Aging Matters

Aging Matters:
Humanistic and Transpersonal Approaches to Psychotherapy
with Elders with Dementia

Matt Spalding, PsyD, EdM and Puran Khalsa, PsyD

Key Words: existential, process-work, humanistic, transpersonal, therapy, elder care,

dementia.

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 Aging Matters

Authors Note

Matt Spalding’s clinical and research work with elders with dementia focuses

upon the therapeutic potential of non-ordinary states of consciousness and the invitations

of enhanced freedom, relaxation, and wisdom in progressive states of not knowing. His

evolving experiences as a psychotherapist, teacher, and dog owner continue to remind

him of the importance of trust and how little he really knows about anything at all.

For more than ten years now, Puran Khalsa has been working/training in the field

of psychology. During recent work with clients suffering from numerous forms of

dementia, he had the unique opportunity to witness existential theory effectively put in

practice. Working with a broad spectrum of clients from children to elders, Puran

believes that there are many points along each person’s journey that offer potential

meaning specific to their stage of development.

Correspondence concerning this article should be addressed to both Matt

Spalding, 166 Gates Street, San Francisco, CA 94110, and Puran Khalsa, 172 Ivy Street,

San Francisco, CA 94110. E-mails: spaldingmatthew@gmail.com;

purankhalsa@gmail.com.
 Aging Matters

Abstract

The purpose of this study is to discern the relevant and effective components of the
Existential and Process-work psychotherapeutic approaches to the clinical treatment of
elderly clients with dementia. This study explores how these specific humanistic and
transpersonal approaches to this population’s presenting concerns represent unique
alternatives to the mainstream medical model of dementia treatment that frames dementia
as a mental illness. 10 therapist interns at two of Pacific Institute’s assisted living
facilities in San Francisco, CA were interviewed using open-ended questions designed to
elicit detailed accounts of their clinical work using these two therapeutic modalities. The
interview transcripts were coded using a qualitative thematic analysis methodology and
computer software assistance to identify prominent factors that influenced the therapy,
including therapist attitudes, embodiments, clinical conceptualizations, interventions, and
impediments to effective treatment. These research results systematically thematize the
prominent aspects of Existential and Process-work approaches in the effective treatment
of the elderly with mild to advanced symptoms of dementia. It is hoped that this study
will inform further exploration of these effective therapeutic modalities in diverse clinical
populations and settings.
 Aging Matters

I. INTRODUCTION

Literally meaning “loss of mind,” the vague and pejorative term dementia refers

to a progressive course of mental and physical decline due to a variety of known and

unknown causes. This pattern of deterioration tends to be most evident in significant

cognitive impairment in the realms of memory, language, orientation, and attention,

accompanied by an increased agitation and lack of ability to care for one’s basic physical

needs. One in eight, or 13% of people over the age of 65 in America are estimated to

have Alzheimer’s disease, a ratio that is predicted to double by 2050. By this same year

more than 100 million people world-wide will have some form of dementia, while many

more will struggle with age-related memory impairment (Herbert et al., 2003).

The standard medical model of care views dementia as pathological in nature and

relies chiefly upon medication and dismissive behavioral interventions to ameliorate its

symptoms. In a recent meta-study of diverse therapeutic approaches to dementia, Hogan,

et al. (2008) concluded that, “Although the available therapies for dementia can help with

the management of symptoms, there is a need to develop more effective interventions”

(p. 788) This present study investigates the core components of the Existential and

Process-work approaches to psychotherapy with mild to advanced symptoms of

dementia, in the hopes that these representative traditions of the humanistic and

transpersonal perspectives may contribute to such enhanced treatment efficacy.

The term “humanistic” in this study refers to the conviction that each individual’s

subjective experience of meaning-making has an intrinsic value. This core worth must be
 Aging Matters

taken into consideration in the ethical and effective treatment of dementia so as to affirm

the dignity and fullness of the human experience. The term “transpersonal” refers to the

validation of psychological categories that transcend the normal features of ego-

functioning. Such altered, or non-ordinary, states of consciousness often accompany the

experience of dementia, calling into question the hegemony of the dominant culture’s

‘consensus reality.’ Both of these perspectives allow for a view of advancing

‘forgetfulness’ as potentially imbued with meaning and relevance to the human journey, a

transitional experience that may entail novelty and benefit as well as loss.

There has been little research to date analyzing the relevance of humanistic and

transpersonal approaches to treating elderly clients experiencing dementia. These

modalities call into question the central tenet of the medical model, which frames

forgetfulness as a condition to be prevented or corrected. Indeed, the choice of diagnostic

lens in large part determines whether a client is regressing or working through,

dissociating or revisiting, decompensating or integrating. What is typically diagnosed as

pathology may in fact be an individual’s need to process, prepare, rehearse, or repair,

emphasizing healing and growth over maintenance and comfort. Such organic unfolding

of symptoms is likely to be inhibited by excessive medication, often the prescribed norm

for clinical patients. Well-intentioned attempts to behaviorally control and minimize

symptoms can similarly antagonize and undermine both clients’ and therapists’ potential

recognition of an underlying coherence and meaning to the various psychological,

emotional, physical, and perhaps spiritual signals that comprise “dementia.”

This study examines the foundational notions of two humanistic and transpersonal

approaches to therapy in light of newly generated interview data, serving as an initial

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inquiry rather than a definitive test of a particular hypothesis or set of theoretical

assumptions. It seeks to identify the essential components of the Existential and Process-

work modalities of psychotherapy, both of which may effectively complement the current

mainstream model of treatment. The study authors interviewed 10 Pacific Institute

therapist interns, reviewing the transcripts using a computer-assisted qualitative thematic

analysis methodology to identify prominent therapeutic factors influencing the treatment

of geriatric patients with mild to advanced memory impairment. These factors were then

assigned to categories, giving rise to an initial “codebook” of successful Existential and

Process-work approaches and obstacles to treatment.

Pacific Institute’s Gerontology Wellness Program is an assisted living facility of

100 residents and 20 interns in San Francisco, CA. It makes available a variety of

therapeutic offerings for elders with mild to advanced symptoms of dementia, who

comprise most of the client population. Pacific Institute seeks to model a new way of

working “elders with forgetfulness,” prioritizing holistic and irreducible humanistic

values over symptom checklists as the chief criteria by which to assess the subjective

experience of a person’s meaning-making. The treatment clinic endorses Existential and

Process-work approaches to psychotherapy as uniquely relevant to addressing both the

personal and transpersonal values and concerns of this client population. The intern

training program also includes expressive arts and somatic interventions, providing

activity enrichment, sense stimulation, and attempted rehabilitation of clients’ behaviors

and functions.

These research results make data accessible for further assessment of the

appropriateness and efficacy of Existential and Process-work approaches to

 Aging Matters

psychotherapy with the geriatric population. This study also illuminates the need for

further exploration of the relevance and implementation of humanistic and transpersonal

approaches to dementia in diverse therapeutic settings. It is hoped that information from

this study will help to stimulate greater general interest in alternative modalities to

working with individuals with dementia, with the overall aim of offering more

comprehensive and integrative services to this client population.

II. RESEARCH QUESTION

This study’s main inquiry is, “What do effective Existential and Process-work

approaches to psychotherapy look like with elders with dementia in a residential

treatment facility?”

III. LITERATURE REVIEW

Alzheimer’s disease represents the most common type of dementia, accounting

for 60 to 80 percent of all documented U.S. cases, followed by vascular dementia, which

is also known as post-stroke dementia. Less frequently cited, but equally impactful types

include dementia with Lewy bodies, dementia precipitated by Parkinson’s disease,

frontotemporal dementia, Creutzfeldt-Jakob disease, and normal pressure hydrocephalus

(Plassman et al., 2007). Although it is not yet fully understood what processes are

responsible for the accelerated deterioration of neurons that leads to dementia-related

symptoms, it is theorized that rapidly forming ‘plaques’ and ‘tangles’ of various proteins
 Aging Matters

in the brain lead to a pronounced shrinkage of vital brain mass due to cell loss and debris

from accumulated dead neurons. Prominent risk factors for dementia are also imprecisely

known, although advancing age clearly accounts for the vast majority of its occurrences.

Enhancing opportunities for novelty, creativity, exercise, group activity,

processing end of life issues, and grief and bereavement support have all proven to be

moderately effective in working with dementia. Together with a consistent exercise

regimen, a low-fat diet rich in vegetables and fruits, and properly prescribed medication,

such treatment strategies can dramatically help to stimulate intellectual curiosity, creative

engagement, social interaction, and meaning-making processes that mitigate encroaching

forgetfulness (Grasel et al., 2002).

The extensive available literature on dementia reveals that each of the bio-psycho-

social aspects of an individual’s experience must be taken into account for an effective

and ethical course of treatment, addressing the patients’ physical, cognitive, emotional

and relational concerns (Slumasy, 2002). The biological component of this triumvirate

approach includes pharmacological medication, nutrition, and exercise. The social

component of dementia treatment includes family involvement, a purposeful role or

identity in one’s residential community, and potential participation in larger societal

spheres of influence. The psychological component, which is the focus of this study,

involve four chief categories of emphasis: activity enrichment and sense stimulation,

rehabilitation of behavior and function, emotional exploration, and cognitive processes

and function. These psychological approaches emphasize person-centered individual

counseling, support groups, and cognitive-affective enrichment activities. They also rely

upon codified environmental modifications paired with strict routines, behavioral

 Aging Matters

interventions that can help reduce the patient’s experience of disorientation and stress

levels (Grasel et al., 2002; Rayner, 2006; Slumasy, 2002).

Psychological care has increasingly adopted ‘person-centered’ therapies tailored

specifically towards the patient’s immediate emotional, behavioral, and environmental

needs. (Rayner, 2006) The central tenets of the person-centered approach to dementia are

consistent with the humanistic vision and include, “1) Valuing people with dementia and

those who care for them; 2) Treating people as individuals; 3) Looking at the world from

the perspective of the person with dementia; 4) A positive social environment in which

the person living with dementia can experience relative well-being” (Brooker, 2004, p.

216).

The humanistic and transpersonal paradigms, known respectively as the ‘third and

fourth forces’ of psychology (following upon the behavioral and psychoanalytic schools

of thought), support caregivers’ deepening empathy for their patients by reorienting them

towards a more curious, investigative, community-oriented, and anti-discriminatory view

of dementia. They also honor a client’s unique subjective experience and validate ‘trans-

egoic’ states of mind, which may not be available to empirical or clinical observation.

Rather than attempting to halt the inevitable progression of an illness, both the humanistic

and transpersonal lenses focus upon the internal lives and perspectives of affected

patients and their social network of family and caregivers.

A. Overview Of the Medical Model

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Pharmacological interventions are typically aimed at treating memory and

learning impairment by reducing the breakdown of acetylcholine in the brain (Hogan,

2008). This treatment at best slows the progression of dementia, though there remains no

known cure for the associated cognitive decline. The most common class of drugs

prescribed to this population are central nervous system suppressants with the associated

side effects of sedation and potential cognitive impairment (Ganjavi, 2007). In the case of

pharmacological interventions for behavioral disturbances, antipsychotic medications are

typically used. However, in a recent meta-analysis of 13 studies, Yury and Fisher (2007)

found that the use of atypical antipsychotic medication “is not very effective for the

management of neuropsychiatric symptoms of dementia, and the effects are modest.” (p.

216)

The many risks involved with medication and geriatric populations (Hogan et al.,

2008) strengthen the consideration that non-pharmacological interventions be considered

prior to pharmacotherapy for psychic and behavioral disturbances. Several drugs can

temporarily slow advancing symptoms for up to a year in half of those who take them,

while no reliable medical treatment is available to prevent or even significantly delay the

deterioration of brain cells responsible for this complex of symptoms. It should, however,

be kept in mind that many of the non-pharmacological interventions that draw upon

traditional behavioral models have also demonstrated limited short-term efficacy in the

general population. Antipsychotic medications have in fact been shown to be the most

effective treatment for severe behavioral problems associated with dementia, though

unfortunately tend to be disproportionately prescribed to elderly communities (Hogan et

al., 2008; Yury & Fisher, 2007).

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B. Overview of the Humanistic and Transpersonal Frameworks

This study is situated within a transpersonal framework, which includes the

humanistic world-view while viewing psychology and spirituality as complementary in

awakening the psyche to newfound dimensions of freedom (Cortright, 1997; Walsh,

1993; Washburn, 1994, 1995). According to transpersonal scholar Brant Cortright (1997),

“Transpersonal psychology in this sense affords a wider perspective for all the learning of

conventional psychology; it includes and exceeds traditional psychology” (p. 10).

“Trans-”personal psychology, which literally means an understanding of mind as

existing “across and beyond” the ego identity, seeks to address both the personal and

transcendent, or spiritual, realms of human experience. Building upon the central tenets

of humanistic psychology, which affirm each person’s effort to make meaning of his or

her life and to receive the freedom and support to live this meaning, the transpersonal

framework also acknowledges that humanity's range of experience includes ‘trans-egoic’

states of consciousness. While psychology seeks to intervene on the level of thoughts,

emotions, and behaviors, spirituality can be seen to address the source and foundation of

these bio-psycho-social activities that sustain our illusionary sense of separation from one

another.

Existential psychotherapy in this study represents the humanistic polarity of the

psychospiritual spectrum. It engages the client in personal issues that address the

concerns of the psyche. Process-work is understood here to more overtly support the
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transpersonal dimensions of the psyche. It emphasizes expanded awareness and deep

states of consciousness, including non-dual awareness, which may be more suitably

interpreted as spiritual in nature.

Clearly the ‘personal’ and ‘transpersonal’ poles of human consciousness are

artificial categorizations of experience that in reality lie on a vast and subtle continuum.

Indeed, the differences between Existential and Process-work psychologies are often

semantic, as both share a generous philosophical and clinical terrain. Such conceptual

divides are nonetheless helpful in highlighting the respective dimensions of the human

condition and the most suitable therapeutic approach to working with them.

C. Overview of Existential Psychotherapy

The diverse existential schools of therapy, referred to collectively in this study as

‘Existential psychotherapy,’ have their roots in existential philosophy. The origins of

existential philosophy are often attributed to the 19-century writings of Kierkegaard,

Nietzsche, and Dostoyevsky, and later enriched by the 20th century reflections of

Heidegger, Sartre, and Camus. While the term ‘existential’ connotes a wide variety of

associations, most existential writing emphasizes experience over abstraction, the dangers

of isolation and depersonalization, and the invitations of authenticity, responsibility, and

freedom. It also reminds us that human beings are not static objects, but processes of

becoming; our infinite potential is either a blessing or a curse, depending upon our ability

to affirm the vital experience of being alive.

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Prominent tenets implicit to the existential vision might be summed up as: a) an

emphasis on the concrete here-and-now “existence” of the individual (in contrast to

theoretical assumptions or abstract speculations about one’s “essential” nature), which

takes into account the immediacy of one’s intra- and inter-personal context; b) the

framing of such existence in light of one’s inevitable impending mortality, which

necessarily entails “dread” or anxiety in the face of one’s finitude and an intrinsic guilt in

response to the recognition that each life choice necessitates the elimination of infinite

other potential “right” choices; c) the subjective meaning of participation in the world

from “within” one’s engaged lived experience (in contrast to a fictional idealization of a

detached, disinterested, or objective perspective upon one’s being in the world); and

finally, d) the ultimate responsibility of the individual to steer his or her fate, each choice

demanding a “leap” of faith into a new moment, a process inherently devoid of certitude

(D. Stewart & A. Mickunas, 1990, p. 63; M. Freidman, 1964, pp. 3-9)

Existential psychotherapies can be seen to seek to instill in the client a growing

appreciation of the opportunity to live one’s life with increasing awareness and

responsiveness to these foundational philosophies. In practice, this is likely to entail an

emphasis upon the intrinsic values of freedom, presence, participation, and responsibility,

encouraging and affirming one’s authentic being in the world, and prioritizing concrete

choices over abstract premises. Contemporary existential approaches to therapy owe

much to Kierkegaard’s “absolute paradox,” which views the human condition as a

dynamic oscillation between ‘finitude’ (limitation) and ‘infinitude’ (freedom).

Existential-humanistic psychologist Kirk Schneider reformulates this continuum

in his Existential-Integrative approach to psychotherapy as that of ‘constriction’ and

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‘expansion.’ Working with such a model, the therapist assists the client in recognizing

where he or she might be adopting extreme or static stances on this continuum,

supporting their efforts to relate to their experience with greater fluidity, acceptance of

paradox, and an increasing ability to embody and identify with what had once been

feared or denied (Schneider, 2008, pp. 62-80).

Schneider is aware, however, that any theoretical model is as potentially

restricting as it is liberating. Indeed, as noted by Basset-Short & Hammel, “students too

often apply their techniques and knowledge to clients instead of working with them in

shared endeavors… theory can obscure one’s clients if one applies it around them like

scaffolding… one of the most formidable challenges for beginning therapists, then, is to

draw structure from a particular orientation without letting theory obscure the complex,

unique individual in front of them.” (Schneider, 2007, pp. 24-25)

D. Overview of Process-work Psychotherapy

Process-work, also known as “process-oriented psychology,” is a modern

therapeutic modality developed in the 1970’s by Arny Mindell, which seeks to increase a

client’s awareness of psychological and physical processes on several planes of

consciousness in service of clarifying and resolving personal and collective issues. Such

healing and resolution work entails three levels of investigation, that of a) “consensus

reality,” or of concrete and observable personal and collective experience; b)

“dreamland,” which includes the seemingly invisible realms of dreams, deep imaginings,

synchronicities, subtle feelings, proprioception (inner body sensation), and phantom

 Aging Matters

presences or “ghosts”; and c) “essence,” the non-dualistic realm of source awareness that

manifests as tendencies or forces that prefigure and transcend manifestation.

Process-work is especially relevant in working with extreme states of

consciousness, death and dying, somatic symptoms, problematic relationship issues, and

clarification of inner conflict. Its intervention strategies seek to utilize psychological and

physical agitation as gateways through which to explore ordinarily unknown and

potentially frightening domains of experience. Such exploration entails amplifying and

unfolding initial psychological and emotional signals to assist in revealing more subtle

experiential insights in service of psychospiritual integration. The therapist in turn attunes

to and trusts his or her own psycho-somatic experience, either as information for what the

client is experiencing or for guidance on how best to proceed in a course of therapy. In

this sense, the traditional empirical method of attempted objectivity is dismissed, as the

therapist recognizes the greater richness of data in simultaneously observing external and

internal sources of information.

In the words of Mindell, through Process-work “one can begin to change one's

relationship to oneself, to others, and to the world, enlivening an awareness process that

enriches life to re-emerge with new knowledge and awareness” (Mindell, 2000, p. 509).

Process-work is cited as a transpersonal approach in this study due to its validation of

non-ordinary states of consciousness, which may themselves be arenas of letting go,

working through, or preparing for unknown and potentially frightening experiences to

come. As noted, the transpersonal paradigm frames consensus reality as just one

legitimate perspective among many, allowing for multiple concurrent dimensions of

consciousness. While Existential psychotherapies clearly allow for non-consensual

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realities, Process-work approaches speak more directly to the existence of different levels

of reality formation, often of prominent relevance in the experience of dementia.

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Clinical Training Philosophy and Psychotherapeutic Emphasis

of the Pacific Institute General Wellness Program
(As outlined in the light gray boxes below)

Biological Psychological Social Spiritual

Pharmacology Cognitive Family Hospice
Rehabilitation • Mental Processing Community Pastoral Services
Nutrition • Meaning-Making Societal Role Rose Petal Ceremony
Exercise Affective
• Emotional Exploration
Behavioral
• Activity Enrichment
• Sense Stimulation
•

Medical Model Alternative

Heavy reliance upon psychopharmacology Humanistic & Transpersonal emphases
“Dementia”-Symptoms Evidence of Pathology “Not Knowing” May Have Psychospiritual Meaning
Empirically-Validated & Manual-Driven Intuitive and Empathic
“Distract & Redirect” “Mirror and Join”

Existential Psychotherapy Process-work Psychotherapy

(Humanistic Psychology) (Transpersonal Psychology)

Existence Precedes Essence Consensus reality

• Experience over Theory • Facts
• Tangibility over Abstraction • Relationships
Dreamland
“Thrown into the World” • Felt Sense
• Freedom of Self-Determination • Intuition
• Responsibility of Meaning-Making • “Ghosts”
Essence
“Being-Towards-Death” • Tao
• Recognition of Finitude • Quantum tendencies
• Acceptance of Anxiety and Despair • Dynamic Ground
 Aging Matters

The above diagram situates the clinical philosophy of the Pacific Institute General

Wellness Program within the bio-psycho-social framework of both contemporary

mainstream and alternative treatment paradigms. The contemporary mainstream “medical

model” approach to treating dementia-related symptoms favors pharmacological over

psychotherapeutic interventions. Pacific Institute, while acknowledging in appropriate

circumstances the clinical relevance of medication and manualized care strategies, chiefly

advocates humanistic and transpersonal approaches to working with distressing

psychological issues associated with memory impairment. These alternative treatment

perspectives assume there to be an inherent meaning underlying “dementia”-labeled

symptoms, which can be effectively assisted through the Existential and Process-work

therapies.

IV. METHODS

A. Design, Materials, and Procedure

This study uses Boyatzis' qualitative thematic analysis method to code the 10

interview transcripts, developing and organizing themes based upon one of Boyatzis’

specific procedures (Boyatzis, 1998). This design is well-suited to address the paucity of

qualitative research related to dementia, which is essential to understanding the variety

and nuances of the lived experience of this multi-faceted condition. As this is the first

empirical study to systematically explore the influence of Existential and Process-work

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psychotherapies with elders with dementia, a qualitative research design is appropriate to

further illuminate the efficacy of these two unique treatment modalities (Creswell, 1994).

The phenomenologically-informed research method of thematic analysis locates

themes based upon the number of times they occur in the transcripts, rather than upon any

pre-established treatment philosophy (Miles, 1994). Semi-structured interviews with the

study participants were designed to elicit unrehearsed accounts of therapeutic styles and

interventions with an emphasis on what does and does not work in treatment (Rubin &

Rubin, 1995). An inter-rater reliability protocol, detailed below, was meanwhile

established to help mitigate the inevitably biased and value-laden vulnerabilities of

thematic analysis.

B. Procedures for Subject Recruitment, Timeline, Informed Consent, and

Qualitative Interviewing

The interview subjects included 10 current pre-doctoral and postdoctoral interns

at Pacific Institute’s Gerontological Wellness Program who had been working with their

clients for at least 6 months. This study utilized an open-ended interview format to

guarantee that participants were able to answer all the questions given their time

restrictions and limited accessibility (Patton, 1990). At the outset of the interview

participants were given an Invitation to Participate in Research form, a Bill of Rights for

Participants in Psychological Research, and a Confidentiality Statement, all of which

detailed and safeguarded the prospective participants’ rights of participation. Interviews

were then conducted in person with both of the study authors in a comfortable private
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office setting at Pacific Institute. Any questions about the nature and purpose of the study

were answered at this time. As suggested by Rubin and Rubin (1995), all interviews were

recorded in digital format for later transcription so that the researchers could give their

full attention to the sensitive interview process. The interviews lasted an hour on average

and the data collection took a total of 1 month.

C. Interview Questions

The interview questions were designed to reveal nuanced details of intern

assumptions, states of being, and interventions employed when working with clients with

dementia. Questions also focused upon contextual factors that either facilitated or

impeded effective treatment, in addition to interns’ reflections on their training at Pacific

Institute. The interview questions were designed to generate a natural flow of

conversation and not asked in any specific order. Such flexibility allowed participants to

speak about their experiences in the spontaneous and organic way in which they were

recalled (Mason, 2003).

D. Instrumentation/Materials

QSR NVivo 7 software is a qualitative research tool used for sophisticated

analysis and management of text data, which was employed during this study’s coding

process for its unique capacity to help manage the extensive text-based material derived

from the 10 interviews. Key phrases were highlighted in the text and assigned to specific
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codes so as to be efficiently located when later searching for common themes. NVivo

provided the ability to search all texts for key words and phrases, thus allowing easy

cross-sample comparison of major identified themes without having to remove them from

their original source documents. Coding in NVivo 7 allowed for specific pieces of text to

be labeled for later analysis by category (themes) or by source (specific interns), while

also revealing quantitative data such as the number of times each word or phrase was

used. These codes provided an essential link between identified themes and supportive

textual data from the interns’ accounts, while preserving subtle distinctions in language

usage between participants that could not alone be detected from the coding process.

The identified codes with supportive text were then organized into hierarchical

‘tree code’ structures. Tree code structures organized the large number of codes into

categories based on their relationship to newly emerging themes. When text references

were applicable to more than one code, a new parent code was created to include the

closely related child codes. These more encompassing parent codes eventually became

the foundation for more complex theoretical conceptualization of the data, representing

themes that consistently presented across narratives.

E. Thematic Analysis and Coding

For the purposes of this study a “code” is a mnemonic device or abstract

representation of an identified theme (Boyatzis, 1998). In thematic analysis, codes refer

to distilled words or phrases from shared text entries. Creating highly defined codes both

enhances the qualitative richness of the data and increases the later likelihood of inter-
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rater reliability. The process of defining themes itself increases the visibility of patterns,

encouraging increasingly subtle refinements of distilled themes.

Phase 1: Inductive / Data-driven coding.

‘Tree structure’ of coding is the first movement toward making sense and finding

order in the large amount of data that resulted from the ten interviews. During this phase

codes were assigned specific definitions according to Boyatzis’ (1998) five elements of a

good thematic code:

1. A label (i.e., a name),

2. A definition of what the theme concerns (i.e., the characteristic of issue
constituting the theme),
3. A description of how to know when the theme occurs (i.e., indicators on how
to “flag” the theme),
4. A description of any qualifications or exclusions to the identification of the
theme), and
5. Examples, both positive and negative, to eliminate possible confusion when
looking for the theme.

The researchers read all ten transcripts straight through to get an overall “feel” for

the participants’ narratives. Three interviews were then coded from beginning to end,

after which those codes were entered into the tree code structure. Key phrases that

applied to more than one code suggested a potential relationship between codes,

revealing further macro or ‘parent’ codes that stemmed from several micro or ‘child’

codes branching out from them. Each child code contained more specific information

than its parent code. Bazeley (2007) suggests a two- or three-layered code structure of

classifying and differentiating nuance in codes, which this study adopted.

Phase 2: Initial test of validity.

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Three new transcripts were then coded with the newly established tree codes,

which allowed for a quick review of all other codes and an even more sensitive and

thorough coding process. Emerging themes were then checked against all new codes

resulting in a new theory infused code.

Phase 3: Reliability and the interrater.

Five of the most prominent codes were used to re-code three transcripts picked

randomly by the interrater until a 95% accuracy was reached. Reliability of this code was

determined by two factors: (a) consistency of judgment based on two separate coders, and

(b) consistency over the span of 10 different interviews. Having multiple coders was

deemed the best way to control for the potential biases of the researcher. The second test

brought the code to a level of “data saturation,” in which no new themes are generated

and all of the transcripts can be accounted for in the final coding structure (Boyatzis,

1998).

Phase 4: Validity–the final code.

The final four interviews were coded with the established reliable code, validating

the identified themes across the entire sample. This refined coding structure was viewed

as sufficiently representative of the transcripts after the final transcripts could be coded

with only minor additional changes needed to the coding structure. With all the transcript

data divided into the respective codes, queries were used to search for specific key words

or phrases by again assembling the pieces of fragmented text. This final review of key

concepts while viewing their coding classification revealed interrelationships between

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themes with supportive quotations. Queries also revealed associations between large

concepts that could not be displayed by the tree codes in a hierarchical structure.

V. RESULTS

The research findings, presented in the charts below, confirm that Existential and

Process-work approaches to psychotherapy are largely effective in treating elders with

mild to advanced symptoms of dementia in a residential treatment setting. These results

were consistent across all ages and genders of the interviewed therapist interns, validating

the suitability and efficacy of these alternative therapeutic approaches for this sample

therapist population.

Upon analyzing the emergent patterns of the therapists’ perceived successes with

their clients, it became apparent through emergent and distilled themes that therapeutic

efficacy could be classified into two main categories: A) Therapist qualities (“Being”);

and B) Therapist behaviors (“Doing”). The “Being” category in turn encapsulates both

“Attitudes,” which refer to the therapists’ conceptions of their adopted clinical frames

and roles that were most conducive for successful treatment, and “Embodiments,”

describing the stances and qualities deemed by the study participants to be most effective.

The “Doing” category includes both “Strategies,” which refer to conceptualizations of

effective therapeutic practices, and “Interventions,” which detail the actual enactments of

such practices. It is of note that the categories of Being and Doing were often difficult to

tease apart in the coding process, testifying to the subtle experiential distinctions between
 Aging Matters

quality of presence and active expression when working in the humanistic and

transpersonal modes of clinical engagement.

The Being category emphasizes the quality of presence of a therapist over their

enactment of behaviors. Prominent Attitudes (a subset of Being) that emerged from the

thematic analysis of the interview data included a stance of basic trust towards both the

client and the efficacy or sufficiency therapeutic process, emphasizing the significance of

the relationship over interventions, an openness to not knowing what the moment will

bring (such as the outcome of any intervention), an investment in empowering the client,

an empathic attunement to the uniqueness of the client, an appreciation of the present

moment, an increasing acceptance of one’s unfolding experience, a non-pathologizing

perspective, and a humility and willingness to learn in the face of one’s experienced

elder. Embodiments (the other subset of Being) meanwhile included patience, the

willingness to be authentic and increasingly transparent when deemed clinically

appropriate, relaxation, loving kindness, play and humor, equanimity and groundedness,

and the increasing ability to tolerate discomfort.

The Doing category emphasizes the therapists’ activity or framing of action, and

includes both Strategies and Interventions. The specific strategies, or conceptual frames,

most frequently cited were rapport-building, acknowledging another’s boundaries and

right to set limits, tailoring therapy sessions to each client’s unique capacities, creativity

and imagination, utilizing all five senses in the course of treatment, creative

improvisation, and honing one’s unique therapeutic style through observation of and

consultation with co-workers in a milieu treatment setting.

 Aging Matters

The most popular interventions included the simultaneous affirmation of non-

consensus and consensus perspectives upon reality, acknowledging and mirroring verbal

and non-verbal signals, active listening and reflection, following the client’s lead in their

experience of meaning-making, affirming the client’s basic health underlying their

potentially distressing experience, using touch and encouraging embodied self-

expression, and teaching clients skills and tools to enhance their well-being.

All of the study participants commented upon challenging aspects of their clinical

work that impeded upon their ability to deliver effective therapeutic services. These

responses were classified into a third category of Inhibiting Factors (“Interfering”), which

fell into two the main groupings of “Personal” and “Environmental” obstacles to

treatment. These challenges included doubt and self-criticism, an attachment to

preconceived notions or outcomes, the risk of burnout or compassion fatigue when

overextending one’s clinical role into the personal domain, the inability to tolerate

distressful experiences and circumstances, and rigid notions of therapeutic dynamics that

inhibit the ability to spontaneously respond to unpredictable arising needs of the moment.

Environmental challenges meanwhile included seeking to reconcile Existential and

Process-work intervention approaches with medical-model documentation, the

pharmacological and behavioral suppression of disruptive client behaviors that can

eclipse unique opportunities to process difficult experiences, the progressive nature of

dementia, and distractions unique to the milieu setting.

In the below bar graphs, “therapist response density” refers to the frequency of

theme occurrence in the interview trasncripts. The themes in the corresponding tables are

similarly numbered in accordance with their frequency of mention by study participants.

 Aging Matters

I. BEING: Therapist Qualities

ATTITUDES: Conceptualizations of the therapeutic frame and
the therapist’s role conducive for effective treatment

1. Trusting the Process: Assuming client’s and therapist’s inherent

movement towards health will reveal itself in relational unfolding

2. Prizing the Relationship: Prioritizing interpersonal attunement over

interventions

3. Openness to Not Knowing: Letting go of preconceived notions and

receptivity to newly arising experience

4. Client Empowerment: Affirming dignity and autonomy of client as a

whole person instead of an amalgam of symptoms

5. Person-Centered: Affirming that each client deserves a unique and

empathic therapeutic approach that reveals and supports their unique
meaning-making system

6. Strength-Based Emphasis: Non-pathologizing perspective

7. Receptivity to Being Taught: Facilitating client’s desire to impart

wisdom of accumulated life experience

EMBODIMENTS: Therapist stances and qualities conducive

for effective treatment

1. Patience: Mindful acceptance of need to tolerate unsettling encounters

2. Radical Authenticity: Veracity and transparency, emphasis of

personhood over clinical role, and generous self-disclosure when deemed
clinically appropriate

3. Relaxation: Embodiment of ease and confidence

4. Compassion: Communicating both loving-kindness and a sensitive

awareness of another’s suffering with the wish to alleviate it

5. Humor and Play: Appreciation of levity and laughter to initiate and

strengthen rapport building

6. Equanimity: Embodying a neutral stance of objectivity, balance,

groundedness, and ease with arising experience

7. Distress Tolerance: Ability to withstand or abide in unpleasant

experiences of cognitive, affective, or somatic sensations
Aging Matters
 Aging Matters

II. DOING: Therapist Behaviors

STRATEGIES: Conceptualizations of effective therapeutic practices

1. Rapport-Building: Establishing a foundational trusting relational bond

2. Respecting Boundaries: Acknowledging and supporting the client’s defenses

and limit-setting

3. Accommodating Constraints: Tailoring therapy session frequency, duration,

and environment to client’s unique capacities

4. Creative Improvisation: Present-centered emphasis on fluidity,

improvisation, and imagination over rigid and linear goals and expectations

5. Multiple Sense Modalities: Acknowledging importance of having an

extensive repertoire of clinical tools and perspectives that accommodate all five
senses

6. Collegial Collaboration: Honing unique therapeutic style through

observation of and consultation with co-workers in milieu treatment setting

INTERVENTIONS: Enactments of effective therapeutic practices

1. Essential Validation: Simultaneous affirmation of client’s non-consensus and
therapist’s consensus perspectives upon reality

2. Joining and Mirroring: Energetic attunement to and reflection of a client’s

conscious and unconscious, verbal and non-verbal cues and signals

3. Active Listening: Acknowledging and encouraging client’s need to tell their

story

4. Co-Authoring Therapy: Following the client’s lead in their experience of

meaning-making

5. Normalizing: Affirming basic health underlying client’s potentially

distressing experience

6. Somatic Engagement: Use of touch and encouragement of embodied self-

expression

7. Psychoeducation: Teaching clients skills and tools

Aging Matters
 Aging Matters

III. INTERFERING: Inhibiting Factors

PERSONAL: Conceptualizations of unique challenges of

and impediments to the therapist’s internal experience
1. Doubt: Self-critical internal monologue heightens anxiety and fear
of inadequacy, inhibiting ability to be present to relational
attunement

2. Attachment to Outcomes: Having conclusions in mind that

interfere with evolving goal-setting

3. Overextension of Therapist Role: Temptation to blur therapeutic

boundaries by assuming caseworker or conservator domains of
influence

4. Distress Intolerance: Inability to withstand or abide in unpleasant

experiences of cognitive, affective, or somatic sensations

5. Functional Fixedness: Rigid notions of therapeutic dynamics that

inhibit ability to be spontaneous to arising needs of the moment

ENVIRONMENTAL: Conceptualizations of unique

challenges of and impediments to the clinical setting
1. Clinical Paradigm Dissonance: Reconciling Existential and
Process-work intervention approaches with medical-model
documentation

2. Obstacles to Shadow Work: Pharmacological and behavioral

suppression of disruptive client behaviors hinders valuable
opportunities to process ego-dystonic experiences

3. Progressive Nature of Forgetfulness: Client’s advancing

symptoms of dementia result in inevitable loss of capacities and
limited possibilities of treatment

4. Milieu Setting Challenges: Distractions endemic to a clinical

residential environment
Aging Matters
 Aging Matters

VI. DISCUSSION

Thematic patterns became increasingly evident to the coding inter-raters during

the course of the interview, transcription, and coding processes. These emergent codes

represented the intern therapists’ essential criteria of both what “worked on the floor”

with their clients in the residential treatment setting and what impeded such efficacy.

While the interviewers did not prompt the participants to speak directly to the Existential

and Process-work modalities, the distilled themes clearly reflect the basic tenets of these

psychotherapeutic approaches, confirming the applicability of these alternative treatment

modalities to effective dementia treatment.

Although the therapist interns were trained in these specific therapeutic

paradigms, rarely did any of the therapists speak explicitly of utilizing Existential or

Process-work approaches; rather, all of the participants spoke about trusting themselves

over the training material as their ultimate refuge of discernment. 1 This finding is clearly

reflected in the code named “Trusting the Process,” ranking among the highest in

significance to participants. These factors lend an aspect of spontaneity to the

participants’ response of treatment choices, safeguarded from theory-driven recitation,

and a nod towards the natural fit of Existential and Process-work therapies with the

unique needs of this population.

The study participants all shared the belief that there is a possible, indeed likely,

subjective meaning and intrinsic value to the experience of dementia apart from

deterioration and loss. Most reported that this meaning can be “held” by the therapist

1
Pacific Institute interns were also trained in expressive arts, somatic awareness, and
psychopharmacology.
 Aging Matters

even as the client experiences increasingly intermittent gaps of “consensus-reality”

cognition and memory, which Process-work might label “ghosts” or “dreaming.” Indeed,

many of the interviewees claimed that simply positing an inherent value to the

progressive condition of dementia can inspire a more effective co-investigation of a

client’s experience.

The study results also testify to many of the participants’ shared conviction that a

deeper form of knowing can emerge from their own and their clients’ increasing

acceptance of not knowing. This openness to not knowing, paired with a growing trust in

the unfolding process of therapy, served as a cornerstone conviction for many of the

study participants. It was similarly reported that preoccupation with a client’s history and

diagnosis did more to interfere than assist with understanding their client. Such a present-

centered emphasis freed the therapists from imposing a restrictive therapeutic agenda

upon the client, reflecting a prioritization of fluidity that is discouraged with manualized

treatment approaches.

The majority of therapists emphasized the importance of empowering their clients

by supporting their freedom of choice and independence within the restricted freedoms of

the institutional context. Many cited the importance of focusing upon the clients’ strength

and abilities rather than their symptoms of pathology. The therapists also recognized their

clients as being the ultimate experts in making meaning of their own experience of

progressive forgetfulness and loss. Regardless of their level of functioning, all of the

clients represented in this study were perceived by their therapists as striving to clearly

communicate their will and perspective. Such communication often included resisting

and rejecting the invitation of relationship extended by a therapist. Indeed, several

 Aging Matters

interviewees reported that simply acknowledging and accepting a client’s rejection can

serve as a powerful foundation for future connection.

In regards to relationship, most interviewees emphasized the importance of a

steady empathic companion on the painful path of grief, loss, and forgetting. One

participant referred to a recurring sense of paradox in the work that simply by sharing

one’s experience of ultimate aloneness and alienation with an empathic other can make

one feel more at home in the world. Several study participants also spoke towards the

delicate balance of validating a client’s unique experience while maintaining one foot

planted firmly in the ground of consensus reality, neither negating nor colluding in a

client’s apparent fantasy.

All of the participants reported that an enhanced receptivity to a meaning and

value underlying “dementia” symptoms consistently emerged in the course of their

sustained empathic connections with their clients. By attuning with compassion to both

the shared humanity of a client and his or her unique individuality, often aided by humor,

imagination, and a willingness to put one’s worldly impatience aside, therapists described

a growing appreciation of potentially latent meanings underlying many of their clients’

apparently meaningless behaviors. Indeed, many participants stated their belief that a

client’s sustained reverie or agitation is often rooted in a need to work through an

unresolved trauma or fantasy in another time or realm.

The unique combination of working with forgetting and dying in a humanistic and

transpersonal framework presents a powerful crucible for maturation as a person-centered

therapist. An unexpected finding of this study was that most of the interns reported their

style of working with the elders as generalizable to a wide variety of therapeutic

 Aging Matters

populations. Several participants offered freely, without prompting, that deepening one’s

skills as a therapist using these particular modalities with this population’s presenting

symptoms would likely translate to most clinical settings. Among the unique effects of

working with clients enduring the loss of both memory and life seems to be that one

comes to naturally take on humanistic and transpersonal values. It is possible, of course,

that the clients in this study also ‘pulled’ for Existential and Process-work attitudes,

embodiments, strategies and interventions from their therapists, essentially coaching their

therapists to take into account their imminent encounters with loss.

Because the majority of research conducted on the treatment of dementia is

pharmacologically-based, there is limited related research with to compare these study

findings. Previous studies reviewing the literature on psychotherapeutic work with

dementia by Richard Cheston (1998) inquired into the environmental and personal

limitations that emerge when treating dementia patients in a residential treatment facility.

Cheston’s research revealed that the states embodied by therapists are particularly

influential in how well received they are received by their patients. The study also found

that particular adaptations often need to be made to a therapeutic setting to accommodate

the progressive cognitive limitations specific to dementia patients.

The fact that all of the participants worked at the same treatment facility

undoubtedly influenced the therapist responses to the interview questions and thus limits

the generalizability of this study’s findings. Considering that the 10 participants in this

study were colleagues, we could expect to see the participants’ views to be relatively

similar. This study does not, however, confirm such a unilateral bias expected from this

relatively homogeneous sample. The participants’ actual therapeutic work often differed
 Aging Matters

significantly both from each other and the theoretically effective clinical interventions

taught in the clinic trainings. For example, one of the major training emphases cited by

the study participants was a classic Process-work technique called “amplifying.” In this

specific intervention, the therapist seeks to locate the predominant “signal” being

expressed by a client and reflect it back to him or her in an exaggerated way in order to

help them “unfold” it in service of its ultimate release. It was notable, however, that not

one of the participants in this study talked about successfully using this intervention.

On the other hand, most participants in this study agreed that some form of

“essential validation” is among the most effective interventions when working with

dementia patients. The code of “essential validation” as defined by this study is the

“simultaneous affirmation of client’s non-consensus and therapist’s consensus

perspectives of reality.” Because dementia patients at times perceive their inner and outer

worlds differently from one moment to the next, it becomes critical to recognize the equal

validity, if not reliability, of their altered state of consciousness. This validating process

was often reported as being a powerful method of building rapport and establishing trust,

helping to relieve the client’s frequent feelings of alienation from themselves and others.

As this study is a one-sided account of the therapist-client exchange and draws its

participant sample from a single professional context, future research may wish to focus

upon the effectiveness of treatment from the perspective of the dementia patients, clinical

supervisors, interview caregivers, and/or family members in diverse clinical or domestic

environments. Another of the design limitations of this method is the sustained time,

energy, and concentration needed to carry out a thematic analysis. Testing the

assumptions of Existential and Process-work theoretical approaches cannot be achieved

 Aging Matters

by a simple questionnaire. In the course of the lengthy coding process, ten hour-long

interviews were transcribed and reviewed several times, each interview coded separately

to insure inter-rater reliability. Without the help of coding software like NVivo and ample

time for the inter-raters to meet, such a detailed analysis would not likely be available to

a study of this scale.

The categories presented in the results section represent an initial step in the

empirical validation of two effective non-pharmacological therapeutic approaches with

elders (Gatz et al., 1999). While it is hoped that these results may be used to inform better

practices, they are not intended to contribute to the rigid calcification of a standardized

treatment manual, which would be largely antithetical to the open-ended nature of

humanistic and transpersonal exploration. Professionals from both the academic and

clinical domains who might wish to expand upon this research are encouraged to gauge

the effectiveness of these results findings with diverse clinical populations.

VII. CONCLUSION

The research findings suggest that Existential and Process-work psychotherapies

are uniquely effective in the treatment of elders experiencing mild to advanced symptoms

of dementia. This study proposes advances in both clinical research and therapy with this

population by categorizing successful experience-tested, non-pharmacological

approaches reported by therapist interns. This research can be considered an initial step

towards establishing Existential and Process-work therapies as empirically validated

 Aging Matters

treatments for working with progressive memory-impairment and its accompanying

symptoms.

The research results, in the form of a thematic codebook, convey effective ways

of responding to diverse behavioral problems and psychic disturbances associated with

dementia that do not rely upon medication or invalidating behavioral interventions. In so

doing, this research presents what is essentially a humanistic and transpersonally-oriented

toolkit for working with dementia as an adjunct to or substitute for the medical model of

treatment. While this study’s findings emerged from the specific context of providing

therapeutic treatment to a geriatric community with varying degrees of loss and

forgetfulness, it is hoped that the generalizable nature of the research results may help to

inform person-centered therapeutic work with diverse clinical populations.

 Aging Matters

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