Review

Growing beyond good intentions

DEMENTIA RECONSIDERED: the person comes first
Tom Kitwood
Open University Press, 1997, £14.99
CULTURE, RELIGION AND CHILDBEARING IN A MULTIRACIAL SOCIETY: a handbook for health professionals
Judith Schott & Alix Henley
Butterworth Heinmann, 1996, £19.99

What is the difference between a young black couple’s experience of racism in maternity care and the feelings of an old person with dementia slumped in front of a television in a nursing home parlour? Enormous, at first sight, but these two remarkable books converge on similar explanations for the bewildering, undermining and sometimes plainly offensive treatment experienced by ‘outsiders’ – those who are different, misunderstood, disliked or simply feared.

For Schott and Henley, cultural differences metamorphose easily into clinical pathology, given practitioners’ limited experience of differences, their rapid retreat into stereotyping and the absence of an open and reflective professional culture in a society permeated with racist thinking.

The late Tom Kitwood coined the term ‘malignant social psychology’ to describe how well-intentioned care staff could unknowingly infantilise, disable and abuse people with dementia, while all the time believing they were providing a good service.

The processes of exclusion, avoidance and domination work in different ways in different settings with different players, but the processes of dehumanisation seem similar.

Scott and Henley offer a detailed approach to personalised care and reflective practice by an experienced, educated workforce. It is an antidote to the protocol-driven, de-skilled work culture promoted throughout the NHS.

Challenging questions that tax the reader about their beliefs, feelings and expectations are set out in 41 chapters spanning the broad impact of racism on housing, work and psychology, to the details of cultural difference around pregnancy, birth, childcare and death. The breadth and depth of information is remarkable, making Culture, Religion and Childbearing into a true workbook, ideal for on-site teaching but also valuable as an reference work.

Kitwood liked people with dementia, admired their courage and produced a programme of ‘positive person work’ to train practitioners, as well as a devastating critique of conventional care.

He was well aware of the resistance to change in health and social services, and understood the professional and commercial forces behind it. He argued that cultural shift will occur through the accumulation of small changes initiated by enthusiasts.

Everybody in the health service should read his affectionate description and defence of the damaged practitioner, meeting her needs through attention to those of others, and how she can change into a truly moral person in an age of greedy, egoistic cynicism.