- Commentary on "The Alzheimer's Disease Sufferer as a Semiotic Subject"
I welcome this paper as a contribution to our thinking about Alzheimer's disease and the people who suffer from it. The paper has some important clinical implications, and it is humane. It is difficult for physicians, at the best of times, to understand the experiences that a patient is undergoing. This is doubly difficult when the patient's illness causes brain damage. "The Alzheimer's Disease Sufferer as a Semiotic Subject" shows how, through conversation predicated on the assumption that the patient has something meaningful to say, the patient's meanings may be understood. Steven Sabat and Rom Harré write: "If confronted with conduct that appears to be nonstandard, one's first hypothesis should be that meaning to the subject was involved in the genesis of that conduct."
Sabat and Harré also put in an important caveat. The AC sufferers discussed in their paper are unusual, or at least not typical of many people suffering from dementia, in that they may "fall into a group in which the discrepancy between formal tests of cognitive function and abilities shown in other ways would be greatest."
There is, undoubtedly, a tendency for physicians, when assessing a patient with Alzheimer's disease (AD), to focus on the cognitive deficits and thus to emphasize the patient's "confused and irrational nature" while ignoring what he or she can do. Sabat and Harré's paper provides not only a demonstration of the practical methods for gaining understanding of patients' meanings but also some theoretical analysis—analysis that complements and helps to underpin validation therapy. I would like, in this commentary, to take issue with one theoretical point that the authors make—but my remarks in no way detract from the practical importance of the paper.
Sabat and Harré state that "the sufferer from Alzheimer's condition is like "someone...trying to play tennis with a racket with a warped frame." This analogy, it seems to me, is part of the "ghost in the machine view" of a person: the ghost—the person, with his or her inner mental life intact—is trapped inside the machine, the brain; but owing to damage to the machine, the person is unable to express that intact inner life. The theoretical problem with this model, in the present context, is that it sees the body—the brain—as involved purely with the output of the mind. But brain damage, surely, can affect the inner mental life itself, not only the expression of that inner mental life. The brain is not just the tennis racket, it is the tennis player as well. The analogy of the warped tennis racket can be used to make a point that is well understood, at least [End Page 161] in theory, in clinical neurology: brain damage can lead to greatly impaired expression of the inner mental life while leaving that inner life relatively unimpaired. The "locked-in syndrome," in which fully conscious individuals are virtually completely unable to express themselves, is the paradigm of this. Pure dysphasias provide more common, but less dramatic, examples, in which a person's thinking is very much more complex than his or her ability verbally to express that thinking. In these situations the clinician needs time, empathy, and imagination to appreciate and understand the richness of the inner mental life, in light of the impairment in the ability to express that life. Here the tennis racket analogy holds. We need to recognize that the player really is good despite the poor score due to the bad state of the racket.
The limits of the analogy, however, need to be recognized, and this is particularly true of AD, which can damage the inner mental life as well as its expression—the player as well as the racket. Certainly—and this is of great clinical importance—we must never assume that the inner life of someone with AD is as it would seem on the basis of a superficial look at the way it is expressed. But it would be wrong to suppose that the inner life itself cannot be affected—damaged—by the disease process...