Fernando Alvarez Zamudio is a Gestalt therapist and practitioner researcher living and working in Mexico City. This web-based interview is the distillation of discussions which took place over an extended period, across two continents and two languages. Our curiosity about Fernando's therapeutic work with elderly clients, in particular those with neurocognitive impairment, led us to follow through and raise our own awareness of how this growing client group could be seen and supported.
Many of us have experienced the impact of dementia, or are living with this experience currently and witnessing the gradual adjustments and ultimate transitions in those we love and in ourselves in response. We felt moved by Fernando's commitment to his work and we hope what follows will allow others to reflect and connect in their own ways.
________________________________________________________________________
Can you tell us a little about yourself and your journey to becoming a therapist? In what settings are you currently working as a therapist?
Since I was small something has been calling to me about the way of being of adults. As well as living with my parents I also lived closely with my grandparents on both sides of the family. Ever since the time my great-grandfather died from cancer, I wanted to understand how it was that even with this disease he continued to smoke and smoked his last cigarette in hospital. At times my great-grandmother also talked to me and I understood something of her way of being.
A large part of my childhood was spent in hospitals for various surgical procedures and my grandparents accompanied me there. Whilst my school friends had to make hospital visits to see their unwell grandparents, my grandparents had to make those visits with me. This gave me many experiences of illness and death which I can now say were very enriching. So when I first approached a career in Gestalt therapy I knew that this was the path which would have most meaning for me.
At the moment I am mainly teaching in the IHPG (Instituto Humanista de Psicoterapia Gestalt) in Mexico City as well as running a private practice. I have a place in a neighbourhood in the centre of the city, ‘Roma’, made famous in the film of the same name by Mexican director Alfonso Cuaron. It is here that I give my therapy sessions but it’s also what I call the laboratory of dreams, which is the space where I write and develop my research activities. Research in Mexico is a bit tricky if you want to follow your own path - everything has to be paid for out of my own pocket; travel, conferences etc.
I love my way of researching. At present I am pursuing three strands of qualitative enquiry both through publication and primarily through presenting at international conferences. My first theme focusses on my work with hallucinations and dementia, the second is about dreams, fantasies and Gestalt therapy and the final one revolves around playfulness and bodily expressiveness in movement (this last one is a proposal I presented at last year’s Gestalt research conference in Chile)
Could you briefly outline for us the nature of the healthcare system in Mexico, specifically in relation to care for the elderly and those with major neurocognitive impairment?
This question is complex and I will give as brief a description as I can. First we need to define health care in Mexico. To clarify, there are two general types of health care in my country. The first is government hospitals which cater for those on minimum salaries and those who work for the government. The other is private hospitals which cater for people who have health insurance. In both cases the prevailing discourse follows a medical perspective, such that the care provided, either in government or private facilities, will actually follow a medical model whether dealing with the classic illnesses of old age such as diabetes, cardiovascular problems, impairment of the senses, hypertension or related diseases involving neurocognitive impairment.
In the national healthcare system, the major cause of death in old age is physical inactivity, therefore outside of hospitals the focus for older adults is on their taking part in activities in the fresh air. However in the light of the current economic situation it has been some years since there were people employed who specialised in this area and generally we rely on volunteers. Although it seems to me to be an important area, there does not exist any concept of personal development work or transition towards ageing other than this, and often it is the grandchildren who take on a sort of role of guardians for their grandparents.
The major difficulty in terms of the theme of ageing and the care offered to elderly people with neurocognitive impairment is that in Mexico, as in many other places in Latin America, there is no culture of ageing. Thus elderly people who rely on any type of medical help will be living at home and facing economic challenges and it will be their relatives who take care of the elderly ‘unwell person’. In psychogerontology this has been termed informal caregiving. In my work I have even known elderly adults who are caring for another elderly adult – daughters of 75 years old caring for their mother aged 90.
Due to the absence of specialised help, supplies, equipment or even medicines, there is a large number of elderly people who are either abandoned or remain living in violent situations. Moreover, many elderly people view residential homes or institutions as synonymous with being abandoned due to the unsanitary conditions in some centres, which often do the best they can with the few resources they have. The centres which are not privately run find themselves over-populated and unable to help all those who need their help. Those who are able to pay privately with insurance or attend as a day resident are more comfortable. In both cases these centres will only have one or two psychologists for the entire centre and they will work primarily on a group basis focussed on cognitive stimulation and play activities.
It’s for the above reasons that the sort of work I am proposing is not a priority in the Mexican healthcare system. As I have explained previously, we need statistics to be able to say that the population of elderly people is on the rise but this then leaves aside the question of self-development work. Work with a humanistic perspective with this population is scarce and this has an impact on how the elderly are viewed by Mexican society.
So how are people with dementia and similar neuropsychological disorders generally viewed in Mexican society and what social or emotional/psychological support is there for their relatives?
In general, Mexican society, just as societies in many other parts of the world, is fearful of old age, especially when combined with any sort of dementia.
So both the general population and family members alike have no real awareness when faced with these kinds of issues. Far less do they have any knowledge of how to look after these patients. It is common practice both in urban and rural areas for them simply to be left at home, which leads to situations of isolation. Often therapist colleagues ask me about specialist centres where such patients can be looked after due to the fact that their clients are taking on the role of carer. In general the only sort of input which relatives receive is by way of very general talks, for example on topics such as ‘What is Alzheimer’s?’ and a short ‘history of the disease’ as viewed by doctors and psychologists who take a medical and positivist perspective. The care and preventative measures offered consist of playing memory games or sudoku. These talks are sometimes organised in health centres and are delivered by groups of trainee nurses, doctors or psychologists. I’ll say it again, it’s not bad, but it’s not really a solution.
It is only those relatives of a certain socioeconomic and cultural status who can access private therapy on their own initiative; the majority arrive in therapy through referrals.
Hence we need to focus attention on all aspects of work with older people who have neurocognitive impairment: humanistic, Gestalt and emotional work. It is vital that the therapeutic community in Mexico and society in general come to know that we do not need more medical knowledge, but rather a more human approach. In terms of my personal experience, I can say that there are some truly incredible people who may be repetitive in the stories they tell but these can be construed differently if we allow ourselves to really listen. The popular belief is that these people cease being people and this is not the case. Another mistaken belief is that they are like robots who don’t feel anything and that little by little they stop responding to the demands of modern life.
I have witnessed and maintained conversations with people who have spoken only one word and they have given a lot to me; I have lived through the creation of new experiences with them even though they never remembered my name. But they were transformed through Gestalt work even though it was assumed that they couldn’t remember anything. I vividly recall working with someone who was having persecutory hallucinations; they were living in a state of distress, running away. After accompanying them in this, we were able to embrace the hallucinations (which were a facet of their condition) and wait together for what they believed was coming. And what they believed was coming - which was death - was calm and free of distress, with myself alongside them until the moment of their passing.
In Mexico in IHPG we have been trying in vain for many years to open up specialised work with older adults. When students ask us to explain our reasons for this, we realise that they are confusing work with older adults with the work of carers. Even in our own profession it is difficult for people to see the importance of working with patients’ relatives to enhance the quality of life or the quality of death of those with neurocognitive impairments. It’s hard for them to see how enjoyable and rewarding it can be to be with them and see their facial expressions. Working with this client group is definitely the best therapeutic test of what it is to be human, because we need to go with the rhythm of the person and trust in how they want to be with us.
Different media sources in the UK have drawn attention to a study indicating that around a thousand patients with dementia are admitted to Accident and Emergency departments in hospitals every day. This is the result of inadequacies in the British system of social care. From what you have said in your initial responses, it doesn’t seem as if the situation in Mexico is any better. It seems that there is very little help available for this population. Do you consider that we ought to be doing something more than working individually in order to achieve more impact in the social arena?
We actually need to broaden the focus on group work for older adults with any sort of dementia as well as for their families and for the communities in specialised centres. Misinformation and economic shortcomings (government centres which are overpopulated or non-existent in some regions) and a lack of preparation for growing old (fear of ageing; fear, on the part of the individual or their families, of taking part in neuropsychological or psychiatric assessments) has resulted in a normalisation of senile dementia, hence the neurocognitive difficulties of old age are not anticipated and the main risk factors are dealt with on an individual basis - not psychosocial, but rather medico-biological. There is an avoidance of focussing on vulnerability.
People who barely have the beginnings of dementia end up being over-cared for, as if dementia and old age were an illness curable by complete rest. All this does is to create situations of deep sadness, frustration, feelings of loneliness or isolation and a reduction in any physical activity which then leads to deterioration of muscle tone. For example, many families who do not have a wheelchair or any other specialised equipment will go out with the patient less and less and even sometimes stop them from getting out of bed at all and will try over-much to distract them. I would describe this as superimposing on them another need; it’s a sort of symbolic egotism similar to deflection, such as is encouraged by patients’ relatives and regrettably sometimes also by professionals.
For this reason, the importance of group work is not only necessary for maintaining social skills in older adults with any level of dementia but crucial for breaking through the stigma that dementia is only about the sufferer. Dementia is part of the field, and its treatment and care can also be part of the field - including caring for the carers - the majority of whom, in the case of Mexico and Latin America, tend to be relatives, including grandchildren. Group work can facilitate the interweaving of a new experience, one which is often denied, diminished and even silenced.
Earlier you mentioned that you were interested in investigating the hallucinations of people with dementia. Could you briefly outline for us your experiences of Gestalt therapy with any of your patients who had hallucinations?
It interests me that this issue takes into consideration that dementia is a condition which can be alleviated by medication and kept under control but not eradicated completely. Our way of working in Gestalt therapy can adequately support coping with the type of psychic phenomena found in this population. At times I have been shocked to observe doctors, nurses, therapy colleagues, psychologists, professional carers or family members taking advantage of episodes of hallucination.
For example, there was one patient diagnosed with Alzheimer’s whose apraxia was very obvious. I worked with her in making sense of her feelings of abandonment and her progress was striking; she rediscovered her favourite place and at times even acknowledged the space as being her ‘new home’. In order to facilitate the job of moving her to the dining room in the care home or to other places within it, most of the medical professionals would say things to her like ‘your sister is looking for you over there’ or ‘look for your friends’ and they would gesture in the direction they wanted her to go, which made it easier to move her or to get her to more easily accept using the wheelchair.
Of course the above had an impact on the therapeutic work; at times I was touched to be with her in her vexation, which she herself did not remember, but I knew from the outset that the reason for her upset was because of the situation in which this sort of abuse took place. I have observed situations similar to the above in various places where I have been involved, even though in some cases people were well aware of my position as a researcher. This was behaviour which outraged and annoyed me personally, given that my inspiration for taking a different approach in the face of this condition came from my grandmother, who also had dementia.
When I first began this research, I came across the person referred to in the above example going through a situation in which she believed that she was a little girl looking for her friends. When I arrived she asked me whether I, too, was her friend. The first time this happened I wasn’t sure what would be the best response. Even now I get goosebumps thinking about sharing space with ‘the imaginary’. In our interaction with the non-physical being which arose experientially out of her background, we conversed about things which I couldn’t see but which she perceived. The information in her case file was of no help to me. In truth, it crossed my mind to perhaps give up my research but I opted for congruence, I chose intuition and humanity and was even able to tell myself that this was the most ethical thing to do. It’s true that I touched her hands and I learnt that not only did I help but that it was necessary to work with other forms of contact and to respect what she perceived. I learnt that she repeated herself and I never wanted to take this away from her.
It isn’t that I wanted to get into her world - I believe that what I am proposing for this type of work is to foster contact between two sentient people. A sensory focus is all the more necessary with this group of people in order for them fully to get in touch with their feelings. At times it would take me up to an hour afterwards to ground myself.
We have the impression that you consider there is something fundamental in Gestalt which makes it more compatible for work with dementia patients and perhaps those who are approaching the end of their lives (or their final gestalt). Could you speak about this?
I consider it fundamental and of great importance. Its compatibility lies in how a person can authentically make contact in the world according to their own ability to do so, with our awareness being able to support this rather than avoiding. There is still a lot of work to do on these issues. When I began this research with older adults with dementia I was looking for something specific. Theoretically I found it but I never published it. I was looking for ‘the beginning’ - a kind of original principle of ‘being’. I intended to take the opposite path from that taken by psychologists or Gestaltists who had explored theories of development and growth. My hypothesis was based around describing my therapeutic journey with people whose neurodegenerative condition evidenced the ultimate in disappearing. Instead of studying what is evident in being human I chose the path of legitimising ‘the ultimate’. I believed this would be more primordial - the ultimate letting go, the final closure, the biggest and final gestalt - the end of life itself.
Each therapeutic encounter I engaged in, right up to the last breath, was unique. In the end I discovered some of the most ridiculously obvious things which I cannot demonstrate in my writing. I believe there is still a lot to do. I realise that both the ultimate and possibly the very first aspect of being human is ‘being’. Elsewhere in an article I recount that before the Mexican conquest, people with dementia were known as ‘Oppa piltontli’; this phrase means that they revert to childhood. This experience, however, is denied by those taking a hegemonic perspective who are looking for ways in which not to lose one’s faculties or ways to avoid memory loss. I find that there is something natural in the way in which a person with dementia ends their life: a way of being which possibly fits with their body and their situation, and this is evidenced in what we know as dementia.
Perhaps it is only Gestalt therapy which has the potential to change the field in a way which will support the end of life for all of us by experiencing this way of being in contact with the world.
You mention how patients with dementia tend to be over-cared for. This brings to mind Laura Perls’ belief about support: as therapists, we give as much support as is necessary and as little as possible. Could you comment about this in your experience?
Of course, I believe this too, although trying to stay in the middle is not easy. I have had the good fortune of being alongside some people’s dementia journeys from the outset and what I can say is that there is no way of knowing the speed at which neurocognitive deterioration will take place. This creates uncertainty about how to be with someone therapeutically. For this reason I think it’s about allowing complete equalisation, like when listening to music, with all our senses being available for meeting one another.
I use the word equalise, or balance, as a metaphor for therapeutic support. I believe that with this group of people it’s not a question of tips on how to work but rather about the specifics of the work. In this way, therapists can modulate and equalise so that the sound can be more accurate.
Sometimes I’ve had to move from greater to lesser support even though the patient’s neurocognitive impairment had increased. It’s easy to imagine that where there is an increase in the severity of any sort of illness this will call for greater support; but sometimes the least possible support can be a way into hearing the patient better, just as with music. If we equalise according to the particular genre or song, what we hear will be truer to the original and we will be able to enjoy all the tones and clearly hear the silences.
I emphasise silences in particular because without effective equalisation, silences can find themselves blocked by noises which are intended to be supportive but which in fact interfere with the rhythm of meeting with the other.
You talk about the necessity of working with other forms of contact with one patient in particular. Can you say a little more about your experience of contact with dementia patients and how they have impacted you?
When I was still new to research in 2016, the first person I saw was already unwell with quite advanced Alzheimer’s disease. I can share that I found her overwhelming (I was scared that she was too big and I was very small). But our eyes met almost immediately and I felt intuitively ready. Instantly and very naturally I stretched my hands out a little to touch hers and she stretched out hers whilst looking at a photo of the lake opposite the room. At that point one of the medical staff told me not to touch her, thus interrupting this moment. I recall being upset and surprised to notice that the patient had herpes. I noted that there was a lack of this kind of contact and I can’t help but think how this is intensified by the sort of gerontophobia which I sometimes now see in supermarkets due to Covid19.
It’s obvious that I was not going to be a Gestalt therapist without contact. It’s possible in every case to make use of touch whilst taking the necessary care. Faced with an emotionally intense situation I see this form of contact as ‘anchoring’, because in clinical supervision I use the analogy of touch as being an anchor for the experience of both parties. Every time I sat with someone and used my hands to make contact, I felt in their gaze and in the way they squeezed my hands that we were anchoring ourselves in a moment of awareness. This whole phase of work was surprising; seeing how they supported themselves in situations where we had worked together, and which they wouldn’t have remembered if there hadn’t been contact. In truth this was a little problematic for their family members at first. Sometimes those who could speak now even refused to say or do things.
We would love to hear your vision for the future in terms of how patients with dementia are cared for by society.
I believe that over time there are great opportunities for focussing attention more completely on aspects which at present are not taken into account, although I also believe that this won’t do much good without humanistic awareness and the application of our Gestalt perspective. In this respect I am convinced that we have an enormous social responsibility, even if at the present time our collaboration is not considered essential. Even if the specialists and the public are not paying much attention to the possibilities offered by our work and are not seeking the ‘golden thread’, if we consider ways in which people can live their experiences around dementia from a standpoint of acceptance and work with what is, staying continually abreast of a condition which is not static, then as I said earlier, with the possibility of equalising to include even the support and experiences of family members we will be able to make these situations more manageable, less overwhelming and more focussed on the encounter.
I think our perspective will not only change the focus but it also provides opportunities for focussing attention until the condition can be prevented in the future, as many of us believe and few of us say it will. This condition may possibly be the result of difficulties in deciding how to deal with emotionally intense situations and resolving unfinished business. We have a huge responsibility here, as greater importance is still being given to treatment and failed attempts at a cure. It would be amazing to me if science could bring about the prevention of dementia; however, until this happens, I believe we have to keep drawing attention to how the quality of life and the quality of death can be improved in a more humanistic way. As I said in another answer, let’s acknowledge that these patients have a voice and that all we need to do is listen.
Thank you, Fernando, for sharing your experience with such sensitivity and for giving us the opportunity to glimpse some of your valuable work.
In closing we cannot fail to acknowledge the significant challenges which the coronavirus pandemic currently poses to therapeutic work with this quality of contact and express a hope that face to face work can soon be resumed.
Hilary Holford and Beth Newton, June 2020