The Power of Substitution not Subtraction

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Teepa Snow teaches the art of substitution not subtraction. If Hand-under-Hand® is my favorite skill, substitution not subtraction, comes in at a close second.

I have seen firsthand what happens when you try to subtract or take something away from a person with dementia. I often recount the following story to illustrate the point:

I visit dad during lunch each day and he used to sit at a table with a man that I will call Joe. One day after the meal, Joe was holding his empty mug. A staff person that I will call Mary, asked if he wanted tea. Joe said yes. Mary asked for his mug so she could pour the tea and Joe refused to hand it over. She asked him a few times and “explained” that she couldn’t pour the tea unless he gave her the mug. After a few attempts, Mary was visibly frustrated and left the table. Joe was upset and was still holding his empty mug. Another staff person who I will call Susan, came over and the same conversation repeated itself. “Joe, would you like a cup of tea?” Joe replied yes. “Joe, give me your cup so I can pour your tea.” Joe replied no in an angry tone. Now Susan was frustrated.

I watched the scene unfold and decided to introduce Susan to the idea of substitution not subtraction. I asked Susan if she had another mug that she could pour the tea into rather than trying to wrestle the empty mug from Joe that he clearly did not want to give up. Without saying a word she went to the kitchen and returned with a full mug of tea. She passed it to Joe. He dropped his empty mug and proceeded to pick up the full cup and to enjoy his tea. At this point Susan didn’t actually need the empty mug but the task of getting Joe a cup of tea had been fulfilled.

I have told this story to several people who don’t care for a loved one with dementia. Most of them have interrupted me before I get to the end and said “Why didn’t she just get another mug?” Exactly. This is an excellent example of how we, as caregivers, get focused on the task that we want to complete and shove our agenda in the other person’s face. We only see one way of doing something and a common sense solution of getting another mug, in this situation, was totally evasive. Two people chose to tangle with Joe rather than tango.

Here are four examples of how I use substitution not subtraction:

1. Dad will try to eat his soup with a fork rather than a spoon. I’ll say “Here dad, try this one instead. It may work better.” I hand him the spoon and he puts the fork on the table.

2. Dad likes to have things in his pockets. He will take the spoon off the table, put it in his pants pocket and say that he’ll need it later. I’ll say “Yes, right on. You’ll need napkins later too so how about we use the spoon now and save the napkins for later? Will that work do you think?” He will remove the spoon from his pocket and replace the spoon with napkins. If he doesn’t want to replace the spoon with napkins, no big deal. I just get another spoon. Another thing I’ve learned is to not make a big deal out of nothing. So what if there’s a spoon in his pocket? That’s not behavior worth getting upset about.

3. At the end of the meal, dad and I stroll around the floor. He’ll be wearing an apron when he gets up from the table. I have my agenda of wanting to remove the apron and put it in the dirty laundry basket near his table. I used to say “How about we take off the apron?” and I noticed that he would often say no. He would want to keep it on. Now I try something different. Although the basket is only a few steps away from his seat, I don’t say anything until we are in front of the basket. Then I’ll say, “Oh look, here’s the laundry basket. Since we’re going right by, how about we put your dirty apron in it?” This works better than when I used to try to take it off at the table. I’ve learned to put my agenda in my back pocket even for a few seconds. Sometimes he will say “No, I’m cold, I’ll keep it on”. If he makes this comment, I know there is an unmet need and I substitute a sweater for the apron. He removes the apron, I give him a sweater and all is good.

4. The other day dad and I were walking through the hallways when he approached a member of the cleaning staff. He took her hands and was holding on tight. He commented on how cold her hands were and wouldn’t let go. I said “Oh wow, that’s interesting. My hands are really warm.” I held out my hand and he dropped hers. We continued on our way in Hand-under-Hand®.

How do you use substitution not subtraction? Do you have any examples to share? I would love to hear about it!