Dementia, Through-Lines and the Diminished Person

Recently, The Boston Descriptive Psychology Study Group spent an afternoon discussing the effects of dementia. We applied the paradigm case formulation of persons described in “The Problem of Other Possible Persons.”  Our starting point was the effect dementia has on the ability to engage in Deliberate Action.  

Deliberate action requires the ability to choose or select a course of action among alternative ways of reaching a goal. This is more relevant for some motivational perspectives than others and is a central feature of action guided by ethical or aesthetic perspectives.  These motivational categories intrinsically require the possibility of renouncing an option.  I am going to take the “high road”, not the “low road”.  Choice may be less essential when behavior is guided by hedonic or prudential concerns. I keep doing it because it feels good.   That’s scorching hot. I’m not going to touch it.

We wondered what happens when patterns of behavior are no longer as informed by a code of ethics and aesthetics as they would be if the person was better able to deliberate. What happens if we remove a significant degree of ethics and aesthetics from the human equation?  

As a person, I have the job of actor, observer and critic.  As an actor, I am the author of my behavior.  As an observer, I note what is happening.  As a critic, I evaluate how I’m doing, and if it isn’t to my satisfaction, I attempt to change course. Observer and critic functions are hobbled in dementia. Self-regulation suffers. 

A paradigm case person is an adult with all the powers and dispositions to successfully act in the relevant communities of his or her culture.  The actual pattern of a person’s life has the qualities of a story or narrative. This is called a Dramaturgical Pattern in Descriptive Psychology.  All the world’s a stage. 

Dramaturgical patterns are organized by ongoing activity that the actor finds significant and that observer-critics will identify as “in character”.  This is a pattern of “through-lines” that corresponds to what a person is up to when they perform various social practices that may resemble each other only in their significance. For example, a person’s life might be identified by consistent attempts to act with modesty, tact and compassion. This could result in a deferential pattern of being overly careful to be fair, expressed as “others come first”.  A mild mannered politeness might become the style of performance.  What happens if such a person suffers dementia?

If dementia interferes with the quality of deliberation, it impedes judgments that require the ability to choose among alternatives. A demented state might disrupt significant practices that would have been influenced by a person’s ethical and aesthetic perspectives of fairness and manners.  Of course, deliberate actions that concern a person’s hedonic and prudent perspectives would also suffer, but ethical and aesthetic judgment is more vulnerable. To the extent that an ethical and aesthetic appreciation of a social practice’s significance is not adequately present, we could expect hedonic and prudent behaviors to be less regulated. It would be unsurprising for behavior to become more pleasure-seeking, impulsively sexual, overly hostile, competitive or unduly concerned with safety.

A diminished aesthetic perspective can create other fundamental disruptions in a person’s status. The loss of an adequate aesthetic perspective corresponds to a loss of concern with the question of what is fitting or not fitting given the sort of person I am. Self-maintenance, concerns with personal integrity, and self-status assignments falter as appraisals of self and world are made with less reference to what fits.

Consider different end of life dramas.  With “death as an advisor”, the knowledge of nearing the end of one’s days may carry profound reason to approach the time remaining with a heightened ethical and aesthetic resolve. To the extent a person remains able to engage in deliberate action, the full use of hedonic, prudent, ethical and aesthetic judgment potentially fosters a more dignified ending than what dementia ordains. 

A dynamic wrinkle:  aesthetic judgment involves a range of social, intellectual and artistic values of truth, rigor, objectivity, closure, beauty, elegance and fit. Ethics concerns fairness, justice, the “level playing field”, the Golden Rule and similar notions. The competence needed to maintain the ability to successful employ these perspectives, i.e., the ability to engage in Deliberate Action, probably changes in different ways given different degrees of proficiency, value and locations of damage. Change in any area would result in a dynamic change across a variety of actions dependent on the contingent or independent nature of the domains affected.  All of this will be compounded by the memory disruptions and other loses of competence, also hallmarks of dementia. 

One consequence of a diminished capacity for deliberate action is a diminished empathy with a corresponding failure to appreciate what other people can tolerate. Having less perspective, understanding is limited. Behavior is not tailored to what the other will feel.

A person whose life had a through-line of mindfully polite, compassionate action, who always practiced deference and tact, in a state of diminished capacity may now behave without accurate caring regard.

But does dementia allow a person’s “true colors” to finally appear? Probably no more than the nastiness that can come out in rage. Instead, ordinary human ambivalence is no longer competently managed by the kindness and compassion that counted for more.

Complex interdependent and intimate relationships invariably carry a degree of ambivalence. Emotionally competent adults learn to express this carefully. In the absence of a robust capacity to engage in Deliberate Action, ambivalence can devolve into an oscillation of love and hate, of poorly modulated idealization and devaluation. This is not a person’s “true colors” but only a black and white shadow of what was there before. 

                    Odi et amo. quare id faciam, fortasse requiris?
                    nescio, sed fieri sentio et excrucior.  Catullus

Today, The New York Times reported the very good news that rates of dementia are falling.Ned Kirsch, a neuropsychologist trained in Descriptive Psychology, has written a compelling essay and discussion about the assessment of dementia.

By: Wynn Schwartz, PhD

Dementia, Through-Lines and the Diminished Person was originally published @ and has been syndicated with permission of the author.

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