Take away my license,
but don't steal my independence.
I will let you drive,
But let me tell you
Where I want to go.
-Joanne Coste

From "Learning to Speak Alzheimer's" by Joanne Koenig Coste:

The staff was busily opening draperies, letting the first beams of morning light into the rooms inhabited by the forty-five residents on floor two of the nursing home.

"I want to see my mother," Mary said softly to no one in particular as she shuffled from her room, holding onto the wall.

Claire, a young nurse's aid who happened to pass by at that moment, took Mary's hand. Then she said, sympathetically, "Mary, your mother has been dead for a long time."

"Don't be so fresh," Mary said, pulling her hand away. "You don't know what you're talking about."

"Try to remember, Mary. You haven't seen your mother in years. She died when you were in your forties. You're eighty-seven now."

Mary shoved Claire out of her path. "My mother was right here this morning. We had breakfast together like always. Now, get out of my way."

Gently, Claire took Mary's arm and began to guide her to the large-print calendar hanging in the nurse's station.

"No. I'm not going with you."

Claire tightened her grip. "I want to show you the date. Your mother died a long time ago."

Mary sputtered. "You-you-you-hussy!" Then, swinging her free arm, Mary caught the aide with a backhand slap to the face.

Claire called for help. Her colleagues responded and quickly subdued Mary, injecting her with an antipsychotic medication. For the rest of the morning, the staff kept Mary restrained to a chair in front of the nurses' station, where they could see her.

Until recently, this kind of scene occurred often in nursing homes where, in dealing with residents who might harm themselves or others, staff followed a protocol known euphemistically as "appropriate care." Claire's part of the dialogue with Mary followed a theory called "reality orientation." Staff members were taught to enforce a sense of the here and now. The idea was to make sure that all residents knew where they were, what food they had for breakfast, the date, the day of the week, the year, and the name of the president of the United States.

"Your mother has been dead for years" is a prime example of reality orientation, although the person being address is far beyond being able to process the information. Sadly, the primary effect of forcing Mary to "face the truth" of her mother's long-ago death led to an escalation of negative behavior. Her outburst was a way of defending herself against what she saw as a lie. Guided by emotion, her words failing, she reacted physically. In her internal reality, her mother was alive and they had enjoyed breakfast together earlier that morning.

Reality orientation is the antithesis of habilitation. Habilitation teaches care partners to place themselves in the patient's world, no matter where that world is. This teaching-live in the patient's world-is the fourth tenet of habilitation. The habilitative approach also acknowledges that reasoning with someone who has lost the power to reason only ensures confrontation.

Now imagine the same scene with staff members trained in the habilitation model of care.

When Mary expressed her wish to see her mother, the nursing aide said simply, "Tell me about her."

"She's a great cook," Mary said.

"What does she make that you especially like?"

"Oh, her pies are the best," Mary recalled. "I can never match `em. Oh, dear, now I'm getting hungry."

Clair took Mary's hand and guided her toward the dining room. "Me too," she said. "You have a cup of coffee while I go get your friend Pat-we'll be right back."

Dignity intact, free from medical or chemical restraint, Mary sat back with her coffee and awaited her friend's arrival. Thoughts of her mother faced, replaced by the positive experience of Claire's smiling face and extended hand.

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