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Dementia

Improvisation's Benefits for People With Dementia

"Yes, and" can increase positive engagement for people with dementia.

Photo by Micheile Henderson on Unsplash
Source: Photo by Micheile Henderson on Unsplash

When memory starts to fail, the past and future can be particularly frightening for people with dementia. Improvisation allows them to focus on the present and on community building.

The Memory Ensemble and Hearthstone’s Scripted IMPROV are both bringing the benefits of improv to people living with dementia.

The Memory Ensemble

In 2009, Christine Mary Dunford and Darby Morhardt created The Memory Ensemble, a collaboration between the Mesulam Center for Cognitive Neurology and Alzheimer’s Disease and the Lookingglass Theatre Company. The Memory Ensemble uses improvisational theater to help people with dementia engage socially, communicate, and get creative.

The Memory Ensemble’s curriculum focuses on fundamental improvisation skills such as listening, observing, and saying yes to ideas. Sessions progress from these fundamentals to global, community, and personal concerns as group rapport develops over time.

In their explanation of the work, Dunford, Morhardt, and Hailee M. Yoshizaki-Gibbons explain that disability is relational. They elaborate, “Memory Ensemble participants participate in creative activities that do not require the ability to bring the past into the present, but rather ask individuals to work together in relationship.” This focus on relationship helps participants to overcome feelings of isolation as they playfully share their experiences with each other.

The reason improvisation is especially important to this work is the Yes, And principle. Mary O’Hara, a social worker at the Cognitive Neurology and Alzheimer’s Disease Center at Northwestern University’s Feinberg School of Medicine explains:

Maybe thinking about the past and trying to remember makes the person a little anxious or even a bit sad because their memory is failing. And maybe thinking about the future too much is also anxiety-provoking. So being in the moment is such a safe and a good place to be.

Improv’s emphasis on the present-moment may alleviate some of the anxiety associated with living with dementia.

The Hearthstone Institute’s Scripted IMPROV

John Zeisel, Michael J. Skrajner, Evan B. Zeisel, Miranda Noelle Wilson, and Chris Gage did a study to see how Scripted IMPROV affected people with dementia’s positive engagement and depression symptoms. They describe Scripted IMPROV as semi-improvised drama that is designed specifically for people with dementia. One similarity between Zeisel’s Scripted IMPROV and the Memory Ensemble’s curriculum is their focus on the Yes, And principle. Both versions of improvisation emphasize the importance of participants listening closely to each other and adding to each other’s ideas.

Zeisel et al.’s study measured the effect Scripted IMPROV had on 178 people with dementia. The study measured engagement, affect, and depression before and after Scripted IMPROV participation.

They measured engagement with the Menorah Park Engagement Scale and found that positive engagement (eye contact, smiling, laughing, reacting) increased and negative engagement (repetitive movements, avoidance, trying to leave the activity) decreased. The idea being that positive engagement helps people with dementia experience fewer behavioral disturbances and is therefore essential for overall mental health.

They also used the Mini-Mental Health Examination, Geriatric Depression Scale-Short Form, and the Dementia Quality of Life scale to measure participants’ affect and symptoms of depression. In addition to improved positive engagement, the researchers found that the Scripted IMPROV intervention reduced symptoms of depression for participants who were clinically depressed before the intervention. There was not a measurable effect on depression for participants who were not clinically depressed pre-intervention.

The other interesting finding was that the number of participants had a positive impact on engagement and affect. More participants meant more engagement. However, there was no long-term impact from the Scripted IMPROV intervention, meaning improv is most likely an ongoing, nonpharmacological intervention for people with dementia and not a one-and-done solution.

The "Yes, And" Principle

I reached out to Zeisel to ask him why he thought improv was beneficial for people living with dementia, and he points to improv’s Yes, And principle. He says:

If one imposes a linear structure on a conversation with most persons living with dementia — it’s easy to say the person you are talking to "doesn’t make sense." If one follows the thread of the person living with dementia wherever it takes us — using "Yes … and" improv techniques — the conversation always makes sense.

Zeisel elaborates on the Yes, And tenet when working with people with dementia in his book I’m Still Here: A New Philosophy of Alzheimer’s Care.

Evan Bass and Electronic Bass Entertainment are working with Hearthstone on their improvisation research. Bass explains that people with dementia are often told “No. That’s wrong.” This leads to aggression, depression, and withdrawal. Zeisel et al.’s research highlights how leading with "yes, and" decreases negative engagement and replaces it with positive engagement such as listening, laughing, and eye contact.

Photo by Aziz Acharki on Unsplash
Source: Photo by Aziz Acharki on Unsplash

That’s why Hearthstone and their partners integrate the Yes, And principle beyond their Scripted IMPROV sessions. Zeisel poetically explains, "We believe that as those with dementia change in how they are able to interact on a day-to-day level, those who interact with them must learn to change along with them, to maintain a connection to the personality and the person who is never really lost." Improv and its principles help people with dementia and their caregivers and loved ones maintain a connection as dementia changes all of them. In this case, improv’s power lies in its ability to help people create together in the face of uncertainty and change.

I’m always advocating for more research and research funding for improvisation and applied improvisation, but Zeisel makes what I think is an important clarification. Instead of calling improv a nonpharmacological intervention, Zeisel suggests “ecopsychosocial” because it describes what the intervention is instead of what it’s not. Ecopsychosocial encompasses the mental, social, and relational quality of interventions such as improvisation instead of just saying that no drugs are involved.

Either way, work like The Memory Ensemble and Hearthstone’s Scripted IMPROV are giving people with dementia the space to be seen and heard and to see and hear others in their communities. It helps build relationships and community and increases positive engagement and quality of life. As dementia reduces linear thinking, improv can give caregivers and loved ones the tools to follow along anyway, without shame or judgment.

References

Drinko, C. (2013). Theatrical improvisation, consciousness, and cognition. Springer.

Dunford, C. M., Yoshizaki-Gibbons, H. M., & Morhardt, D. (2017). The Memory Ensemble: improvising connections among performance, disability, and ageing. Research in Drama Education: The Journal of Applied Theatre and Performance, 22(3), 420-426.

Hill, J. (2011, August 15). Improv For Alzheimer's: 'A Sense Of Accomplishment'. Retrieved from https://www.npr.org/2011/08/15/139585522/improv-for-alzheimer-s-a-sense…

Zeisel, J. (2009). I'm still here: a new philosophy of Alzheimer's care. Penguin.

Zeisel, J., Reisberg, B., Whitehouse, P., Woods, R., & Verheul, A. (2016). Ecopsychosocial interventions in cognitive decline and dementia: a new terminology and a new paradigm. American Journal of Alzheimer's Disease & Other Dementias®, 31(6), 502-507.

Zeisel, J., Skrajner, M. J., Zeisel, E. B., Wilson, M. N., & Gage, C. (2018). Scripted-IMPROV: Interactive Improvisational Drama With Persons With Dementia—Effects on Engagement, Affect, Depression, and Quality of Life. American Journal of Alzheimer's Disease & Other Dementias®, 33(4), 232-241.

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