Dementia Gateway: Difficult situations

Case study: Active listening in action

Rose was finding it difficult to communicate.

People with dementia can usually let us know a lot about what is troubling them, either verbally or non-verbally (or both), if we listen actively

Read the full case study:

• Understanding the situation - 1. Research and development findings Open

  Claire, the care worker in this case study, had received training in active listening, and so was aware of what it involves. The term 'active listening' was originally used by the psychologist Carl Rogers in the 1950s. A number of dementia experts have written about how active listening can be applied in the context of working with people with dementia (see the suggested reading at the end of this case study, in particular Killick and Allan 2001). Here is some background information about active listening with people with dementia, including lots of practical examples.

  Active listening involves much more than simply hearing what another person is saying. To listen actively means that:

  • we show the person that we are paying full attention
  • we try to understand exactly what the person means
  • we help the person to express themselves.

  Active listening involves:

  • Paying full attention – focusing on the other person, with openness and respect, and putting our own concerns and thoughts to one side for a while. We observe all the person's non-verbal communication as well as listening to everything the person says. We are seeking to understand the messages lying behind the person's confused words or challenging behaviour.
  • Offering prompts if these are necessary – for example, to help the person remember what they were saying, to make suggestions (if necessary) based on our knowledge of the person and their concerns, or to help the person find a word they are searching for.
  • Repeating and paraphrasing – either using the person's own words, or finding our own words to represent what we think the person means, we say back to the person what they have said to us. For example, the person with dementia shouts, 'I hate this place – I want to go home; we respond, 'You hate it here. You want to go home'.
  • Reflecting feelings – noticing feelings that the person indicates verbally or non- verbally and mentioning these – for example, 'you sound angry' or 'you look very sad'.
  • Mirroring – keeping our own body language in tune with the other person's body language. If, for example, the person with dementia is hunched over, crying, we might lean forward and show a sad facial expression.
  • Focusing – if necessary, finding the appropriate moment to take a conversation back and focus in on an area of significance mentioned or a feeling demonstrated by the other person – for example, 'when you told me how much you hate it here, you looked very sad…'.
  • Questioning – when we are listening actively, we ask questions mainly to help the person expand on what they are saying – for example, 'You said you hate this place…can you tell me what you hate about it?' or 'You said you want to go home…can you tell me what you want that's at home?'. We might also need to ask questions to clarify that we've understood the person correctly. It is important to avoid questions that the person may find challenging (such as 'Why did you shout at me?') and questions that are too complex.
  • Summarising – when appropriate, re-capping on a section of a conversation or at the end to ensure you have understood the person's key messages.
  • Silence – staying quiet at the appropriate moment can give the person the space they need to bring together their thoughts and express what's going on for them.

• Understanding the situation - 2. Views collected from key people Open

  The care worker's previous knowledge of Rose certainly helps her communicate better with Rose.

• Actions Open

  Active listening often helps people with dementia express themselves more effectively. This is particularly important if the person is experiencing difficult emotions. By using these techniques we convey our empathy, which can help the person feel safe enough to open up about what's bothering them. Furthermore, using the active listening techniques of repeating, paraphrasing, reflecting and focusing, also gives the person an opportunity to hear what they have communicated and clarify or expand on it. Importantly, when we listen actively, the person with dementia is taking the lead in the interaction and we are more likely to discover what's important to them.

  Active listening is not a magic solution that will make difficult situations disappear, but its benefit lies in the support we can give to individual people with dementia through using these techniques.

  ESMI Weekend Day Centre in Stockport uses active listening as one of a range of approaches in its work with people with dementia. This is an example of a care worker using active listening and comes from Claire Carr who works at the centre.

  Rose suddenly becomes tearful and agitated. She stands up from her chair and looks around, as if searching for something or someone.

  I approach Rose, mirroring her sadness with my own facial expression, and say 'Rose, you look sad.'

  'Sad… yes.'

  'Why are you sad?'

  'Can't… not… where.'

  'You can't?'

  'No, can't get…' Again, Rose looks around, as if searching.

  'Can't get?… Can't find?'

  'Find. Yes.'

  'You can't find something?'

  'Yes'. Rose's eyes widen at being understood. She becomes more animated and less distressed.

  'Can't find what?'

  She takes my hand and leads me to a door. 'Gone there'.

  'Gone outside… Do you mean Derek?'

  'Derek. Derek. Yes.'

  Rose relaxes and her face looks happier. I have understood what is worrying her, and now I can answer her concerns by explaining where Derek is and when he will be returning. She frequently gets upset about her husband not being here, but we always try and work out whether this is what's concerning Rose, rather than assuming. It helps her to feel that she's being listened to and she is visibly relieved when she feels that someone understands.

  (Rose and Derek are pseudonyms but the conversation is a true event.)

• Results Open

  Rose showed that she felt relieved to be understood: her non-verbal communication told us that this conversation helped her relax and feel happy. With active listening this communication became a positive exchange, turning a moment of anxiety and sadness into relief. If Rose had not feel heard, it is quite likely that her initial tearfulness and agitation would have escalated into a situation that could have been challenging for staff to respond to. Rose may have tried to leave the centre or been very upset for an extended period.

  Claire was pleased to be able to answer Rose's concerns in the present, and also glad that she was able to make sense of Rose's message because of what she knew about Rose from working with her before.

  Claire was able to intervene like this because she knew Rose, in particular she knew about Derek: who he is, when he was likely to visit next, and where he was likely to be at the moment. She also knew that Derek's absence is a regular cause of sadness and distress to Rose. Claire was also familiar with Rose's difficulties with using words: she was patient, not rushing Rose, and always looking to try to make sense of Rose's few words.

  A new care worker, or one who hadn't taken any time to get to know Rose, would not have this valuable information to help them. Without it, it is likely that the conversation would be very different, and far more likely that Rose's concerns would be misunderstood.

  The outcome of this exchange was not surprising. On this occasion, Rose repeated a pattern of behaviour that she's shown before: she becomes agitated and frightened when she thinks of, but can't find, her husband, and is then relieved when care staff reassure her and talk to her about her husband. But as Claire says, the staff are open-minded to what Rose might be trying to say to them: they don't assume that this is always what is concerning Rose. On another occasion, it may be that Rose is disoriented and can't find where the toilet is.

• Advice for others Open

  When we find ourselves in a difficult situation with a person with dementia it is helpful to feel that there is a strategy we can use. Attempting to 'manage' the person's behaviour would often serve only to create more stress both for ourselves and for the person with dementia, so rather than trying to control the person's behaviour, we need to try to understand it. People with dementia can usually let us know a lot about what is troubling them, either verbally or non-verbally (or both), if we listen actively.

  Sometimes, just listening is enough to help the person – through active listening we help the person feel that someone understands and they are not alone with their problems. Moreover, when we have understood what's going on for the person with dementia, we may be able to give constructive help to resolve their problems.

  While active listening is, in many ways, a very simple strategy, it can help to attend a training course in listening skills or basic counselling skills in order to have an opportunity to practise and feel confident in using the methods described.

• Financial implications  Open

  There is a general consensus in dementia care that active listening, as one of a range of good practice approaches, leads to better care, and that good care is cost-effective. Busy carers and care staff may feel that they can't afford the time to devote to active listening, but it is an investment worth making – through using these techniques, we often prevent situations from getting out of control and we can resolve a person's problems before their emotions escalate to a point when we can no longer do anything to help.

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