Specialised Early Care for Alzheimer's (SPECAL)
The Contented Dementia Trust is a charity based in Oxfordshire which offers its own unique approach (SPECAL) to the care of people with dementia. It provides a range of courses, services and advice for carers and family members. The theory and practice of SPECAL have been described in a best-selling book, Contented Dementia by Oliver James.
Alzheimer's Society's view of SPECAL
The SPECAL approach is popular with some carers and includes elements that do reflect established good practice. Its emphasis on the feelings and emotions of people with dementia is a strength, for example. However, Alzheimer's Society has serious misgivings about how SPECAL is implemented. SPECAL has long been controversial and, in our view, much of the approach runs contrary to the practice of person-centred care as established by leaders in the dementia care field.
People with dementia and their family carers say (National Dementia Declaration) that they want to see the following outcomes in their lives:
- I have personal choice and control or influence over decisions about me
- I know that services are designed around me and my needs
- I have support that helps me live my life
- I have the knowledge and know-how to get what I need
- I live in an enabling and supportive environment where I feel valued and understood
- I have a sense of belonging and of being a valued part of family, community and civic life
- I know there is research going on which delivers a better life for me now and hope for the future.
Alzheimer's Society struggles to see how SPECAL can help deliver such outcomes. We do not accept that a total ban on asking direct questions of someone with dementia - one of the 'three commandments' of SPECAL - is appropriate. People with dementia tell us that they want choice and control over their lives. A key goal of the Mental Capacity Act 2005 (England and Wales) is to empower people with dementia, by ensuring that they are supported and involved in decision-making as far as is practical. Contrary to all this, by prohibiting the asking of direct questions, SPECAL seems to disempower people with dementia and deny them an effective range of choices, from their diagnosis on.
Another reason why SPECAL has been heavily criticised in the dementia care field is because it suggests a blanket approach to deception of people with dementia. A key element of SPECAL - what it calls 'making a present of the past' - in our view amounts to encouraging people with dementia to believe that they still living at a certain time in their younger life.
We do fully support the need to understand the perspective of the person with dementia and to provide an environment which meets social and psychological needs. However, we struggle to see how the systematic deception of SPECAL, however well intentioned, is in the best interests of the person with dementia. Individualised care requires appreciating the relevance of someone's unique history for the present, not encouraging the person to continually 'live in the past'.
In its 'third commandment', SPECAL requires that carers 'always agree with everything' that someone with dementia says. It is freely admitted that this will in some instances equate to deceiving the person, as will SPECAL's requirement to provide 'acceptable explanations' to the person for a range of day-to-day visitors. Even where this team-wide approach is supposedly taken in the person's best interests, we struggle to see how systematically deceiving someone with dementia can be part of an authentic trusting relationship in which the person's voice is heard and their rights promoted.
Finally, SPECAL claims to offer the only approach to caring whereas it is only one of a range of approaches. In our view SPECAL is controlling and prescriptive, and fails to acknowledge the unique needs of a person with dementia met from a range of approaches. It is for these reasons that the Alzheimer's Society does not publicly support efforts to spread the use of SPECAL.
Last updated: August 2012
Read Graham Stokes' (Head of Mental Health, BUPA Care Services) book review on Contented Dementia
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