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Australian Journal of Dementia Care
June/July 2016 Vol 5 No 3
T
om Kitwood and Mary
Marshall both saw
communication as a
cornerstone of dementia care,
and of all those who have
made a major contribution in
this area I have chosen Steven
Sabat (pictured) as their
representative for this article.
He is probably less well-
known than other people
featured in this series, and has
written only one book, but it is
a master work; his co-editing
of another, and his various
papers and chapters are
ancillary to that achievement.
To those who haven’t had
the pleasure or privilege of
meeting Steven, a glance at the
acknowledgment pages in his
book
The experience of
Alzheimer’s disease: life through a
tangled veil
(Sabat 2001) will
tell you what sort of a man he
is. Never has an author
acknowledged his sources of
support more fulsomely. His
students at Georgetown
University in Washington,
where he taught for 40 years
and where he is now Emeritus
Professor of Psychology, were
fortunate indeed.
Before I begin outlining
Steven’s achievement I must
register a small caveat.
Throughout his book he freely
employs the words ‘sufferer’
and ‘afflicted’ in reference to
people with dementia. For me
these terms jar and tend to
contradict his message, which
is one of humanity and
compassion.
Crucial observations
In the preface of his book
Steven makes two crucial
observations in view of what
is to follow. The first identifies
our responsibility towards a
person with the condition, and
the consequences of our
dereliction of it:
“How we view the sufferer
–
as
a human being whose sense of
self, whose dignity, dispositions,
pride, and whose ability to
understand the meaning of
situations and to act
meaningfully, remain intact to
some degree on the one hand, or
as a ‘demented’, defective,
helpless and confused patient
lacking a self, on the other
–
will
affect the ways in which we treat
that person, which in turn will
affect how that person behaves.”
The second is summed up in
the words:
“This book represents
a paradigm shift in that the
afflicted person is seen as the
subject
of study rather than as an
object
of study.”
Once that transition is
accomplished it becomes
possible to let “the wealth of
living reality” (Luria 1987) in.
It complicates the issue, of
course, but this acts as a
necessary corrective to
mechanistic theorising.
Misunderstandings
of communication
From his experience as a
psychologist, Steven noticed
that his medical colleagues
attributed errors in speech and
understanding by people with
dementia entirely to brain
damage, whereas his instinct
was to see them as
misunderstandings of
communication. As such they
could be characteristics of both
partners in an interaction.
Since the medics could not
provide a cure for the
condition, he concluded that
concentrating on the mistakes
in reading language and
situations by the parties might
yield insights which could
affect the quality of care. He
determined to pursue this line
of inquiry.
An example of what he
meant was the phenomenon of
what (borrowing the term
from social psychology) he
called ‘positioning’. This is
best illustrated by an example:
“It was immediately following
a talk I had given to caregivers
that an intelligent and sensitive
caregiver, and her spouse who
was an AD
[Alzheimer’s
disease]
sufferer, approached me
with a few questions and
comments. She began by
thanking me for the lecture, and
introduced herself. She then
introduced her husband who was
standing to her side and slightly
behind her, by saying, ‘This is my
husband; he’s the patient’. In this
situation the spouse of the
speaker was positioned
immediately as an Alzheimer
sufferer”
(Sabat 2001 p18).
Positive and negative
consequences of positioning
can result in an individual
feeling “powerful or
powerless, confident or
apologetic, dominant or
submissive, definitive or
tentative, authorised or
unauthorised” (Harré & van
Langanhove 1999).
These are distinctions which
Steven draws in the first
chapter of his book. Amongst
the subjects covered by later
chapters are: language (the
longest), disability, self-esteem
and selfhood. These titles,
however, give no indication of
their tenor – they are first and
foremost packed with in-depth
portraits of individuals,
extracts from conversations
with them, analyses of these,
and references to other
authorities on the subject. It is
a rich and confident mix.
One chapter introduces the
idea of a person with dementia
as ‘a semiotic subject’. In 1994
Steven and his colleague Rom
Harré published a
groundbreaking paper in
which they defined this
concept as behaviour which
reveals intention, which
demonstrates interpretative
powers, and which evaluates
events and situations (Sabat &
Harré). This idea that people
with the condition can still act
in the world in various ways,
and ways which are
demonstrable, informs all
Steven’s work.
Communication and its
possibilities becomes the
central plank in any positive
philosophy of dementia, and is
a major contribution to the
development of caring
strategies.
Unique approach
It is time I illustrated the
unique method of Steven’s
The story of dementia: Steven Sabat
John Killick
continues his series of articles for
AJDC
, exploring
the history of dementia through the stories of individuals