When the past is gone

I’m a psychotherapist and I recently started working with a client who has been diagnosed with early-onset Alzheimer’s (he’s 57). Much of my experience involves delving into people’s past – how do I work with this patient when he is starting to forget it?
Ronald N.

Dear Ronald,
I don’t even pretend to understand how psychotherapy works, as that is not my area of expertise. However, I would like to clarify something that doesn’t ‘ring true’ in your statement. While you may be worried that the person you’re working with is starting to forget his past, that is not really how Alzheimer’s works. He is very likely to be able to remember the past, but may not be able to recall much of the very recent past.

One of the points often made regarding a person with Alzheimer’s disease is that they can remember second grade perfectly, but have no idea if they have eaten breakfast or taken their medications today. What I am guessing you may be experiencing is his inability to remember what you were discussing in your last session together. In my opinion, that could be very useful as he will have very little ability to be selective about what he tells you, and by monitoring your own notes, you could delve into his past very deeply.

My suggestion for the approach would be, “Last week we were talking about an incident in your family when you were in junior high, and your brother stole a car. Lets continue where we left off with that.” If he remembers it he will probably start right into it, if he doesn’t, then it may not be a very important event. If he can’t follow that flow of conversation, try going at it from a different perspective, such as asking about some other event or aspect of that time-period. A person with Alzheimer’s will very often pick up in the conversation if it is brief and to the point. You can usually read if they are following you by paying attention to their body language.

Your patient may be reluctant, as most people are, to answer direct questions. People with this disease so often don’t really know the answers, and the only safe answer when you don’t understand is a yes/no answer. However, if you can put him at ease and discuss time segments in his life, you will find that he’s an excellent historian, lacking only recent memories. If he is, by nature, a “pleasing person” or just has excellent social skills, he may be likely to engage in what we call “confabulation” – he may just tell you things, true or not, because that seems to be what you want to hear. Once again, this is based on his survival instinct to read your body language. The most important thing for you to understand is that the feeling part of the brain is not the area that is impaired – it is the storage and storage-retrieval that’s damaged, beginning with the most recent things and then regressing backward in time from present to past. If you can tap into his emotions this way, you can probably have great success.