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Journal of Dementia Care – July/August 2011 “Why we are at home with the SPECAL method
Zoë Elkins shares The Good Care Group’s positive experience of using the SPECAL method in their domiciliary care service.
Caring for a person with dementia who lives in his or her own home is a huge challenge. At The Good Care Group we have been using the SPECAL method since April 2010 as the foundation of our care for people with dementia living in their own homes (SPECAL stands for Specialized Early Care for Alzheimer’s). We now use this method in our work with over 30 people with dementia.
While the method is controversial in some quarters, the success we have experienced has reinforced our confidence in it. We have a strong working relationship with the SPECAL charity and we believe we are the only domiciliary care provider to be working systematically with the method.
An evaluation by the Royal College of Nursing (Pritchard & Dewing 1999) proved that SPECAL can help people stay at home longer. In this article we explain the SPECAL method and share one particular example of Steve, a man with dementia who has responded very well to it.
The SPECAL method uses intact memories, often from many years ago, to assist in creating a feeling of wellbeing. We learn about a person’s likes, dislikes and motivations by extremely detailed observational tracking which we call SPOT (SPECAL Observational Tracking). Listening to the person being cared for and identifying actions, gestures, frowns and smiles helps build an accurate picture of the individual’s personality, strengths and needs.
There is a clear, ongoing need to protect the emotional state of a person for whom care is provided and promote quality of life above all else – enabling people to live well with dementia. By responding to the needs of the individual and by boosting the self esteem of the person, care can be more effective and the individual’s life measurably improved. An added benefit is that family members can feel assured that their love done is being well looked after in a professional way.
Fundamental to the SPECAL method is the SPECAL Photograph Album, an analogy likening our normal memory system to a photograph album, in which each photograph represents an individual memory (see Garner 2008). Each stored photograph reflects the facts of what has just occurred in the person’s life, together with the feelings associated with those facts. With the onset of dementia, new photographs randomly contain just the feelings of what has just occurred, without the associated facts. Identifying intact positive photographs from the past becomes a crucial part of helping the person to make sense of their present.
Training for staff
Our training programme gives care staff an insight into dementia, underlining how psychological stress often has to be reduced and eliminated, and how best to support the person being cared for so that health and wellbeing are optimised. Care staff learn why it is important not to question or contradict the person being cared for, but to listen intently to everything being said. Careful listening can reap significant rewards – an individual may provide subtle clues as to what he or she finds pleasurable or positive in another way and if these are noted they can be utilised to further step up the person’s contentment and ability to have enjoyment.
We offer instruction, education and mentoring on a continuing basis. As our care staff work across a wide geographical area, we are planning to introduce a hand-held communication tool that will allow secure interactive web conferencing, emailing, texting and phoning. Care staff will be able to communicate with each other as well as provide electronic reports to central office.
Care staff learn that it takes time to develop a fully personalised care plan. As the member of staff begins working with an individual, their approach is fine-tuned through trial and error and ongoing careful observation over a long period of time. Usually we try to have just two care staff working as a team to cover each other’s days off. As a care plan takes shape, care staff establish ‘building blocks’ associated with aspects of a person’s life and long-term memories: these provide a context and reassurance for the individual, helping them feel good about himself or herself and creating links with today’s activities of daily life. Over time, the delivery of the care plan becomes more subtle and succinct.
The cues serve as ‘hooks’ marking pages in the photograph album where there are many happy photographs or memories. Once a person with dementia has found an old page with fully intact photographs they have a context, and are not constantly at a loss as to what is happening or what they should be doing next. SPECAL refers to this as ‘Making a Present of the Past’: we enable the person with dementia to use the information that they have from the past to overlay as context onto the necessary activities of today.
Does it work?
The SPECAL method can be applied successfully at any stage of dementia, although it tends to be easier to start at an early stage of the condition, when the information we can gather from the person is richer.
Before we begin, we discuss the SPECAL method with the person for whom care is to be provided, seeking the individual’s approval and consent for the method to be used. In the case of a person with advanced dementia, the communication process is more difficult but, with patience, messages flow in both directions. A person with failed memory will have an insight into his or her condition, knowing something is wrong and wishing to communicate. Such an individual is likely to have poor verbal skills and has largely lost the ability to offer explanations about any subject. However, consent can be obtained by carefully working with the individual over a period of time, interpreting positive and negative signals given by reactions such as frowns and smiles.
The role of family
We show care staff how to capture information effectively about an individual’s past. Family and friends may need encouragement to provide details about an individual’s likes and dislikes, what makes them tense, and what the person is likely to view positively and negatively. We do need family and friends to ‘buy into’ the way in which we work. Family members may feel they do not have much time available to help us and rather hope that we will just get on with looking after the individual and not bother them. They are gently shown that a little investment in time – to help build up a picture of the person being cared for – will be hugely beneficial all round. Family members also have to understand that there are limitations to what can be done and that there is no cure for dementia. They will not be able to ‘get mum back again’, but they will see how she benefits from having feelings of wellbeing and comfort.
Steve is in his eighties and had been taking antipsychotic drugs for two years before we began working with him. During the first month, we used the SPOT technique to find out as much as possible about who Steve is now, who he was, and who he would have been, had dementia not come into his life. This took time and the first month was quite rocky: Steve was suspicious, anxious, and unhappy about accepting assistance and could be aggressive.
In the second month, our approach to caring for him began to take shape as we put into place communication ‘building blocks’. At the end of the third month, the pattern of care had settled down. Steve was no longer a threat to himself, his wife, and others and could cease taking antipsychotic drugs. More importantly, Steve spent each day in a state of calm contentment, free from anxious questioning, frustration and agitation, feeling good about himself and feeling he has a rightful place in life again.
Themes in Steve’s life
As a young man, Steve had been a military pilot and later he had continued flying in his own light aircraft. Soon after we first met him, he made a wide circular movement with one arm, saying, “I flew round the world you know”. This was obviously a very enabling statement for Steve, and signs of wellbeing were clearly visible when he made it – he sat up straighter, looking us in the eye in an assertive but relaxed manner, smiling. He repeated the statement many times. Clearly, it was an important part of who he was and something he took much pride in. While it was a long time since he had piloted a plane, thoughts of flying and his military career were still vivid in his mind. We found that greeting him with a quick salute worked wonders. It indicated that we were in the same club, that we were ‘OK’.
Steve stored information sporadically; he did not understand where he was or what he should be doing, and this was a huge source of anxiety for him. Identifying and working with cues stemming from flying could be used immediately to provide him with a sense of context, purpose and pride in himself. In future, these cues will no doubt prove invaluable as non-verbal communication begins to take precedence over verbal skills. The circular arm gesture, for example, will carry a message for Steve even when words fail. The main benefit of using these flying cues – which include physical items such as a military jacket and headwear, photographs of his jet, and model aircraft – is enabling Steve to feel good about himself.
Steve had been a very independent person, so needing help with personal care upset him. Before we began caring for him, he was often aggressive and even violent, and his wife was at breaking point. While using references to flying (the ‘flying theme’ was Steve’s ‘primary theme’, in SPECAL language) did wonders for Steve’s self esteem, it did not help to persuade him that he might accept a little help from time to time. The care plan is rather like a jigsaw puzzle, with different elements that have to fit together in order to create wellbeing for the person with dementia. Another jigsaw piece is the ‘health theme’, which serves as a balance to the ‘primary theme’ – and a reason to accept support when needed.
Throughout Steve’s life he had had high blood pressure, and had many memories of having to temper the activities of life to accommodate this. We were able to use his ‘blood pressure’ as an acceptable reason to ask him to accept a little help from time to time, without ever having to confront him with the fact that he was losing his memory to dementia. For Steve, thinking about his blood pressure does not dent his self esteem in any way.
Care in practice
So in Steve’s case, we use the flying theme to build rapport and boost feelings of wellbeing, as the carer and Steve amble gently upstairs to the bathroom. On reaching the bathroom, the blood pressure cuff is brought out and Steve is asked to take his shirt off to have his blood pressure read. This is totally acceptable to Steve and in no way implies that he is unable to do certain things anymore – in fact, he quite likes the attention. The bathroom is filled with flying props, his air force cap and pictures of his jet. Once his shirt is off (which happens without concern, as the blood pressure context does not alarm Steve), the carer moves fluidly back to the flying theme, ensuring that Steve remains in an emotionally safe place. This enables a smooth and comfortable move through the activities of washing and dressing, with no stress involved for Steve.
We have developed a strategy with Steve in which no one ever says “goodbye” to him. “Goodbye” confuses and worries him. Where are they going? For how long? Is it OK? Does he need to do something? While Steve is being held in a calm contented state of well-being by another person, he does not wonder where others, such as his wife, maybe. The need for his wife stems from anxiety, which is mitigated by ensuring that he is never left alone, scared and wondering where he is and what he should be doing. The carer shares the role of the wife in providing context and information, enabling the baton of care to be passed from wife to carer and back again as needed.
So rather than make a big deal about going out and saying “goodbye”, whenever anyone leaves a room Steve is in, it is with a quiet murmur of “needing to use the bathroom”. This leaves him feeling calm and does not invite him to follow or feel he needs to do anything. With good care and attention to manage his emotional state, he rarely asks after his wife now. This is a huge success because it demonstrates how much more confident in himself he is feeling. But occasionally he does ask where she is. And so an acceptable reason for her absence needed to be identified, as this could still be a major source of agitation that sometimes led to quite violent behaviour from Steve.
At first we found it difficult to answer his question “Where is my wife?” We tried saying things like, “She’s out shopping”, or “She’s at her daughter’s”, but these made him very cross. It took a lot of trial and error before we came across the explanation that was most acceptable to Steve, which was that she was at her office sorting out a problem. The ‘problem’ was critical, as it implied she was not having fun without him. The ‘office’ was also important because he had always been proud of her for running her own business, but had regarded it as somewhat ‘small’ business and not anything that he would ever need to be involved in.
This explanation made perfect sense to him, and did not cause him to worry that she was off doing things without him that he really should have been involved in. How much better than: “Well she’s gone to France for a long weekend without you because you are exhausting her.”
At the beginning of the care programme, we suggested to Steve’s wife that we would try to work towards her being able to go out for the day and then later go on holiday for a week. She welcomed the ideas but did not think it would be possible. Like so many carers, she thought her loved one was unique and that these techniques that worked for others would never work for her. Steve’s wife, who had not been on holiday for the past three years, has recently enjoyed a five-day break in France. Steve’s progress is proof that the application of the SPECAL method can achieve measurable and profound results.
Bridge building with the person living with dementia
To communicate effectively with a person living with dementia, and to give the person the optimum lifestyle, the greatest reduction in anxiety and the most happiness, The Good Care Group advocates that caregivers follow the SPECAL golden rules:
Do not contradict
Never contradict the person. Informing and correcting an individual with dementia is a fruitless exercise. It is far better to go with the flow and join the journey that the person is on as a travelling companion, rather than be constantly reminding the person that he or she has got something wrong or cannot do something any more.
Avoid direct questions
Never ask the person direct questions, as this can heighten the individual’s level of stress. Questions, by their nature, are a direct request for information, and it is information that people with dementia lack. Due to a dysfunctional working memory, new information is often not stored. Asking questions places a direct strain on the working memory and can easily highlight a person’s disability, reducing emotional wellbeing in an instant.
Asking a person with dementia if he or she would like a cup of tea would appear on the surface to be innocuous. But the question could be stressful if the person starts wondering whether or not he or she has just had a cup. The individual might wonder if anyone else was having tea or if having tea would prevent them doing something else and if a charge for tea would be made. Soon, the individual is searching for answers to questions that have not been stored, and panic is not far away.
So, instead of a question, a statement would be better. Perhaps: “I think it might be time for a cup of tea”. An option has been presented – a platform from which unlimited choice can be made. The person can accept, decline or even ignore the choice in front of them, but no pressure has been placed on them. The risk of them not finding the right information and feeling like they have failed in some way has been totally removed.
Look for cues from the ‘expert’
Learn from the ‘expert’ – the ‘expert’ being the person with dementia. The carer or healthcare professional should look for behavioural clues to identify what generates positive and negative reactions and which phrases delivered to the individual with dementia are best at building and maintaining a dialogue bridge. People living with dementia will always tell us if we are getting it right or wrong.
Become used to liking and making use of the tendency of the person with dementia to repeat stories and information. Once positive intact memories and activities that bring the individual joy are tapped into, these can be revisited and recycled at any appropriate time.
If a difficulty arises, opt for saying ‘silly me’ rather than ‘silly you’. While blaming a person with dementia for a minor difficulty may seem harmless, the individual is likely to lose self-esteem and further retreat into himself or herself. By saying ‘silly me’, the carer is defusing the situation by apparently taking blame. The person with dementia is provided with a bolster for self-esteem and retains emotional safety, becoming the competent person in the relationship, caring about the carer rather than the other way round. Sadly, this is not often seen in caregiver/care recipient relationships.
Pritchard EJ, Dewing J (1999) A multi-method evaluation of a service for people with dementia. RCNI Report No 19. Oxford: Royal College of Nursing Institute.
Garner P (2008) The SPECAL photograph album. 3rd ed. Hawling: Windrush Hill Books.
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