The power of a cup of tea: psychosocial interventions in dementia

Dementia is a complex condition characterised by a loss of cognitive and social functioning caused by progressive neurological disorders (National Institute for Health and Care Excellence (NICE), 2022). The causes of dementia are multifactorial, as are the needs of those affected by the condition (Vernooij-Dassen et al, 2021). People living with dementia and their carers are more likely to have additional comorbidities than their age-related peers (Public Health England, 2019; NICE, 2020). Behavioural and psychological changes such as agitation, anxiety and depression can occur in up to 90% of those living with dementia, causing distress for the person and their family (Altomari et al, 2022). Dementia is the leading cause of death in the UK (Alzheimer's Research UK, 2021) and disproportionately affects women due to mortality and carer roles (World Health Organization, 2023).

Dementia can have a significant impact on the wellbeing of the entire family. Individuals living with dementia and their carers, who are typically family members, require meaningful support that addresses all aspects of their biophysical needs. Providing person-centred care involves considering not only the biomedical diagnosis but also the person's environmental, social and psychological needs. This is the foundation of Kitwood's (1997) argument that the effects of dementia are multifaceted. Therefore, any interventions must meet the practical and psychosocial needs of the entire family (Fontaine et al, 2016; Schulz et al, 2020; Teahan et al, 2020).

Kitwood (1997) further made the point that in contrast to the historical biomedical narrative that regards dementia as a pathological condition to be diagnosed and treated, psychosocial interventions recognise the importance of communication and relationships in a socially and psychologically active environment.

This article will explore the importance of psychosocial interventions for families living with dementia and discuss such interventions in the ‘everyday’ and a more structured approach with mindfulness and Acceptance and Commitment Therapy (ACT) (Atefi et al, 2023).

The therapeutic power of a cup of tea

In her book, Mitchell (2022) talks about her relationship with, and the importance of, a cup of tea while living with dementia:

“Tea is more than a beverage; for me, it has always felt like a warm hug … I liked to sit with each palm wrapped around it, savouring as much the ritual as the taste … I never felt lonely with a cup of tea”.

Mitchell (2022) described drinking tea as more than a necessary act to hydrate the body. It provides a sensory experience that brings comfort and warmth, creating a sense of grounding, emotional stillness and familiarity. Drinking tea can be a moment of mindfulness, particularly during difficult times, when relaxation and calmness are needed. Offering a cup of tea to someone in distress is perceived as a kind gesture that displays empathy and fosters a sense of connection. This simple act of kindness can help individuals remain grounded and focused, even in chaotic situations.

Building trust and rapport between a healthcare professional and a family with dementia is vital in any intervention, as it is essential for establishing a therapeutic relationship – in itself, a process of mutually agreed actions (Price, 2017).

Demonstrating to a person the willingness to share and dedicate time to them has both social and psychological effects. When greeting a friend or stranger in one's home, it is important to negotiate the context in which that interaction will occur. Offering or accepting a cup of tea should be viewed as the start of this process – the framework for the following interaction. Therefore, offering a cup of tea can carry more significance than providing hydration to a guest. It opens the door to a shared experience and increased personal connection between one or more people.

Drinking tea with someone else can promote therapeutic communication by setting a comfortable pace and flow for conversation. It can improve communication by providing an opportunity to pause and reflect. Mannix (2021) suggested that we should listen to understand, not just to reply. One can fully engage and show respect for those involved by slowing down the conversation and actively listen.

Nurses are often offered a drink when they enter a person's house. This offering is a societal norm and an interpersonal gesture of shared space and time. For Micheal (Box 1), offering a cup of tea was an act of politeness to a person entering his home and an invitation to a more developed therapeutic relationship through a shared space and experience. Accepting the offer of a cup of tea opens up the opportunity to build and maintain rapport. Sharing a cup of tea demonstrates an openness to a shared experience with someone else. Having the drink with Micheal enabled this opportunity to pause and reflect on the cause of his dejection and distress, and begin to offer a suitable mode of support.

Box 1.Anonymised case study to demonstrate the application of psychosocial interventionsMicheal is a carer for his wife, Liz, who lives with dementia. Liz became concerned about her memory 7 years ago when she started having difficulty recalling conversations and gradually became less confident in familiar tasks such as operating domestic appliances. After being seen by her local memory assessment team, Liz was diagnosed with vascular dementia. The couple were determined to ‘live well’ with dementia and sought ways to remain active, to ‘fight until the end’. They felt their quality of life was reasonable, allowing them to prioritise the things that were important to them. However, Liz now needs more support with activities of daily living and is less confident in social interactions with friends. She increasingly has difficulty with maintaining her urinary continence and is eating less. She is frailer in appearance and prone to setbacks with less resilience to infections and gets easily frustrated at the deterioration in her abilities.Micheal has always been clear with Liz that he will continue to care for her at home. However, he finds the practicalities of this more challenging than anticipated, aware that his own well-being is being affected, and so is becoming increasingly unsure about his ability to keep his promises to Liz. He finds the attempts of health professionals to discuss their future needs distressing and believes that services feel he is not able to care for his beloved wife. When an Admiral Nurse arrives for a planned home visit, Micheal is in a very dejected state. He offers the Admiral Nurse a hot drink as they remove their coat.

Psychosocial interventions

Dementia impacts the physical, social, economic, spiritual and psychological lives of those affected. People living with dementia often face an uncertain future. Although carers may express positive aspects of their role, their wellbeing can also be negatively impacted as they transition into the caring role. This can lead to an increase in carer burden and higher levels of depression, anxiety and stress, especially when dealing with the physical and psychological loss of a person with dementia (Schulz et al, 2020; Lindeza et al, 2022). Micheal and Liz (Box 1) had managed to overcome some of the challenges dementia had presented to them but were reaching a point where coping mechanisms were no longer able to mitigate these issues. While Liz was becoming frailer, Micheal found that his psychological and physical resilience was more challenged. He needed support, not just for the practical aspects of supporting Liz but also for the emotional impact on himself as he attempted to adjust to the shifting sands of his caring role.

Failure to address the psychosocial needs of carers can result in adverse outcomes for both the carer's mental and physical health and also the person with dementia through early transition into long-term care and overuse of medication (Teahan et al, 2020). Many of these adverse effects can originate from the psychological and social effects of the condition and the struggles to adapt to and manage the physical and practical impact of the caring role.

There is a growing evidence base for the significant and positive effectiveness of psychosocial interventions in dementia (Teahan et al, 2020; The British Psychological Society, 2022) (Table 1). Psychosocial interventions are those approaches by which support may be offered to a person to help them overcome the challenges they face and can improve physical, cognitive, relational and social well-being (McDermott et al, 2019; The British Psychological Society, 2022). The term is often applied to differentiate such interventions from pharmacological-based approaches, implying that psychosocial interventions are an alternative means of symptoms management (McDermott et al, 2019). However, psychosocial interventions go beyond basic problem management and seek to enable a person's individual goals and improve their quality of life (Patel et al, 2014; McDermott et al, 2019). Crucially, they provide opportunities to recognise and maintain personhood, moving away from a pervading nihilism that there are no successful interventions for those affected by dementia (Patel et al, 2014). This view originates from a purely biomedical stance about dementia, which ignores the vital importance of person-centred and holistic approaches, and continues to contribute to the stigmatising and exclusionary impact of dementia.

Psychosocial interventions are person-centred (Turton, 2014) and can be just as effective as medication in reducing the burden of caring for a person living with dementia (Patel et al, 2014; McDermott et al, 2019). Specific interventions may help families affected by dementia to maintain relationships, adjust to diagnosis, support relationships and continue to live independently (McDermott et al, 2019).

As such, there is increasing interest in psychosocial interventions to address the whole family's well-being. However, evidence suggests that there is no ‘one size fits all’ and tailored approaches accounting for circumstances and needs are recommended (Patel et al, 2014; Fontaine et al, 2016; Teahan et al, 2020).

Effective interventions

One tool to consider what approach may be most supportive and to reflect on when interacting with families is that suggested by Chochinov et al (2013). ‘Personal growth’, ‘therapeutic approaches’, and the ‘creation of a safe space’ are the three domains of effective interventions. The three overlapping sub-domains of ‘therapeutic humility’, ‘therapeutic pacing’ and ‘therapeutic presence’ are also suggested (Figure 1 and Table 2). This model highlights 50 elements within the domains, such as accepting and naming distress and emotions, valuing the person and their own insight, understanding the urge ‘to fix’ from nurses and families, and the acceptance and tolerance of control. This requires a flexible approach, good communication skills and the opportunity to talk and to listen.

Communication as a psychosocial intervention

Communication is the verbal or non-verbal information exchange between a recipient and sender, a reciprocal process with situational context (van Manen et al, 2021). It is enhanced or degraded by many factors, and its importance has been known and discussed for centuries (Sharma and Gupta, 2023).

Communication can be described in biomedical or psychosocial approaches. Biomedical styles are used to exchange information about a disease's diagnosis, treatment, and prognosis, but effective communication in healthcare should also account for psychosocial factors (Sharma and Gupta, 2023). These factors revolve around holistically understanding the person and their goals. Therefore, successful outcomes rely on effective therapeutic communication that enables psychosocial approaches.

Therapeutic communication can help improve diagnosis accuracy, identify emotional and psychological needs, support collaborative decision-making, and empower people to take control of their own well-being. Communication becomes therapeutic when there is active engagement and partnership, inclusion of values and goals, and the application of ways to overcome barriers such as emotional or psychological distress (Underman Boggs, 2023). Such approaches align with the person-centred care advocated by Kitwood (1997), who argued that a person with dementia should always be offered the opportunity to be actively involved in their care and decision-making.

For Micheal, talking about the current challenges faced by the couple started with a cup of tea, which set the context, pace and flow of the conversation. The enforced silence when drinking, the reflection and the pause to allow the other person to drink help incorporate the aspects of effective therapeutic communication (Table 3) but also provide a safe environment to begin to explore aspects that created discomfort and fear for Micheal. Naming his fears and emotions (Table 2) was effective in helping the Admiral Nurse understand the root causes of his distress and the context of these concerns. Active listening and being fully present, aided by a cup of tea, ensured that Micheal felt heard, that his worries and fears were understood and that meaningful solutions would be offered.

Mindfulness

Mindfulness is a cognitive-based therapy and form of meditation that helps people become aware of their internal states and surroundings by learning to observe thoughts, emotions and experiences without judging or reacting to them (Berk et al, 2018). Mindfulness is an effective intervention for carers of a person with dementia, particularly in the reduction of self-rated stress (Berk et al, 2018; Liu et al, 2018; Chacko et al, 2022).

Mindfulness aims to increase awareness of the present moment, including body sensations, emotions and sensory experiences, to counteract elements that can cause psychological distress or discomfort (Creswell, 2016) (Box 2). Mindfulness enables people to understand and accommodate painful and distressing experiences, while reducing their negative impact. By reducing common forms of psychological distress, including rumination, anxiety, worry, fear and anger, people can use mindfulness to experience negative emotional experiences without ‘being caught up in the moment’ (Treadway and Lazar, 2009). Accepting and examining life's experiences, rather than being overwhelmed by them, is critical. Altering the response to unavoidable challenges can significantly impact our well-being (Creswell, 2016). Clarifying and naming the source of distress, problem-solving, acknowledging distress and acknowledging emotions are part of effective therapeutic approaches (Chochinov et al, 2013), which mindfulness enables.

Box 2.Example mindfulness exercise (5,4,3,2,1)

• Take five deep breaths
• Look around the room and name four things you can see right now
• Name three things you can touch right now
• Name two things you hear right now
• Name one thing you can smell right now.

One can experience emotional pain and distress when confronted with adverse events or circumstances internally perceived to be damaging (Siegel et al, 2009). Different circumstances can trigger this perception, for example, when feeling unable to achieve a goal, have a feeling of loss, or are forced to face an unpleasant set of circumstances. People with dementia and their families often face such experiences, and psychological distress can be higher for carers of those with dementia than in peer groups with other long-term conditions (Berk et al, 2018), as in Micheal's case.

Micheal faced an internal crisis – maintaining his promise to Liz and continuing to care for her at the expense of his own wellbeing or facing the apocalyptic prospect of transitioning into a more formal care arrangement. Mindfulness-based approaches suggested by the Admiral Nurse supported him by focusing his awareness on the present rather than the future and examining the painful prospect of Liz transitioning into care. These allowed him to prevent these thoughts from becoming all-consuming and allowed a better exploration of the steps and strategies needed to support Micheal and Liz in achieving their goal of staying together at home. Reducing the impact of distress, namely the physical, psychological and emotional distress of the situation, and helping Micheal be more present in the moment reduced the rumination and cycling of ‘what if …’ types of thoughts.

A simple approach to mindfulness is sensory grounding and breathing exercises that can be self-directed when a person is taught the technique. This can be accomplished with a simple cup of tea in creating the space and sensory input. For Micheal, using this technique early in the session helped to calm anxiety and provide focus in the moment.

Acceptance and commitment therapy

Acceptance and commitment therapy (ACT) is a form of psychotherapy that emphasises the acceptance of negative thoughts, circumstances, symptoms and feelings. It is an approach that incorporates elements of mindfulness (Berk et al, 2018). This approach enables individuals to integrate these challenges into their coping mechanisms and commit to healthy activities aligning with their values and aspirations. ACT has been shown to have a positive impact on anxiety, distress, carer burden and reducing feelings of guilt (Atefi et al, 2023).

Carers of people with dementia often face a prolonged period of caring, and many feel their own needs are overlooked (Lacey et al, 2023). Carers often feel overwhelmed, guilty and disempowered, leading to psychological distress. Micheal experienced increasing distress due to Liz's declining abilities. Acknowledging the source of his distress and helping him accept the changing circumstances empowered him to understand that the connection with his wife was still meaningful and that he could continue to care for her changing needs.

Carers may struggle to reconcile expectations and outcomes and may need support to acknowledge that it is possible not to have all the answers every time. Skilled intervention from specialist services such as Admiral Nurses (Dementia UK, 2022) to help families understand the complexity of a person's needs can help build carer confidence, moving from fear of the unknown to freedom from negative self-perceptions that hamper well-being (Harris, 2022).

Excessive expectations and self-criticism can often contribute to negative self-perception, which can be overcome through mindfulness and diffusion techniques employed in ACT (Harris, 2019). Diffusion is a fundamental aspect of ACT (Figure 2) that allows individuals to break down complex issues into more manageable components, particularly during critical moments and break free from unrealistic self-expectations. It promotes focusing on current challenges, building confidence to face the future, accepting the present situation and devising a plan for the future. By applying other principles of ACT, based on openness (acceptance and diffusion), awareness (contact with the present moment and self as context) and engagement (contact with values and committed action), a circular process of navigating current challenges and reassessing future actions can be achieved.

ACT uses metaphors to describe situations and how they affect the present by promoting honest and open conversations and addressing the ‘elephant in the room’. This creates better insight by acknowledging the presence of an issue to make it more manageable. For instance, in the case of Michael, he found the idea of his wife transitioning into care unbearable due to his sense of failure. As a result, the use of diffusion technique helped to explore some short-term solutions, such as taking practical measures regarding continence, examining his motivations for caring for his wife and identifying the root cause of his distress. This approach enabled Michael to consider different alternatives, including future planning for his wife's preferred place of care and death.

Breaking down the concerns and exploring the context of the distress relied on effective communication. Utilising skills outlined in Table 3 during a cup of tea elicited information from Micheal but also created the space and climate for the Admiral Nurse to gently challenge some of those self-perceptions and offer comments on them. This approach also demonstrated an effective intervention strategy (Chochinov et al, 2013) by identifying what was in Micheal's control, eliciting the true focus of his needs and enabling exploration of his personal resources in overcoming the challenges he faced.

Integrating this approach can improve resilience and alleviate the carer's burden by supporting self-acceptance of the challenges that supporting a loved one with dementia produces. In addition, applying targeted interventions to tackle adverse emotions and self-doubt before they become entrenched in daily life can facilitate more frequent and impactful therapeutic outcomes.

Conclusion

Dementia is a complex condition that can affect individuals in different ways. Various psychosocial interventions can be used to address both the psychological and emotional impact of dementia. Simple communication techniques can be viewed as psychosocial interventions if used intentionally to improve the personal aims and objectives of the person and families living with dementia. Mindfulness techniques can help to reduce distress and excessive rumination both in the moment and as a longer-term strategy. For more specialist interventions, ACT has been shown to have notable success in achieving better outcomes for families living with dementia with proper training for healthcare professionals. Any of these approaches can be initiated and supported by the power of a cup of tea, which creates sensory grounding, creates safe spaces and improves interpersonal connections.

Key points

• Psychosocial interventions are vital in providing holistic support to people and carers living with dementia
• Simple actions and consideration of communication styles are the basis for psychosocial interventions
• Controlling the pace of conversation through actions such as drinking tea can have positive effects on well-being and interventions
• Psychosocial interventions such as mindfulness and acceptance, and commitment therapy can reduce distress and support people in maintaining well-being in adverse circumstances.

CPD reflective questions

• How could you use therapeutic conversation skills to enhance your practice?
• How can your practice be supported by utilising Chochinov's model of therapeutic effectiveness?
• Utilising ‘everyday actions’ such as sharing a cup of tea, how can you provide psychosocial interventions that are holistic, and support the whole family?