsay-Jones discusses working through this latter stage in the trajectory of dementia.


Making the transition into a residential, nursing or palliative care setting can be fraught for anyone who is becoming increasingly dependent and unwell. For a person with dementia, whose capacity to process the rationale behind such a change may be limited, this will be a bewildering time. A client with dementia might report feeling out of control, helpless and frightened. There may be a lack of understanding, a belief that a relative might be taking over the care, or that an impending house sale – to fund the care – signifies a simple house move. For some clients, though, this may be positive: the burden of having to think about what the future holds might be taken away, and any associated anxiety may diminish.

The move into a care or nursing home may also signify the end of the therapeutic work; this will be another loss to the client with dementia. It will be necessary to make reference to the ending of the work in each session so that, on some level, the person with dementia can absorb this reality, and associated feelings come to the fore.

On the other hand, a therapist and client might come to the agreement that the work ought to continue in order to ease the settling in process. A third party, from the family, can help with this, liaising with the professional care setting to support further therapeutic input. For a therapist this can be a challenging context to work in: private spaces, without interruption, can be hard to come by; sessions might be overlooked or the person with dementia might be surprised to see the therapist out of context. If therapy is ongoing during the transitional period, it is even more important than before to seek consent on each visit from the client with dementia, and to remind him or her at the end of each session that there will be a return visit. This is to ensure that the therapy will not be disruptive to the transitional process.

I have found it can be particularly difficult to say goodbye to a client who is settling in to a care or nursing home. Sometimes you are experienced as a rescuer, and your visit mistaken as coming to take the person home. Therapy in this context is much less focussed on the cleverness of words and interpretation, and more about mirroring and holding. At this stage I have found myself communicating at a more embodied level, noticing when the client with dementia is in need of a certain facial expression or a change of seating so that proximity is experienced when he or she is far away. Sometimes I have had to draw on other sources as a way into communication, such as objects in the room or sights outside a window.

Paying particular attention (by drawing both on psychodynamic observational skills and the therapist’s countertransference) to the unconscious affective flows and bodily gestures, then, will become more and more important as the client enters into a reality that moves beyond the conceptual into the increasingly experiential.


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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