Caregiver’s Corner: A Deeper Study of Conflict Communication for Dementia

In my previous role as the national director of training at a large senior living company, I found most dementia training to be barely useful at best, and harmful at worst.

There are three main reasons for this that I have heard or seen in one form or another, again and again. I’m going to be blunt here: these aren’t nice, but they’re true in my experience and these assumptions have destroyed dementia training, even for home and family caregivers outside of “the system.” Most dementia information for family caregivers, after all, comes from these professional environments.

1. Companies think caregivers are dumb. No one will say it that bluntly, of course, but it’s what they mean when they tell me that “lots of these folks don’t have degrees” or “they won’t be interested in this level of detail.” I’ve been told that that caregivers can’t or won’t be able to grasp body mechanics, more advanced communication techniques, or better methods for engaging seniors. I have also seen with my own eyes that this is not true.

2. Companies think caregivers are disposable. No one will say this out loud either, but most training only exists to meet state requirements, and that is about all it does. Frankly, most caregiver training is garbage. We act as though the industry can afford to lose caregivers to stress, burnout, or paying them less than a living wage. (PS, we can’t afford to lose them.)

3. Experts mostly don’t know what they’re talking about. Caregiver training happens on a surface level, but doesn’t dig more deeply into scenarios or variations. Once an idea is accepted by the industry, good luck trying to shift it. I come from a scholarly background and expect rigorous testing and continued development of complex ideas: most of the information that is taught by dementia experts wouldn’t be deep enough to score an A from me in the English 101 course I used to teach at the University of Arizona.

So caregivers, both family and professional, are left on their own to learn from each other as best they can. If you feel like you are being given the same advice, over and over, and it doesn’t help, that is why.

So I’m going to dig deep today: we’re going to talk about de-escalation and conflict resolution when working with people who have dementia. This is based on real research and scholarship on how conflict works, even with people who have dementia. You’ll get solid principles you can test in real life and adapt to your situation.

First, let’s look at Chase Hughes’ excellent book, Six-Minute X-Ray: Rapid Behavior Profiling. Hughes says that there are four different filters we can use to explain other peoples’ behaviors. Think of these in the context of dementia care. They go in order from least useful (1) to most useful (4).

1. People are broken: something is wrong with “them.”

2. People are different: another person might not be wrong, per se, but there isn’t a way to reconcile with the other person either.

3. People are facts: nothing can change the way things are — it’s just the facts, right?

4. People are reasons: we act the way we do because of specific — sometimes subconscious — reasons that can be dealt with and understood. This is the highest level of understanding in Hughes’ hierarchy.

When we’re assisting a loved one with dementia, you better find your way to the fourth sphere, “people are reasons,” or you’re in for a world of struggle. Without realizing it, we fall into the trap of believing that people with dementia are disconnected from reason. This isn’t true: we may not understand their reasons, but that’s on us, not them.

Everything is caused, even when we can’t see the cause. Be careful about trying to fix something you don’t understand. In Franklin Covey’s famous book, The 7 Habits of Highly Successful People, the fifth habit is “seek first to understand, then to be understood.” This is critical for caregivers: listen, understand, and then communicate from the best common ground you can find. Ask yourself, “what are the reasons?” Answer this question and you’ll find your way out of conflict with your loved one, and probably a lot of the rest of the world too.

When we start viewing actions of people with dementia as something caused, especially actions that appear aggressive or angry, we have the power to stop treating the person as the problem and start dealing with the reasons themselves.

As a lifelong martial artist, and a teacher of martial arts, I have researched anger, aggression, and violence a LOT, and I’m going to speak from that background. These are skills that are critical to walking back a bad situation, and I’m going to adapt them to dementia behaviors here. If you’re dealing with a loved one who’s having an aggressive moment, or anyone for that matter, here are the things to do that you won’t usually learn in caregiver training.

• Anger is almost always caused by an underlying feeling of fear, and those with dementia have a lot to be afraid of. People are telling them what to do, what to eat, where to go, what pills to take… They may feel a loss of dignity and independence, anxiety over their dementia, and a fear that they are losing their identity and the memories that make them who they are. And, by the way, they are probably experiencing some level of chronic pain. Begin understanding anger by considering the fears they may be feeling.

• Are they actually telling you the answer but you’re not listening? If someone is being aggressive, they may actually be giving you the directions they need you to follow. “Get away from me!” “Leave me alone!” In most cases, if your loved one is telling you what they need, then do your best to give it to them. Does it cause harm to come back later and try again? If not, then respect their wishes and give them some breathing room. How would you feel if you told someone to leave you alone and they kept coming at you?

• Ask more questions. Even if you don’t understand the answers, it’s a start. Many people cause unintentional harm because they assume the person with dementia doesn’t know what they’re saying. Often, it’s just that the caregivers don’t understand what they’re saying. It’s our job to find out. Imagine you’re in a foreign country without a translator and you need to figure out what is being said. Remember that all behavior is caused, and it’s our job to understand the causes.

• No judgment: asking questions is a great way to avoid judgment. Avoid sentences with “should” statements. When we offer a judgment, we are participating in a one-way conversation: “you have to eat dinner now,” or “you must be cold so take this blanket.” When you’re judging, your ears aren’t working. Remember Habit #5 above: seek first to understand.

• Co-opt criticism: are you having angry statements directed at you? Get in front of them. “I’m sorry, dad. I’m new to making dinner for you and I don’t know what you like. Would you tell me what sounds better than this?” When you do something like this, you’re validating the other person’s feelings and asking them how to proceed. Do you see how we brought it back to a question rather than a judgment or criticism? In the process, we invited feedback and asked the person about what they need.

• Congruence: do your words, demeanor, body language, and actions match? If you’re saying soothing words about understanding someone’s medication refusal while you’re opening a pill bottle, you’re not being congruent. If you’re putting a soothing hand on someone’s shoulder while your face is contorted with worry, that’s not congruent either. Make sure everything lines up to create the message you want to send.

• Use positive statements: replace “don’t do” with “let’s do.” When someone tells me not to do something, that’s the best way to make sure I will do it! Maybe you’re the same way. Maybe your loved one is too.

When someone yells at us, our instinctive reaction is to yell back. When someone pushes us, we push back. Maybe this was a helpful response when those instincts were forming 50,000 years ago, but we can retrain those reactions for modern times and modern care.

When we understand that there are reasons for behaviors for everyone, including people with dementia, we begin to see that there are better ways to communicate effectively. When we keep our eye on the goal of providing great care, we are freed to stop seeing the person as the problem and to instead see the opportunities to step into their world, learn their language, and respond to their reasons.

Note: I drew on Rory Miller’s exceptional book, Scaling Force: Dynamic Decision Making Under Threat of Violence, for many of the de-escalation tactics I address here.

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