3.2 Guiding principles of CST

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Aim

To give a clear description of the different CST principles which help the participants to meet and fulfil their psychological needs, improve their relationships with other people, and maintain their social and cognitive skills. In addition, the purpose of existence and the usefulness of 18 ‘key principles’ that determine the success of the CST program will be clarified.

Learning outcomes

After completing the module, you will:

Understand the reasoning of the 18 key principles of CST,
Gain an understanding of how to apply these principles.

Introduction

There are 18 guiding principles of CST that have been developed by the CST pioneers. They should be clearly understood before progressing to the sessions and further planning since they have to be incorporated into them.

3.2.1 Recognize the guiding principles of CST

The skills and experience of group or individual CST facilitators (trained professionals, therapists, and carers) are very important. There are 18 ‘Key Principles’ which facilitators should include into the sessions with individuals or groups. These should be clear and understood before processing to the 14 sessions and further planning. In Table 1, each principle is described, and an example is given, to better understand how it can be implemented.

Table 1: Key principles of CST ^[1,2].

Key Principles	Description/rationale	Applied example
1. Mental stimulation	Getting people’s minds actively engaged. When sessions are planned, the aim is to pitch activities so that people have to make an effort but not too high (if too high, they can potentially feel deskilled).	Asking people to calculate their score in the ‘physical games’ session by adding numbers.
2. Develop new ideas, thought, and associations	Often we talk to people with dementia about things from their past. Although this may be enjoyable, it often involves recalling information that has been over-rehearsed. CST aims to continually encourage new ideas, thoughts, and associations through making new semantic links with the material.	Asking people to think of similarities and differences when they are shown two or more faces in the ‘faces’ session (‘What do they have in common? Who would you rather be?’).
3. Use orientation in a sensitive manner	Orientation needs to be done in a subtle, implicit way at the beginning of each session. Orientation information such as integrating time, place, and person-related information into general discussion and activities.	At the beginning of each session (‘What’s the name of the group?’, ‘What are the names of the other group members?’, ‘Do you think this weather is normal for July, or is it hotter/colder than usual?’). Tasting seasonal fruit in the summer (‘food’ session), Christmas word games (‘word games’ session).
4. Focus on opinions, rather than facts	Always asking for opinions before factual information. Opinions cannot be wrong and are more engaging to discuss.	Asking views on political or topical issues within the ‘current affairs’ session (‘What do you think of politicians?’, ‘Who is the prime minister?’). Avoid questions such as ‘Who can remember…’
5. Use reminiscence	Using memories is an excellent way of tapping into a strength that many people with dementia have, in terms of recalling experiences. Ensure that you know the background of the group’s members to avoid upsetting them when talking about memories.	Comparing old and new coins or the cost of items in the past and present in the ‘using money’ session.
6. Provide triggers to help memory	Using a RO Board and multi-sensory cues (visual images, sound, smell, taste, and touch) are useful ways of triggering memories and aiding recall. Always have something to look at or touch as it aids concentration. Use nonverbal communication as well as verbal; your facial expression, tone of voice, posture, and gesture.	Make the date and other orientation information visible during discussion (E.g. make multiple copies of the materials rather than passing them around).
7. Continuity and consistency between sessions	Memory and learning are supported through features including keeping sessions in the same room with the same facilitator, and the use of a theme song.	Let the group dictate the routine, which may be somebody helping with the tea, another leading the song, another helping to set up. Starting sessions and similarly ending sessions.
8. Stimulate learning and communication	Subtle tasks which avoid asking direct questions and putting people ‘on the spotlight’, focusing on facts; enable more implicit learning. Perceive the groups more as ‘fun activity groups’.	People may learn new things in the ‘current affairs’ session, yet the informal nature of the discussion does not draw explicit attention to this.
9. Stimulate language and discussion	Language skills are stimulated through tasks including naming people and objects, word construction, and word association.	Asking people to describe a word without actually using it in the ‘word games’ session.
10.Stimulate everyday planning ability	Executive functioning skills, particularly involving planning and organizing, are often impaired in dementia. The mental organization is exercised through the discussion of similarities and differences.	The ‘categorizing objects’ session uses executive functioning through mental organization (making a cake in ‘being creative’; selecting food for a meal in ‘food’).
11. Use a person-centred approach	During CST, people should be Valued and treated as individuals (e.g. through consideration of their histories, personality, and coping mechanisms), and provided with a positive and supportive social environment in which the person with dementia can experience relative well-being.	Always making the activities interesting and relevant to those in the group.
12. Respect	People’s views should be valued, recognizing the diversity of opinions. Avoid doing anything to expose people’s difficulties in the group and get to know what is important to each person. Respect should be demonstrated with yourself and group members as well as amongst each other.	Encouraging people to express a range of views, which stimulates interesting discussion.
13.Involvement	Sessions should involve everyone, giving each person the opportunity to contribute, and appealing to each person’s interests. If during the group, you find yourself doing most of the talking, or talking ‘at’ the group – STOP.	Tell the group what the next session will be and let them guide you towards preparing materials that will involve everyone.
14.Inclusion	Everyone should be included, sometimes meaning that quieter people require additional support.	Without putting people on the spot, regularly ask if everyone has had a chance to express their view.
15.Offer choice of activities	The choice should be offered within activities, geared to levels of ability or interests of the group. The activities have been organized according to how demanding they are on the person’s memory and other cognitive skills and ordered accordingly.	Let people choose their activity in the ‘Being Creative’ session. Select a name for the group, choose songs, etc.
16.Enjoyment and fun	Groups should provide a learning atmosphere that is fun and enjoyable. Avoid using equipment that is childish.	Add a competitive element to games (in the ‘team games/quiz’ session). If members make comments about ‘school’, ask them what they liked and disliked about the school, and reflect on whether the leaders are taking the role of ‘teacher’ too willingly.
17.Maximize potential	People with dementia often do not achieve their full potential due to a lack of stimulation or opportunity. In contrast, sessions should maximize potential. Give the person time. Be careful not to overload them with information and provide just enough prompting to enable the person to carry out the activity themselves. People with dementia are more likely to achieve their maximum potential by actively engaging into the activities rather than sitting passively.	Offer a task that is sufficiently challenging, without making people feel as if they have failed. For example, add prices to the task in the ‘food’ session if appropriate.
18.Build/Strengthen relationships	Within a supportive social environment, sessions should strengthen the relationships between group members and facilitators. Assist members to join in, have fun.	Encourage participants to meet socially even in a different context once group therapy ends, for example in the same lunch club.

Synopsis

Key points:

There are 18 guiding principles of CST, including mental stimulation, using orientation, stimulating language, person-cantered, which should be used in every CST program.
These must be clear and well understood before processing the 14 sessions and further planning.

1. List of references

Spector, A. (2019). Introduction. In: Yates, A., YatesJ., Orrell M., et al (editors). Cognitive stimulation therapy for dementia: history, evolution, and internationalism. 1st edition. Oxford: Routledge.
Aguirre, E., Spector. A., Streater. A., Hoe, J., Woods, B, Orrell, M. (2011). Making a Difference 2. Hawker Publications: UK.

Informal Carers (including family, friends)

Participants 9061