How Picture Books can help maintain ‘personhood’ in people with Dementia

In his book ‘Dementia reconsidered’ Tom Kitwood identifies how in really good dementia care which enhances the quality of life, twelve different types of interaction are involved. Each one enhances personhood in a different way.

Below we describe how the use of ‘Pictures to Share’ picture books can be assessed using these twelve criteria.

1. Recognition - a man or woman who has dementia is being acknowledged as a person, known by name, affirmed in his or her own uniqueness.

A carer or visitor approaches a resident holding three different picture books and looking into his/her eyes addresses him/her by name and touches his/her hand.

2. Negotiation - people who have dementia are being consulted about their preferences, desires or needs, rather than being conformed to other’s assumptions.

The carer or visitor asks the resident if he/she would like to look at a book together, and if so, asks them to choose one.

3. Collaboration - two or more people aligned on a shared task

The carer or visitor and the resident sit close together turning the pages and looking at the book together.

4. Play - Whereas work is directed towards a goal, play in its purest form has no goal that lies outside the activity itself.

Looking at picture books is seen by both resident and the carer or visitor as a recreational activity.

5. Timalation - This term refers to forms of sensual interaction in which there is minimal need for intellectual understanding. The significance of this kind of interaction is that it can provide contact, reassurance and pleasure, whilst making very few demands. It is thus particularly valuable when cognitive impairment is severe.

Without the need to use intellectual understanding to fully interpret what they see in the specially selected pictures, the person with dementia recognizes things that still have meaning.  They respond with words, a smile, or by touching the image.  

6. Celebration - any moment at which life is experienced as intrinsically joyful. Celebration is the form of interaction in which the division between caregiver and cared-for comes nearest to vanishing completely; all are taken up into a similar mood.

An image of a happy, smiling mother and baby prompts the person with dementia to touch the picture and smile. The carer or visitor also responds to the image in the same way and both agree how beautiful the picture is.

7. Relaxation - many people with dementia, with their particularly strong social needs, are only able to relax when others are near them, or in actually bodily contact.

Sitting close to the person with dementia looking at the books, and slowly turning the pages, the carer or visitor is quietly and calmly engaging in a relaxed manner with the person with dementia.

8. Validation - acknowledging the reality of a person’s emotions and feelings, and giving a response on the feeling level.

The person with dementia recoils from a picture of a child holding a snake, and the carer or relative has the opportunity to talk about the fear of snakes and so validate their response.

9. Holding - To hold in a psychological sense, means to provide a safe psychological space, where hidden trauma and conflict can be brought out; areas of extreme vulnerability exposed.

The person with dementia appears to be sad when looking intently at an image of a man alone in a landscape, as it seems to be connecting with their own feelings of isolation. The carer or visitor has the opportunity to acknowledge this response and talk about these feelings to the person with dementia whilst trying to make the person feel secure and loved.

10. Facilitation - The task of facilitation is to enable interaction to get started, to amplify it and to help the person gradually fill it out with meaning.

 The use of specially designed picture books facilitates a variety of interactions. By using the books with the person with dementia, the carer or visitor can get the interaction started, and by sharing the experience they can also fill it with meaning.

 11. Creation - Here a person with dementia spontaneously offers something to the social setting from his or her stock of ability and social skill.

The books include song lyrics and well known poems in large print, and the person with dementia starts to sing the song or recite the poem learned in childhood.

12. Giving - The person with dementia expresses concern, affection or gratitude.

 The person with dementia thanks the carer or relative for spending time with them. They feel relaxed and content. He or she expresses this with a warm smile.