Originally published in AJDC October/November 2017 Vol 6 No 5
Talking Mats is a visual tool developed by speech and language therapists to help people with communication difficulties express their views about things that matter to them. Nicki Ewing and Joan Murphy explain how it works and why it’s a valuable resource for people with dementia.
The right to express our views, be listened to and be heard is a fundamental human right. If our ability to communicate is compromised this can affect our quality of life, our social interactions, as well as our sense of identity and belonging. As a person’s dementia progresses their communication can be significantly affected, which may cause frustration for the person and can be upsetting for family members.
Talking Mats, a not-for-profit organisation based in Stirling, Scotland, has developed a person-centred communication tool and symbol sets, also called Talking Mats, which can be used with people with dementia to help them to organise their thoughts and say what matters to them about their lives.
Using case examples and stories from research projects, this article looks at the positive impact Talking Mats can have on the quality of life of people with dementia. It begins with a description of Talking Mats and settings where it is currently used.
What is Talking Mats?
Talking Mats® is a visual tool where picture symbols are placed on a mat (see photo 1). There are two versions of the tool – the
original physical mat (see photo 1) and the digital (for tablets, smart boards and computers).
Three types of picture symbols are used to represent:
- The topic to be discussed (eg, ‘what do you want to do during the day?’, ‘where do you want to live?’, ‘who do you want to spend time with?’).
- The options relating specifically to each topic (eg ‘What do you feel about going for a walk?’ or ‘What do you feel about living at home?’).
- The top scale to allow people to indicate their general feeling about each option. The meaning of the visual top scale can be adapted to suit the questions you are asking the person, for example, whether they are ‘happy’, ‘unsure’, or ‘unhappy’. Once the topic is chosen, the participant is given the options one at a time and asked to think about what they feel about each one. They can then place the symbol under the appropriate visual top scale symbol to indicate what they feel.
The Talking Mats tool was developed by speech and language pathologists at the University of Stirling in Scotland. It is a unique, research-based communication framework that can be used for consulting with both adults and children with a variety of support needs.
Our small team is made up of staff from speech and language and social work backgrounds. We offer training worldwide to clinical practitioners, carers and support workers in a wide range of health, social work, residential and nursing care and educational settings.
Recently there has been an increased demand from care providers working within the field of dementia to provide training for staff in the use of the Talking Mats tool.
Talking Mats and dementia
Talking Mats can be used to support people living with dementia at home, in a care setting, day services and in hospital. Talking Mats helps the person to be fully involved in support planning, making choices about everyday activities, expressing what areas they need support with, and it has even helped staff identify where someone is experiencing pain. It has proven to be an effective tool to include the person in decisions about their daily life as well as facilitating better conversations.
Talking Mats supports social interaction by helping families, friends and staff to get to know the person better. John Locke (1998) stated that ‘small talk’ is crucial for the construction and enjoyment of relationships with others and that by revealing thoughts we elicit reactions from others. This is what we regard as social closeness or engagement. ‘Small talk’ or ‘social closeness’ is one of the most important purposes of human communication.
The following example demonstrates how using the Talking Mats tool is helpful not only in getting a person’s views, but in facilitating small talk on an individual basis or within a group, especially for those whose dementia is more advanced:
One older man with dementia was not joining in any of the conversations at his day centre. He had lived on a farm all his life, was very quiet and kept to himself. Staff did a Talking Mat on ‘Activities’ to find out what he liked and didn’t like to do. They were surprised when he began to talk about the dances he used to go to in the nearby village when he was a young man. Others were around the table and began to join in the conversation, sharing their own memories about growing up in that area. Not only was there great interaction, but staff gained lots of new information which deepened their understanding of those they were supporting.
Talking Mats has developed a wide range of symbol sets based on the World Health Organisation International Classification of Functioning, Disability and Health (WHO ICF) framework (WHO 2001), which allows the listener to obtain the person’s views on a wide range of topics. Within the ‘Health and Well-being’ symbol set there are 13 different topics.
The following stories are from a small project where family members of people with dementia were trained to use Talking Mats.
Using the toilet
Using the Where You Live symbol set, G explained that he found it difficult to find his way to the toilet in the night. As a result, his wife bought special sensor night lights to help him, which solved their problem. As a result, night-times improved for both of them.
One couple used the topic ‘You’, which includes symbols on health issues. The husband, who has significant communication difficulties, placed the symbol for skin on the ‘not happy with’ side of the mat. His wife had not been aware of any issues and when they got home she found a rash on his back which required treatment.
Around the home
One woman with early stage dementia used the ‘Where You Live’ set to think about her home. Her husband felt that everything was fine, but for her it highlighted things that she felt she should put in place now as she had the insight to anticipate how things might progress. She decided that they should get handrails installed on their stairs.
Another couple did a Talking Mat on ‘Mobility’. P’s wife was worried as P was becoming increasingly reluctant to go outside for his regular evening walk and was becoming agitated. Using the mat, P was able to explain that his difficulty with walking was not due to a mobility problem but to his lack of confidence in finding his way in the street. His wife now goes with him and he is much happier. They also did a ‘Where You Live’ mat which highlighted that he was happy at home. His wife said she felt relieved as she wasn’t sure what he was feeling.
Trying new things
Using the ‘Self Care’ symbol set, one man with early onset dementia said he used to enjoy singing in the shower and, through doing the mat, decided that he now wanted to join a choir. This is not something that had come up in any previous conversations with his wife and children. They were heartened that despite the diagnosis of dementia he was still keen to try new things.
Talking Mats can also help inform discussions around a person’s capacity to make decisions. If someone struggles to communicate, there is a risk that assumptions are made about lack of capacity and decisions are made on their behalf. If there is uncertainty about a person’s ability to make a decision, Talking Mats can be used to help inform assessment of their capacity to do so and what level of decision they are still able to make.
Everyone has the right to get the support they need to make a decision and information to support understanding needs to be given in a way that is appropriate to his/ her circumstances. Talking Mats supports decision making by helping the person:
- understand relevant information
- retain information
- consider or weigh up information
- communicate views, wishes and feelings.
Our work in the field of dementia is based on several research projects:
Effectiveness at different stages
The first project, funded by the Joseph Rowntree Foundation, examined the effectiveness of Talking Mats for people with dementia at different stages (Murphy et al 2010). It found that conversations using Talking Mats were more effective for people with dementia than both unstructured (ordinary) or structured conversations.
Improvements were evident in the participants’ understanding, engagement, and ability to keep on track and make their views understood. Talking Mats enhanced the reliability of information provided by people with dementia, and conversations using Talking Mats lasted longer than ordinary conversations.
Involvement in decision-making
The second project examined how Talking Mats helped involvement in decision making for people with dementia and family carers (Murphy & Oliver 2013). It found that people with dementia reported that Talking Mats helped them to clarify their thoughts, express them to their family carers, and reach a decision in these discussions. Family carers reported that Talking Mats made them feel “listened to” by the person with dementia.
Dementia and mealtimes
This project (Murphy & McKillop) was developed because many people with dementia experience difficulties with mealtimes and it can affect people at any stage of dementia. Mealtimes are particularly important for people with dementia as they may develop difficulties both with eating as a source of nourishment and with the social aspects of dining.
In 2015 Joan Murphy and James McKillop, who has early onset dementia, used Talking Mats to gather information from the first-hand experience of people with dementia about their views of mealtimes. A new Talking Mats symbol set specifically around eating and drinking was developed. This consists of 68 symbols divided into three topics: Meals, Impact On Health, and Things That Might Help.
The people who took part in this study felt that there were significant changes in their eating and drinking since their diagnosis of dementia. For some, their experience of mealtimes had changed and several said that they would now skip breakfast and sometimes lunch. For others, this seemed to be related to forgetting to eat and drink, changes in taste, or that these meals seemed to be less important. Forgetting to eat was particularly noted by the participants with dementia and confirmed by their spouses.
Helpful strategies identified by participants to address the issues around mealtimes
- having more time
- reducing distractions
- getting involved in cooking
- adding additional flavour to food
- eating in familiar cafes when out
- being reminded by others.
Using the mats allowed participants to give their views about what would improve their quality of life around mealtimes and enabled them to identify their own solutions to the difficulties they face.
Talking Mats in hospital settings
This project involved training teams working with people with dementia in long-stay hospital settings (Murphy et al 2016). We wanted to explore the views of staff on the value of using Talking Mats in a hospital ward for older people with dementia. Our training model was developed to give staff practical skills as well as time to reflect on their own communication, to evaluate the effectiveness of Talking Mats and to embed its use in practice.
The findings showed that staff felt the conversations they had were more effective when using Talking Mats than when not. In particular, the person’s engagement and overall involvement in the process were greatly improved.
The following are some examples of the stories staff shared with the group. They all resulted from the staff using Talking Mats and were issues that staff were not aware of prior to using the mats:
- Mrs A indicated she liked to have a long lie in bed. This resulted in staff letting her stay in bed in the mornings.
- Mrs B, whose first language was not English, indicated that she really liked perfume. The nurse arranged for her to get some perfume. Every time she saw that member of staff she smiled and engaged much more than she had previously.
- Mr C said he did not like games and puzzles. This was important as this was a regular activity on the ward.
- Mrs D was a very depressed and anxious lady. She really enjoyed using the Talking Mats and staff said they had never seen her laughing before.
The model of training was shown to be feasible and effective in terms of time and cost and successful in terms of improving the communication skills of staff working in a busy hospital setting with people with dementia.
The use of Talking Mats addresses inequalities and fulfils patient rights to be informed and involved in decisions about health care and services.
Talking Mats at home
Dr Lyn Phillipson, recently accredited as a Talking Mats trainer in Australia, has received an IRT Research Foundation grant to explore the use of Talking Mats to aid care planning and assess social care-related outcomes for home care package recipients.
Dr Phillipson, an NHMRC-ARC Dementia Fellow from the University of Wollongong, is investigating the outcomes and experiences of people with dementia who are recipients of Home Care Packages.
“I am really excited about the potential of Talking Mats to enhance communication between people with dementia and their Home Care Package providers,” Dr Phillipson said.
“It is essential in a consumer directed care (CDC) model that people’s preferences are understood and that their care and supports reflect the things that are most important to them. We know from providers that CDC can be quite challenging with people with dementia. So the support provided by Talki ng Mats to aid expression and communication of personal preferences is really welcomed.”
To find out more about this research contact Dr Phillipson at email@example.com
Training and resources
The Talking Mats team has put the findings from our research projects into practice by developing resources and offering face-to-face and online training. For details of online training, visit www.talkingmats.com/training/online-training/. In Australia, face-to-face training is delivered by Talking Mats’ partner Zyteq. Details: www.zyteq.com.au/events/talking-mats-training.
We also offer a two-day Talking Mats accredited trainer course. There are now more than 100 Talking Mats accredited trainers around the world, including 13 in Australia.
For the full research reports and further information about Talking Mats training and resources, go to www.talkingmats.com.
Nicki Ewing is a Talking Mats Associate and accredited trainer, and a social worker; Dr Joan Murphy is a research speech and language therapist and co-director of Talking Mats.
Locke JL (1998) Where Did All The Gossip Go? Casual Conversation In The Information Age. American Speech Language Hearing Association 40(3) 26-31.
Murphy J, Gray CM, Cox S, van Achterberg T, Wyke S (2010) The Effectiveness Of The Talking Mats Framework With People With Dementia. Dementia: International Journal of Social Research and Practice 9(4) 454-472.
Murphy J, Oliver TM (2013) The Use Of Talking Mats To Support People With Dementia And Their Carers To Make Decisions Together. Health And Social Care In The Community 21(2) 171-180.
Murphy J, McKillop J “I Don’t Enjoy Food Like I Used To”: The Views Of People With Dementia About Mealtimes. Communication Matters Journal 31(1) 27-29.
Murphy J, Alexander J, McLinton A (2016) Talking Mats: A Model Of Communication Training. The Journal of Dementia Care 24(5) 22-25.
World Health Organisation (WHO) (2001) WHO-ICF: International Classification of Functioning, Disability and Health. Geneva: WHO.