It's Not About Memory Alone: The Emotional Landscape of Mild Dementia

With thanks to our member, Jurgen Schwarz, for this article. 

Within professional conversations about dementia, memory loss continues to dominate the narrative. Assessment pathways, diagnostic frameworks, and service provision frequently centre on cognitive decline, measurable deficits, and functional changes. Yet therapists who sit alongside people living with mild dementia quickly recognise that memory impairment is often only the most visible layer of a far more complex emotional and relational experience.

For many clients, mild dementia unfolds as an identity disturbance, an emotional reckoning, and a relational reorganisation. Alongside the practical challenges that dementia charities and support organisations help to address, therapy offers something equally vital: a protected relational space where shame, anxiety, existential fear, and social withdrawal can be understood, spoken, and held.

 

Moving Beyond the Cognitive Narrative

Cognitive assessment tools provide essential information. However, they also risk unintentionally reinforcing a narrow understanding of dementia as primarily a neurological event. In therapy rooms, we often encounter a different story, one shaped by subtle but profound shifts in self-trust, confidence, and relational positioning.

Clients frequently describe an early awareness that “something isn’t quite right” long before diagnosis is confirmed. These moments are rarely experienced as neutral cognitive errors. Instead, they are often felt as small fractures in identity. A missed word, a forgotten appointment, or difficulty following conversation can evoke disproportionate emotional responses because they threaten long-standing internal narratives of competence and reliability.

Therapists may notice that clients are not simply describing forgetfulness, they are describing the loss of a familiar relationship with themselves.

 

The Quiet Weight of Shame

Shame often sits at the centre of early dementia, though it is rarely named directly. Many clients arrive having spent considerable time concealing their difficulties from colleagues, friends, and even partners. The emotional labour of maintaining this façade can be exhausting and deeply isolating.

Clients may speak about “not wanting to look stupid,” or they may minimise symptoms while simultaneously expressing heightened distress. Therapists working from relationally attuned approaches often recognise how shame can be brought gently into awareness without direct confrontation. Rather than emerging through explicit disclosure, shame frequently reveals itself in subtle interpersonal signals, moments of hesitancy, self-deprecating humour, or repeated apologies during sessions. When therapists respond with steadiness, curiosity, and emotional containment rather than correction or reassurance, clients often begin to feel safe enough to acknowledge the vulnerability underlying these interactions.

Working with shame in dementia requires careful pacing. Interpretation that arrives too quickly can intensify defensive withdrawal. Instead, therapeutic presence itself often becomes the intervention. When a therapist remains steady, respectful, and non-corrective in the face of memory lapses, clients frequently begin to internalise a different relational experience, one in which cognitive change does not equate to diminished worth.

 

Anxiety and the Loss of Predictability

Anxiety frequently becomes a constant companion for individuals living with mild dementia. Unlike discrete memory lapses, anxiety often permeates daily life. Clients may describe scanning their own functioning, mentally rehearsing conversations, or avoiding unfamiliar situations to reduce the risk of exposure.

For therapists, it can be striking how anticipatory anxiety shapes clients’ behaviour long before significant impairment occurs. The fear is rarely limited to forgetting itself. More often, clients fear the cascading consequences they imagine will follow: loss of independence, becoming burdensome, or being treated differently by loved ones.

Therapeutic work often involves helping clients tolerate uncertainty, an inherently challenging task when the condition itself introduces unpredictability. Therapists may notice their own countertransference responses, including a desire to reassure or problem-solve prematurely. Yet sitting alongside uncertainty, rather than rushing to contain it, can model emotional resilience and deepen trust within the therapeutic relationship.

 

Existential Fear and the Question of Selfhood

Many therapists describe moments when dementia work becomes deeply existential. Clients may not frame their concerns in philosophical language, but their questions frequently circle identity, continuity, and meaning. Who am I if my mind changes? Will I still be recognised as myself? What happens to my role within my family or community?

For clients who have built identities around competence, caregiving, or professional expertise, mild dementia can provoke profound disorientation. Therapists working from relational and attachment-informed perspectives often notice the depth of relational loss embedded within these fears, particularly when clients describe shifts in roles within partnerships, friendships, or family systems. Changes in who gives support, who makes decisions, and how mutual dependence is negotiated can unsettle long-established relational patterns, often generating grief that sits alongside cognitive concerns.

Therapy offers space for clients to reconstruct identity in ways that remain emotionally authentic. This may involve exploring values, relational legacies, or forms of contribution that extend beyond cognitive performance. These conversations often carry both grief and creativity, allowing clients to develop narratives of continuity rather than solely decline.

 

Social Withdrawal and Relational Self-Protection

Social withdrawal frequently emerges as a protective adaptation to shame and anxiety. Clients may gradually retreat from previously valued social environments, sometimes presenting this as a preference for solitude rather than a fear of exposure.

Therapists may notice how withdrawal often reflects attempts to preserve dignity. Clients may avoid group conversations where rapid exchanges feel overwhelming or decline invitations that once brought joy. Over time, however, this retreat can intensify loneliness and reinforce negative self-beliefs.

Therapeutic work can involve gently exploring the emotional logic behind withdrawal while supporting clients to maintain relational connection in manageable ways. This may include renegotiating expectations within friendships, identifying environments where clients feel psychologically safe, or supporting families to adapt communication styles that preserve autonomy and respect.

 

The Therapist’s Emotional Experience

Working with mild dementia can evoke complex emotional responses within therapists themselves. Feelings of sadness, protectiveness, and anticipatory grief may arise as therapists accompany clients through cognitive and existential change. Therapists engaged in relationally oriented work may notice how deeply they are moved by the gradual shifts in clients’ narratives of self, particularly as long-held identity structures begin to change. Reflective supervision and professional dialogue can provide essential spaces for processing these responses, helping therapists sustain emotional availability while maintaining therapeutic clarity.

Supervision becomes especially valuable in this context. It provides space to reflect on emotional responses, avoid over-identification, and maintain therapeutic clarity. It also allows therapists to process their own fears about ageing, vulnerability, and dependency, themes that dementia work can quietly activate.

 

Therapy and the Role of Practical Support Networks

The emotional work of therapy sits alongside, rather than replaces, the practical support offered by dementia charities and community organisations. These services provide essential guidance around diagnosis, legal planning, daily coping strategies, and social resources. They often reduce practical anxiety and help families navigate complex systems of care.

Therapy complements these supports by addressing emotional experiences that may remain unspoken within educational or advisory settings. Clients frequently describe therapy as the only space where they feel able to express anger, grief, or fear without needing to protect family members from distress.

Family work can also play a crucial role. Therapy offers opportunities to support partners and relatives in understanding emotional changes, facilitating communication, and maintaining relational intimacy despite cognitive shifts.

 

Holding Both Loss and Possibility

Working therapeutically with mild dementia invites us to hold a dual awareness. There is genuine loss of certainty, of cognitive fluidity, and sometimes of previously stable identities. Yet there is also continued emotional depth, relational capacity, and potential for psychological growth.

For therapists, particularly those working from relational or psychodynamic perspectives, mild dementia challenges us to move beyond deficit-based frameworks. It invites us to listen for emotional narratives that remain vibrant even as cognitive changes unfold.

Ultimately, when therapy expands the conversation beyond memory, it affirms the enduring emotional lives of those living with dementia. It reminds us that while memory may change, the need for connection, dignity, and meaning remains profoundly intact.

You can read the rest of Jurgen's series on dementia here.
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