It is important to note at this point that activities which we have categorised under ‘earlier’ developmental stages, i.e. the symbolic, the sensorimotor and the reflex, are not excluded from this reflective phase. Any of the activities listed in other phases may, of course, be welcomed by the person in early dementia. As a general rule, we might say that any activity categorised by the model at an earlier stage to the one the person is in, has a potential for therapeutic benefit. The reverse is not necessarily the case. Any activity categorised by the model at a later stage to the one the person is in has a potential to be counterproductive, perhaps even damaging. For example, a person who is in the reflective phase of a dementia may of course welcome, enjoy and derive great benefit from an activity which we have included at the sensorimotor stage, such as a massage, or a party balloon game. We all know the potential for pleasure and relaxation of activities where we don’t have to think or plan. However, a person who is in the sensorimotor stage of a dementia is very unlikely to enjoy or even participate in a quiz or a game of dominoes, and attempts to encourage such a person in this direction are likely to exert pressure and induce stress; they will not be therapeutic. This is discussed in more detail below.

This is a phase of which a key feature is an increasing egocentricity or, as we have described it elsewhere (p. 63/64), a failure to perceive a progressively narrowing environmental field. The growing difficulty in perceiving and understanding the world of ‘other’ and ‘out there’ leads to difficulties in relationship, and to increasing dependence upon others for wellbeing and survival. The ability to adapt to external environmental influences is diminishing, and is being replaced by a delusory mechanism in which it is the world which changes. So for example, the lady whose purse is not in her handbag when she goes to look for it, is no longer able to say, ‘I must have put it somewhere else; I’d better look for it’ (adapting self to the world), but is quite likely to accuse the nearest other person of having stolen/removed it (assimilating world to self): ‘It cannot be me, because I always keep my purse in my bag, and I have no recollection of putting it anywhere else. It must therefore be someone else’.

Piaget has suggested that in the child, this symbolic period gives way to the reflective period as the child finds more and more opportunity to satisfy needs through his inter-relationships in real life; he has less and less need of recourse to symbolic ‘make-believe’:

Those principles which govern the activity of the previous, reflective phase are becoming increasingly inappropriate as a dementia progresses. The cognitive faculties required to hang on to future goals, and to make sense of sets of rules and procedures, are declining. There is therefore a need to look away from activities which are so driven. Competition also needs careful handling here. It may still, in some circumstances, provide a healthy buzz to an activity, but we need to beware of pitting somebody against his own dwindling abilities, and setting him up for failure. The quiz is a good example of an activity which can be (and often has been) misused in such a way – we need to be absolutely sure that we are not reinforcing a person’s self-awareness of cognitive losses. It is only too easy to do.

As the social world of the person in this phase begins to fracture, the group setting which relies upon cooperative interaction for its function becomes increasingly inappropriate. Socialising naturally continues to be important, but we might expect that a parallel group setting will now be more comfortable for the person whose social skills are declining. A parallel group, such as the reminiscence group or the knitting circle, provides opportunity for sociality, without the demand or expectation of interaction. People can be together, without having to work together, and the group will function with or without any given individual.