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Yes, and...

A Dementia Caregiver's Guide to Improv 

*Resident names and any identifying details have been changed for privacy.

September 04, 2020


I like improv. Watching the actors improvise creative ideas, based on audience suggestions, on the spot. Sometimes what they come up with is so funny it's hard to believe that they're creating it all in the moment.


I would never consider myself an improv actor – or an actor of any sort – but I am.


As a dementia professional, I am constantly acting in all kinds of roles. I improvise constantly. And like any improv actor, sometimes what I come up with works well, while other times it falls flat.


… And we just keep moving along, or as improv actor professor Dan Klein says: "Shoot for average and fail cheerfully!"


The rules of improv

Improv actors live by a few rules – anywhere from three to ten, depending on who you ask.


Actress Tina Fey has boiled them down to four:


Agree

Say "Yes, and…"

Make statements

There are no mistakes - only opportunities


There is one more rule often cited for improv that also really applies to dementia care:


Stay in the here and now


Follow the rules – when they help

Bear in mind that nothing works in every situation – in improv acting or dementia care. These aren't intended to be hard and fast rules – they are just a few more tools in the toolbox.

That said, let's take a closer look at how these guidelines can help us improve our improv. 

Agree 


Rule Number One in dementia care is don't argue. Correct sparingly, if at all. In other words: agree.

In improv acting, when you don't agree with someone the scene grinds to a screeching halt. The same is often true in dementia care. 

"I need to pick up my kids from school!"

In either setting, disagreeing – replying with – "No, you don't. You're 85 years old. Your kids are all grown up now" will not be appreciated by your partner.

But, how do you actually agree with something like this? If you agree with her that she needs to pick up her kids, then what?


In dementia care, try a response that acknowledges and validates the value of what they are trying to do without discounting the need to do it. For example: "What lucky kids they are to have such a devoted mother!"


Next, keep moving. Be agreeable and go with the flow to avoid building frustration, anxiety or stress. She sees you are helping her, not hindering her efforts.

Say "Yes, and…"

In improv acting, if you agree with your partner's premise but don't add anything further, the scene stalls. 

"I need to go get my kids from school."

"Okay..."

[crickets chirping]


So one of the golden rules of improv is to say "yes, and…". You agree and then contribute something more.


This works wonderfully in dementia care.


Let’s continue with our example about picking up the kids from school. Simply agreeing with no further action may not help. (It actually may help in some cases, but assume for now it doesn't.) She's watching you expectantly. It’s time for the “And”.


What you add, the “And” if you will, should depend on the underlying needs at play. Is the person tired? Energetic? Hungry? Restless?


Consider the goal

Your goal should be determined by the need. Is the person tired and hungry? How can you get them fed and rested? You might improvise your way to your goal – and ultimately never end up there – but do look for what is driving the need.

Let’s assume the person in our example is somewhat energetic and restless. She’s often this way in the midafternoon. She is likely triggered by deeply ingrained routines from when she did go get the kids around this time of day.

Our goal will be to help her expend some energy and feel she has accomplished what she needed to. Note that she may not need to accomplish the exact goal she starts out with to ultimately feel a sense of accomplishment and satisfaction.

And, get ready to go !

You might start by "getting ready to go". Go to the toilet, brush hair, whatever. Get moving immediately so her need to get moving is fulfilled without frustration.

If you don't put up your own resistance, or bring up the school again as you're getting "ready", chances are high that the person will become distracted by something else along the way.  

You can help her along the path of redirection through conversation. 

You might start by talking about the school and kids, and then lead the conversation away from there.

Do they enjoy school? Do they get in trouble at school? My kids love school. They play basketball. They're getting good. Sometimes I bring cookies for the team. I think we have some cookies here. Do you like chocolate chip cookies? Do you prefer milk with your cookies, or coffee? Here are some cookies and coffee. 

Be open to the possibility that you may end up heading out for a walk or drive.

Exercise, fresh air, change of scenery – going for a walk or drive can help tremendously. Importantly, it can fulfill her need: to get out and get moving.

Maybe you bring a dog along for a walk, or some mail to drop off. Help her feel she's accomplished something meaningful. 

Saying 'no' stokes feelings of frustration – even panic about her kids' safety.

If you "block" her (as they say in improv) by resisting what she wants to do, you will create frustration and stress. Her feelings intensify. She is determined NOT to abandon her kids. You will find yourself with a "behavior problem" on your hands.  

(Just like you might have to deal with a "behavior problem" if you kept trying to block me from picking up my kids from school. My kids need me.
I might be polite at first, but the more you stop me and get in my way, the more stress I will feel and the angrier I will grow.
I will eventually become "aggressive" if I don't see another path to my kids other than through you.
By the way, telling me that I don't have to worry about my kids because they are all grown up will not help me because, um, they are not.
And while my kids really are school age right now, the person with dementia really believes hers are too.  
Her "reality" is completely real to her. To abandon her kids is not an option.)

Nobody tells me what to do: Reactance in action 


Reactance theory is a concept well known by psychologists and proven by science. Basically: people don't like to be controlled, or told what to do. Whether we are two years old or ninety-two, we are innately driven to do the opposite of what we feel we've been ordered to do.

So, telling someone they can't go get their kids makes them that much more determined to do just that.  

But, what if you can't just take off on a walk or a drive?

You'll just have to improvise.  

-> Stay calm

-> Say yes – don't say "no" or "can't"

-> Stay in the moment

-> Be alert for opportunities for distraction, redirection or other ways to meet the need.


A telephone call is a quick, easy and incredibly effective tool for redirection. A well timed phone call is easier than ever now that we all walk around with cell phones in our pockets!


A walk around the building, or to another room can often be enough to satisfy the need, as long as you:

-> Don't try to convince the person they can't – or don't need – to go.

-> Don't remind them what they're wanting to do - allow them to forget if they will.


They are far more likely to forget and be open to distraction if they feel you are on their side – they don’t have to fight for what they want, need or believe.


But – before you jump to the conclusion that you can't go for a walk or drive, is there any way to say yes?


Why can't you, really? If you talk to your coworkers or supervisors, might there be some way? 

Get creative! Figure out how to say yes!

You will encounter far less resistance, and you may find it replaced with a great sense of fulfillment and satisfaction – in yourself as well as in the person with dementia. 

A "Yes, and" philosophy also works with physical resistance

For example, if someone is walking the wrong direction, for example, don't try to stop them and turn them around. Walk with them the wrong way until you can circle back in the desired direction.

If you're trying to help someone take off a shirt, sometimes they lock up their elbow and push back. Go with their flow! Let them push out and straighten their arm. Once they do, it's a natural movement to continue going and then circle back seamlessly. You end up where you wanted to be in the first place. 

Make Statements, not Questions

In improv acting, asking questions places the burden upon your partner to come up with all the answers.  


"Is this the zoo? Where are the animals?"

Coming up with answers can be difficult and exhausting 


As anyone with public speaking anxiety, or who has ever been asked a stressful question can attest: our brains tend to freeze up when put on the spot. Statements leave us feeling free to respond or not. They don’t tend to trigger the same anxiety reactions as questions often do.

Although improv actors are especially good at avoiding stress-induced blank-mind syndrome, the scene still suffers when only one side is contributing creative energy. It doesn't flow as smoothly or work as well.

Making statements with confidence is a great way to contribute to the scene – and it leads to a far better outcome. 




"This zoo has really gone downhill... That little dog is the only animal I've even seen today."



In dementia-improv asking questions can also present challenges and interfere with the smooth outcome of the situation.

Questions can be tricky with dementia for many reasons:

- It can be hard for someone with dementia to come up with information on demand
- Questions can be exhausting for the person to answer
- Questions, or the difficulty answering them, can trigger negative feelings like embarrassment, frustration, anxiety or stress
- Questions can even trigger a catastrophic reaction at times when it's all just too much to handle
- You may get an answer you don't want 

Questions can be a great tool when used thoughtfully 


When used conscientiously, questions can be a great tool for helping a person with dementia. Answering questions can enable people to:


- exercise choice
- communicate preference
- express themselves
- share information about themselves
- build relationships


Asking someone a question can be an excellent way of subtly reminding or influencing them to do something without "telling" them what to do.

Questions can be an effective way to help the person maintain or feel control over their life and should be used in certain circumstances for sure. Just be aware that they can be tricky.


- Ask only when you are willing to accept their answer.
- Ask questions that will not overwhelm them.
(You won't always know for sure, but try to tune in to where they are in each moment.)

- Consciously consider whether each question is likely to benefit them or not. 

There are no Mistakes – only Opportunities

Many of the best improv moments grow out of misunderstandings and miscommunications. When you say “Yes, and” and keep going with an openness to see where it will lead, the magic can happen.

Spiritual leaders and philosophers across the lands have also recognized the truth in this message and have been espousing it for ages. Mistakes are inevitable. Trial and error is an integral part of growth and of being human.  

The potential of opportunity

There are opportunities to learn, to grow, to apologize, to connect, to make amends, to show we care, to earn back trust and to do better next time.

Whether you are improvising on stage or with someone with dementia, don't let yourself get flustered by mistakes. Take a breath, stay open to what is happening and look for the opportunity the moment is offering. 

Stay Present and Use the Moment

It is important to stay present in the moment, but we do need to keep an eye on the future to a certain extent.  

Know the goal and be prepared for several eventualities

We often do need goals – getting cleaned up, for example. It can be great practice to have a loose plan to get there. In fact, being prepared is key to success! Have supplies and clean clothing ready at all times in any room you’re likely to need them! But be prepared to drop the plan and improvise as the need arises.

Stay alert, observant and present in the moment. You will be more able to spot the opportunities as they arise. 

The unexpected can be a gift

In improv acting, some of the best moments occur when the actors react to and incorporate something unexpected that happens in real-time – a light flickers, a loud crash is heard in the distance. When the actors can weave it seamlessly into the scene, the audience loves it!

An unexpected visitor; the sound of singing from down the hall. Unplanned organic events can provide the best distractions, excuses and motivations – but only if we're aware of them in time to use them. 

If we focus only on following the path we planned, we're apt to miss many opportunities to actually get to our goal. We're apt to create struggle, conflict and behavioral resistance.

So, let us agree, expand, lead the way and stay present... and appreciate the gift in every mistake.


How have you improvised when working with someone with dementia? Did it work well or fall flat?

Share your story on the ABC Dementia Facebook Page.


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