Tom Kitwood, a British psychologist and pioneer in the field of person-centered dementia care, developed a powerful framework for understanding and enhancing the lives of individuals with dementia. His research challenged the traditional biomedical model, which often focused solely on cognitive deficits, and instead emphasized the importance of psychological and social factors. Kitwood proposed that a person’s well-being is intrinsically linked to their experience of personhood—a status bestowed by others within a social context. When a person receives compassionate, respectful care that supports their sense of self, their personhood is upheld, even as their cognitive abilities decline.
Central to Kitwood's theory is the 'Flower of Psychological Needs,' which places love at the core and surrounds it with five interconnected needs. This model suggests that if any of these needs go unmet, it can contribute to a person’s distress and declining well-being, a concept Kitwood termed 'malignant social psychology'.
The 5 Psychological Needs of Tom Kitwood
1. Comfort
This need encompasses both physical and emotional reassurance, providing a sense of safety, warmth, and security. For a person with dementia, who may experience confusion and disorientation, comfort helps to calm anxiety and soothe distress. This can be achieved through a soft blanket, a reassuring touch, a calm tone of voice, or a familiar and predictable routine. It's about creating an environment where the individual feels safe and supported, helping them feel 'in one piece' even when their world feels fragmented.
2. Attachment
Based on John Bowlby's attachment theory, this need is for meaningful, secure bonds with other people. For individuals with dementia, who may often feel lost or in a 'strange place,' the need for attachment remains strong, and potentially even intensifies. Caregivers and family members become a crucial source of security. Fostering attachment involves showing genuine care and affection and providing a consistent presence that the individual can rely on. A hug, holding hands, or simply sitting close by can reaffirm this vital bond.
3. Inclusion
As social beings, humans have an innate need to belong to a group and feel accepted. Kitwood emphasized that people with dementia should not be isolated but should remain active participants in their communities and social life. Inclusion goes beyond simply being in the same room as others; it means being valued for one's individuality and feeling connected. Caregivers can foster this by involving the person in social interactions and activities, whether a family gathering or a community program. Exclusion, in contrast, can cause a person to withdraw and decline.
4. Identity
Having an identity means having a sense of who you are, encompassing both your past and present. Cognitive decline can threaten this sense of self, making the past feel distant and confusing. Kitwood stressed that caregivers must help maintain and preserve the individual's identity by acknowledging their personal history, preferences, and achievements. This can involve using life stories, old photographs, and music to spark memories and affirm the individual's unique story. The care provider must act as a 'story holder,' responding to the person in their uniqueness.
5. Occupation
This is the need to be involved in meaningful and purposeful activities that draw upon a person's skills and abilities. It is not merely about keeping busy, but about having a sense of agency and contribution, which helps build self-esteem and satisfaction. Activities should be tailored to the individual's interests and capabilities. For instance, someone who was a gardener might enjoy tending to plants, while a person who loved music might enjoy listening or playing instruments. The key is to support the individual in finding deep satisfaction and personal significance in what they do.
Applying Kitwood's Needs in a Care Setting
| Aspect of Care | Traditional Medical Model | Person-Centered Care (Kitwood's Model) |
|---|---|---|
| Focus | On deficits and symptoms of the disease. | On the whole person, their psychological needs, and remaining strengths. |
| View of Person | As a patient with a diagnosis. | As a unique individual with a life story, feelings, and identity. |
| Behavior Interpretation | As symptoms of the disease, requiring management. | As communication of an unmet need or emotional distress. |
| Goal of Care | Control of symptoms and maintenance of physical health. | Enhancement of well-being and preservation of personhood. |
| Interactions | Task-oriented and often impersonal. | Relationship-focused, emphasizing mutual respect and trust. |
| Activities | Standardized, often group-based routines. | Personalized, meaningful occupations based on interests and abilities. |
How to Apply the 5 Psychological Needs
- For Comfort: Ensure the physical environment is safe, warm, and calm. Offer gentle touch, such as holding a hand, to provide reassurance. Maintain predictable routines to reduce confusion and anxiety.
- For Attachment: Encourage visits and regular contact with family and friends. For caregivers, building a consistent, trusting relationship is paramount, providing a sense of security.
- For Inclusion: Involve the individual in household tasks or group activities in a way that is meaningful to them. Adapt social interactions to their capabilities, like simplifying conversations or focusing on non-verbal cues.
- For Identity: Create a 'Memory Box' with photos, objects, and music from their past. Engage in reminiscence by talking about their life story. Acknowledge and value their past achievements.
- For Occupation: Provide a variety of activities that tap into their remaining skills and interests. Simple tasks like folding laundry, watering plants, or listening to music can offer a sense of purpose and deep satisfaction.
Conclusion
Tom Kitwood's model of psychological needs offers a compassionate and holistic blueprint for dementia care, moving the focus from the disease to the person living with it. By actively seeking to meet a person's needs for comfort, attachment, inclusion, identity, and occupation, caregivers can help maintain an individual's sense of self and promote their overall well-being, even in the face of significant cognitive decline. This approach affirms the dignity and intrinsic worth of every person, a core tenet that remains foundational to modern person-centered care. A deeper understanding of this model can be found in Kitwood's own work, notably Dementia Reconsidered: The Person Comes First.
