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‘There is Something Missing Out There…’: A Performative Portrait Approach to Understanding the Experience of Living with Dementia

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People with dementia (PwD) often face symptoms that influence their memories and capabilities to express themselves meaningfully. These symptoms make it particularly challenging for qualitative researchers to capture and demonstrate PwD’s complex experiences with the traditional reliance on textual outputs. This paper offers a novel approach through performative portraiture to demonstrate and argue that the use of this approach is needed as an alternative academic output that diverges from textual reliance. The paper begins with an overview of the research, which aimed to improve understanding of the initiation and revision process of Advance Care Planning with and for PwD and was used as a baseline to create ‘Dave’ as a young PwD based on the verbatim interview transcripts of 13 PwD. The methodological process is outlined, and findings are then chronologically discussed. The paper concludes with the strengths and limitations of this approach as well as its future implications.
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There is Something
Missing Out There…’:
A Performative Portrait
Approach to Understanding
the Experience of Living
with Dementia
Tharin Phenwan
1
and Edgar Rodriguez-Dorans
2
Abstract
People with dementia (PwD) often face symptoms that inuence their memories and
capabilities to express themselves meaningfully. These symptoms make it particularly
challenging for qualitative researchers to capture and demonstrate PwDs complex
experiences with the traditional reliance on textual outputs. This paper offers a
novel approach through performative portraiture to demonstrate and argue that
the use of this approach is needed as an alternative academic output that diverges
from textual reliance. The paper begins with an overview of the research, which
aimed to improve understanding of the initiation and revision process of advance
care planning with and for PwD and was used as a baseline to create Daveas a
young PwD based on the verbatim interview transcripts of 13 PwD. The methodo-
logical process is outlined, and ndings are then chronologically discussed. The paper
concludes with the strengths and limitations of this approach as well as its future
implications.
Keywords
dementia, narrative, performative portraiture, social identity, advance care planning
1
Health Sciences, University of Dundee, Dundee, UK
2
Centre for Creative-Relational Inquiry, University of Edinburgh, UK
Corresponding Author:
Tharin Phenwan, Health Sciences, University of Dundee, Dundee, UK.
Email: tphenwan001@dundee.ac.uk
Original Articles
Illness, Crisis & Loss
117
© The Author(s) 2024
Article reuse guidelines:
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DOI: 10.1177/10541373241297769
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Introduction
Dementia is an umbrella term for several neurological conditions that affect individu-
alsmemories as well as capabilities to think, read, and write (NHS, 2021). People with
dementia (PwD) often face challenges in expressing their experiences, especially with
their dementia symptoms that affect the writing, reading comprehension and speaking
skills along with their uctuating mental, anxiety and forgetfulness (Abendstern et al.,
2019; Phenwan et al., 2023a,b; Webb et al., 2020). These inherent symptoms of
dementia are also particularly problematic for qualitative researchers, given that the
approach aims to explore and understand the complex experiences of participants
(Denzin & Lincoln, 2017; Webb et al., 2020). Furthermore, these symptoms are exac-
erbated by the traditional reliance on textual outputs in research, which might not fully
capture the nuance of such experiences, particularly for PwD. As such, alternative
approaches that are not fully dependent on textual outputs and can capture and
express the nuances of participantsexperiences are still needed.
There has been an increasing number of qualitative outputs that utilise creative
methods; all indicate the need to meaningfully present qualitative data in a more
nuanced way. Examples include the use of emotional maps (Goldman et al., 2022),
poetry (Parsons & Pinkerton, 2022), and textile making (Andrä, 2022), amongst
others. To contribute to this movement, this methodological paper demonstrates and
argues the use of performative portraiture approach as an alternative academic
output that diverges from textual-reliant outputs (Rodríguez-Dorans & Jacobs, 2020).
Narrative inquiry has a long history in the social sciences as an approach that allows
researchers to explore an important connection between life as lived and life as told in
personal narratives(Goodson & Gill, 2011, p.5). A narrative inquiry approach is essen-
tial for a deep understanding of lived experience, especially in cases where individuals
voices are not often heard and their perspectives are neglected (Goodson et al.). As PwDs
cognitive functions change and the individual with dementia is perceived as losing the
capacity to articulate their stories, the need for a methodological approach that responds
to this is both an academic requirement and humanitarian endeavour.
Since narrative inquiry relies on the capacity of the individual to articulate their
experience through language (Murray, 2000; Wong & Breheny, 2018), combining
narrative with performative inquiry has been a move towards expanding beyond word-
centred methods that pose limitations for the exploration of phenomena that need mul-
tidimensional representation. Performative inquiry emerges in the eld of arts and
education to invite researchers to explore and share their learning through performative
writing and other creative representations (Fels, 2012). The focus on performance
highlights the importance of co-creation between people involved in research, which
can lead to innovative productions through embodied engagement, listening to the
voices of all involved, recognising their agency, and challenging preconceptions
around who has the capacity to create stories (Fels, 2012).
Thus, performative portraits(Rodríguez-Dorans, 2023) constitute a methodolog-
ical approach that combines narrative and performative inquiry as data sources that are
2Illness, Crisis & Loss 0(0)
complementary of each other. The narrative element draws attention to the verbal
content of peoples stories and how these need to be represented in their own words
(Rodríguez-Dorans, 2023). The performative element highlights that the stories are
not disembodied, abstract products but are embodied and articulated by physical
beings, and therefore, a corporeal element needs to be included in the process and
product.
With its base on narrative, the performative portrait presented in this paper utilises
verbatim transcripts of the participantsinterviews to create a script that is used to be
re-enacted by a performer who gives actual voice and body to the script. This allows
researchers to visualise and experience their ndings in a different light, aiding the data
analysis (Rodríguez-Dorans, 2023; Rodríguez-Dorans & Jacobs, 2020). The result is a
performative piece that can be presented to external audiences to allow them to inter-
pret the participantsnarratives of what it is like to live with dementia beyond the
researchers argument alone. The researcher works collaboratively with the partici-
pants, listening deeply to what they say and how their body aids them signicantly
in the delivery of the story. Then the researcher works with a performer who uses
their body, voice, spaces, and personal interactions to reenact the stories of participants
to an audience who, in turn, have the opportunity to engage with the ndings on a rela-
tional, affective level. Thus, a performative portrait can be used to bring research nd-
ings to life, to the here and now, in an embodied way.
The paper begins with an overview of the research that was used as a baseline to
create this creative outlet. It then outlines and discusses the process of creating a
new persona of young PwD Davebased on the performative portraiture approach.
Next, the ndings are chronologically discussed. The paper concludes with the
strengths and limitations of this approach as well as its future implications.
Methods
Research Overview
The narratives that constitute the basis for the performative portrait presented in this
article are based on the datasets from the rst authors doctoral study. The thesis
aimed to improve understanding of the initiation and revision process of Advance Care
Planning (ACP) with and for PwD to contribute to opportunities for actioning in their
future at the appropriate time and shared with the appropriate people. In the context of
the thesis and this article, ACP is dened as a process that supports adults at any age
or stage of health in understanding and sharing their personal values, life goals, and
preferences regarding future medical care(Sudore et al., 2017, p 286).
Theoretical Framework of the Empirical Studies. Bronfenbrenners bioecological theory
was utilised as the empirical studiestheoretical framework (Koller et al., 2019; Rosa
& Tudge, 2013). Findings from these two studies are not central to this methodological
paper and are presented elsewhere (Phenwan et al., 2023a, 2024b).
Phenwan and Rodriguez-Dorans 3
Bronfenbrenner posits that individuals (in this instance, PwD) are nested under
several interrelated environment systems. This includes their immediate setting
(family, friends) to the more remote and abstract environment (cultural inuences,
societal values and policies) which will inuence each other over time (Rosa &
Tudge, 2013).
In the context of the rst authors doctoral study, the microsystem is PwD and their
interactions with carers and friends. The mesosystem includes inuences from HCPs
and extended families whereas the exosystem relates to the quality of care that PwD
received based on the coordination of care in their area. Each systemsinuence
over each other over time is captured under the chronosystem. The macro-inuence
of dementia policies over the ACP process for PwD is explained under the macrosys-
tem (see Figure 1). A social constructionist approach was adapted to understand the
multiple realities around PwD (Denzin & Lincoln, 2017; Scotland, 2012). With this
approach, the rst author explored and co-constructed the experience around ACPs
with and for PwD.
Ethics
An ethical approval was obtained (rst authors university/ethical approval number/
rst authors family name). The narrative was created in accordance with the existing
ethical approval. An extensive support and distress protocol was created, based on a
rapid review published prior which included strategies to mitigate practical, technical
and ethical considerations to virtually conduct potentially sensitive subject interviews
with PwD (Phenwan et al., 2021). Four pilot interviews were conducted; the protocol
Figure 1. Theoretical framework.
4Illness, Crisis & Loss 0(0)
was subsequently revised based on participantsfeedback. The support and distress
protocol was subsequently applied before, during and after the interviews. Flexible
informed consent process was utilised; PwD could provide their consent to join the
study in either a written or recorded verbal format. Participants could choose to join
the interviews either with Microsoft Teams or a telephone call. These strategies
offered more exibility for PwD to join the study with the method they felt comfort-
able with (Phenwan et al., 2023b).
During the interviews, the rst author observed any signs of potential distress to
ensure their well-being. Participants could withdraw from the interview or have a
break from the interviews at any time without any negative consequences.
Immediately after each interview, the rst author provided a verbal debrief to partici-
pants to ensure that they understood the purpose of the study and how their data would
be used. A written debrief form was also sent to all participants via email afterwards.
Participantsinterviews were transcribed verbatim and anonymised to protect their
identities and condentiality, including this performative portrait.
Participants Characteristics
Thirteen PwD who lived in Scotland were recruited from the Join Dementia Research
platform as a part of the doctoral study. The platform was chosen to enhance inclusiv-
ity and empower PwD to have more exibility and control over whether they want to
join research or not (Karagiannidou et al., 2022; Phenwan et al., 2024a). This decision
aimed to mitigate the common barrier in dementia research; that is, PwD tended to be
hard-to-reach due to several gatekeepers restricting access to PwD without their
knowledge (Karagiannidou et al., 2022; Phenwan et al., 2021, 2023b).
The narrative interviews with participants took place from October 2020 to March
2021. Eight PwD joined the online interviews via Microsoft Teams, four joined tele-
phone interviews and one PwD opted for email interviews. The age range was from 51
to 87 years old with the mean of 68.7. Of which, eight PwD were male and ve were
female. The most common diagnosis was Alzheimers disease (N =8), followed by
vascular dementia (n =3).
The Creation of Performative Portraiture
A performative portrait is created through the researchers close attention to what the
participants say, how they say it, and how they use their bodies to convey their mean-
ings (Rodriguez-Dorans, 2023). The researcher relies on these sources of information
to understand the phenomenon they are exploring and communicate the ndings
through a performative outlet that will allow them to evoke the ndings as they
were witnessed during the research encounter. This format allows the researcher to rep-
resent the ndings through the narrated and embodied experiences of the research par-
ticipants. This embodied representation recognises the role of the body in the
production of knowledge.
Phenwan and Rodriguez-Dorans 5
One of the most important benets of creating a performative portrait is that it commu-
nicates ndings in an accessible way to audiences, enhancing knowledge exchange. As
audiences listen to the stories and witness a performer deliver them using the words of
the participants, the participantsexperiences prevail over abstract theoretical/scienticlan-
guage that can distance the public from what the participants have gone through.
In the work of communicating complex and sensitive material, performative por-
traits can produce a compelling case when the role of the body is central to understand-
ing how dementia is experienced, and attention needs to be brought to embodied forms
of communication beyond verbal language (Rodríguez-Dorans & Jacobs, 2020).
As PwD experience difculties in articulating ideas and communicate with others
as their verbal capacity is compromised, they might gradually be further overlooked
or dismissed in everyday interactions as individuals who are unable to communicate.
Limitations might be perceived as inability. Thus, given the gradual social withdrawal
of the PwDs right to communicate, this research aimed to avoid the epistemic dispos-
session(Pillow, 2020) of the individual and put the person at the centre of the
knowledge-creation process.
In this performative portrait process, knowledge is created with the participants at
the centre of the process of inquiry. The rst author interviewed participants in an act
of recognition of their capacity to make sense of their lives, even in the struggle that it
represents to articulate and connect the words. The interviews and their centredness
of words, make the research process paradoxical and poignant, given that it is the
verbal capacity that is compromised. Still, with the struggles and the limitations, par-
ticipants found the words and made sense of their experiences.
Words were not the only medium used to communicate. Participants stuttered, used
prolonged pauses, gestures, stopped to think and made visual contact and other non-
verbal cues to communicate with the researcher. This means participants used their
bodies to convey the layers of experience in the interviews in a way that the verbal
component of the conversation was not the only source from which meanings were
drawn (Cooperrider & Goldin-Meadow, 2017). The researcher entered a process of
witnessing and experiencing the participants as embodied beings. The interview
then became more than a source of narrative material, but also a source of embodied
material with an additional focus on embodied happenings.
Thus, the interview transcription process focusing on words alone was no longer
enough as a way to convey the complexity of experience. The body became an essen-
tial component of the process of inquiry and in tackling
potential epistemic violence that can be reproduced through practices such as anonym-
isation and language-centred methodologies that protect but also regulate the visibility
of certain subjectivities, certain bodies, certain ways of communication, and certain indi-
viduals. By focusing exclusively on the words and what is said, the research process
might ignore what the body shows without saying a word, it might neglect forms of com-
munication that lie beyond the realms of linguistic capital.(Rodríguez-Dorans, 2023,
p. 7879).
6Illness, Crisis & Loss 0(0)
Taken together, two les were generated from the process.
First, the rst author created a transcript based on 13 PwDs collective verbatim
quotes that aimed to address three key aspects: i) PwDseveryday life and struggles;
ii) affective moments as sources of data and (iii) how and when PwD plan their ACPs
along with their lingering uncertainty towards the discussed future.
The rst author examined the verbatim quotes from participants and paid attention
to these three aspects from each interview. Illustrative quotes that meaningfully cap-
tured the collective narratives of 13 PwD in relation to each aspect were subsequently
utilised. The chosen quotes demonstrate PwDs struggles for words in each moment,
along with the actors performance.
Second, additional notes were given to the performer, a professional actor who was
contacted for the portrayal of this narrative. These notes provided contextual information
regarding dementia as well as the newly created persona called Davewhich consists of
all PwDs background (see Figure 2). The actor was briefed about the context of the study
and the signicance of performing the narratives of real-life experience with dignity and
respect. As the rst author had rsthand experience of the research interviews, the actor
beneted from a discussion with him in which details of behaviour and emotional content
were shared with the aim of presenting the performance in close proximity to the research
encounters. The PwDs collective rst-person narrative is then represented by an actor in
a short video format to bring the affective embodied elements of the experiences to the
fore whilst protecting participantsanonymity (Phenwan, 2021).
Findings
Narrative Portrait of Dave
Losses
The narrative begins with Daves recount of his multiple losses: loss of social identities
(my superpower), loss of personhood (the youthat has been missing out) and
loss of independence due to dementia symptoms (I became dependent on me wife).
For Dave, loss becomes a lifelong process, as he faces the gradual disappearance of
his personhood and seems to become an absent presence. He narrates how people start
talking about, over, and around him, but not speaking to or with him. The disclosure of
a diagnosis seems to activate a response in people in which they change their approach
to him, until they no longer speak to him. His narrative suggests that the diagnosis of
dementia brings, not only the medical implications of his condition, but also a new
stigmatised social identity that takes away his previous social identities as people do
not respond to who he is. The gradual development of his dementia contrasts with
the abrupt aloneness in which he nds himself in, bringing into question whether
Dave is still the same person to his peers. The awkward responses from people who
used to be close and friendly to him leave Dave wondering who he is to them.
Phenwan and Rodriguez-Dorans 7
Realising that something youre looking for is yourselfbecomes an impactful phrase in
which Dave connects with the loss of who he is. That is, Dave realises of his changing
personhood and identities, which he nds challenging to accept (my personality
changed in ways I dont like). This loss of personhood is further compounded by his
social loss. That is, his ability to become invisible in a room full of people)isa
phrase that illustrates the social loss that Dave experiences in relation to the disclosure
of his diagnosis. The impossibility of engaging in social interaction with others in the
light of dementia becomes apparent in the narrative. The question Who am I to you
is a crucial one, in which the loss of social relations friends who used to play golf
with him and engage in ordinary aspects of life no longer engage in the ways they
used to. What characteristics does one need to have to be counted as a person?
From Daves narrative, the relational aspects of his life have vanished. He used to be
recognised as a person and a social being; he felt himself in relationship with others
and as a person who forms part of life. He was part of an us, in which he was
Figure 2. Narrative portrait of Dave. (continued)
8Illness, Crisis & Loss 0(0)
acknowledged and welcomed in social spaces. After the dementia diagnosis, the usin
the relationship between Dave and the people in his life seems to be missing. With the
exception of his wife, there seems to be no usfor Dave anymore.
Finally, his loss of independence was not mitigated when the information he
received from his nurse was perceived as not useful (‘…you probably get to [live
until] 70), thus exacerbating his multiple losses.
Trigger Point for ACP
The performance further illustrates the reasoning behind Daves ACP, as well as when,
how and with whom he discussed his ACP.
The current recommendation to discuss an ACP with and for PwD is to engage with
them as early possible, particularly before the PwD start to lose their mental capacity
(Harrison Dening et al., 2019; Mattos et al., 2023; Phenwan et al., 2023a).
Contrastingly, Dave discussed his ACP much later on after his diagnosis of dementia.
For Dave, he felt the need to have an ACP when he met other PwD who had discussed
their ACPs (they put everything in place). This experience made him realise the
Figure 2. Continued.
Phenwan and Rodriguez-Dorans 9
necessity of ACP for both himself and his family (you never know your minutesand
get it [ACP] in place to save heartaches and confusion…’). At this moment in time,
Dave challenges the current recommendation of an early ACP with and for PwD since
he has discussed his much later in his dementia journey.
He further recounted the person (s) who was involved with the ACP process which
included his wife (me wife and I) and possibly another healthcare professional who
supported the ACP process, indicating that an appropriate support is needed for Dave
and his wife.
Dave further narrated his struggles to discuss ACP with his family due to his
dementia symptoms (I struggled to connect the words) that impede his reading com-
prehension skill (they make no sense to me). The documentation process was also
perceived as another challenge due to the amount of paperwork he had to go
through at once (they gave you that much paperwork and none of it made sense), con-
tributing to his struggle to discuss and document his ACP. This experience from Dave
resonated with the literature which suggests that the ACP process should be iterative
and be discussed over time along with appropriate support (Mattos et al., 2023;
Phenwan et al, 2023a).
Uncertain Future
The narrative concludes with his lingering uncertainty towards his planned future. That is, to
the best of his ability, Dave had discussed his ACP along with his wife (we have planned our
lives down to the last detail). Yet, Dave still felt the lingering uncertainty towards his planned
future. This feeling of uncertainty stems from two reasons: i) he was not sure if his planned
future would be adhered to (whether well be able to do it, I dont know) and ii) there were
certain aspects in the future that he could not be explicitly planned e.g., moving into a care
home, his declining future self that might not recognise others (will I recognise them?)
and how others will treat him in the future (how are they going to be with me…’). This
was further suggested when Daves conversations started to become less coherent towards
the end, indicating his stress as well as uctuating mental capacity.
This part of the performance indicates the unique challenges of PwD to engage with
their ACP. That is, ACP is a complex process that requires an individual (e.g., their
current self) to conceptualise their future preferences (e.g., their future self) (Perry,
2022; Wendrich-van Dael et al., 2020). This complex conceptualisation of ideas contrasts
to PwDs main coping strategy to engage with their present self and maintain their estab-
lished routines as well as current normality that that can control (Han et al., 2015). This
might explain why Dave still expressed his lingering uncertainty towards the discussed
future even though he had thoroughly discussed and documented his ACP.
Discussion
This section respectively discusses the strengths and limitations of this novel approach
of performative portraiture and offers future implications for other researchers.
10 Illness, Crisis & Loss 0(0)
We have created this performative portrait and aim to help researchers, clinicians, carers
and the public have a better understanding of what it is like to live a life with dementia. The
creation of a composite narrative is intended to encompass a series of narrated experiences
that were shared by participants across different interviews. This presents a condensed
version of experience that would otherwise take signicantlymoretimetopresentinthe
form of individual cases. While we acknowledge that a composite narrative might be seen
as a ctionalisation of individualsexperiences, the intention is to stay as close as possible
to the multiple difculties and realities participants expressed and share them with a wider
audience as an educational resource that helps people get a sense of what it is like to live
with dementia from rsthand narrations.
The embodied performance of Dave can be seen as a direct illustration of stigma as
a social issue that accompanies the diagnosis of dementia (Bhatt et al., 2023). This por-
trait can be seen as an activist methodology that afrms the expertise of PwD in nar-
rating their own lives with the cognitive changes experienced due to the condition.
Conceptualising communication beyond verbal language helps to shed light on
concealed aspects of experience, such as the multiple losses that are exacerbated not
by the diagnosis of dementia but by peoples responses to it (Bhatt et al., 2023).
Seeing Dave convey his story which represents the stories of many people with a
similar experience is intended to be a claim for the recognition of the importance
of interconnectedness for PwD (Abbott, 2020; Benbow et al., 2019). That is, Dave
still wants to connect with people, as much as or more than before his diagnosis,
but the way he is perceived by others is different. Consequently, Daves story
should be seen as a call for others to recognise PwDs relational needs. The intention
of this performative portrait is to provide a more nuanced understanding of intraper-
sonal and social issues associated with dementia and highlight the voices and experi-
ences of individuals who live with this condition.
The performative portrait offers a novel and creative research output of qualitative
research. This is particularly useful for this work given that the actor could portrait Dave
in a more nuanced way which the textual outputs alone cannot capture (Burn et al., 2001).
Finally, upon team reection, we found that the performance shows the voice of the
most underrepresented of the underrepresented group (in this instance, a male person
living with early onset dementia). The dominant narrative, assumptions and stigma
around dementia tend to focus around older people (older than 65 years) who have
been diagnosed with Alzheimers disease (Herrmann et al., 2018; Kim et al., 2021;
Stites et al., 2018; Werner & Kim, 2021). However, such assumptions do not fully
capture other conditions under the umbrella of dementia such as vascular dementia
or Posterior Cortical Atrophy. The visibility of people living with early onset dementia
is also often neglected. As such, this performance puts Dave to the fore thus making
this underrepresented group more visible.
Future Implications
We found this approach can be utilised in three ways:
Phenwan and Rodriguez-Dorans 11
First, the narrative portraiture approach can be used as an alternative way to dissem-
inate research outputs to wider audiences. That is, the performance is based on
empirical evidence yet is made more accessible to wider audiences. This is indi-
cated when the rst author contacted several PwD and asked for their opinions
of the video; all felt that the video has meaningfully captured their lives. Family
carers of PwD also expressed similar opinions.
Second, the narrative portraiture approach can be used as an evidence-informed
teaching material. Both authors use this video as teaching material in their sessions
on communication skills, counselling skills, and how to discuss an ACP with PwD,
indicating the usefulness of this approach.
Finally, the narrative portraiture approach can be a useful strategy for creating a
more interdisciplinary collaboration. This is evident from the video given that the
rst author comes from a medical background (a family doctor and gerontologist)
while the second author is from an art and psychology background. Yet our creation
manages to challenge traditional research practices and amplify marginalised voices
that can engage with even more diverse audiences.
As demonstrated by Daves narrative, the difculties he experienced with social isola-
tion emerged from how the people around him gradually withdrew their social connec-
tions. Thus, performative portraiture can contribute to the growing approaches which
provide activist methodologies (see Burn et al., 2001; Geregová & Frišaufová, 2020;
Yeboah, 2020) by extending participantsepistemic power, validating their experi-
ences, and demonstrating the harms of stigma around dementia. This would help
bridge the distance between research and advocacy, highlighting systemic oppression,
and pursuing social justice.
Limitations and Conclusions
This work poses few limitations:
When creating a performative portrait of a PwD, an epistemological limitation pre-
sents in the difculty of articulating an unintelligible experience that is grounded on
the body. Conveying this clarity while accounting for the challenges of the participants
in putting their thoughts into words presented us with the limitation of representing the
experience truthfully and succinctly. Although the difculty in articulating what it is
like to live with dementia and plan for the future represents a limitation, it also repre-
sents a strength of the methodological approach as it emphasises the need to incorpo-
rate the perspectives of PwD as experts by experience(Happell et al., 2020) to
understand from their perspective what is otherwise difcult to grasp. The foreground-
ing of the participantsperspectives through the performative portrait expands their
epistemic power and helps to bridge the distance between the healthcare professionals,
carers, and PwD, as the portrait provides a truthful account of their lived experience.
This is also congruent with the social constructionist approach underpinning this
study, a conceptual understanding of performative portraiture relies on narrative identity
12 Illness, Crisis & Loss 0(0)
explained as autobiography (Ricœur, 1984), where participants provide accounts of their
life stories, bringing an embodied component to complement the narrative, in which ges-
tures, cues, intonations, pauses, laughter, tears, and other non-verbal content occurring
during the interviews convey a richness of emotional content that participants experi-
enced during the interview and cannot be transcribed or even described. This challenge
in incorporating an embodied component to the performative portrait was mitigated by
an engagement with a process of reviewing the recordings for embodied data and then
seeking to convey that to the actor to reenact an impression of the participantsembodied
experience through the lens of the researcher.
A potential limitation of this paper could be the different backgrounds that both
authors have in relation to the topic, which could be seen as partial knowledge.
The rst author has expertise in the subject area of the paper, namely the
medical aspects of dementia. The second author has expertise in the methodolog-
ical aspect of the paper, the creation of performative portraiture. This potential dif-
culty was mitigated by the interdisciplinary work in which both authors and the
actor collaborated in getting a deeper understanding of the qualities required for
this performative portrait by discussing in depth the experiences of interviewing
the participants and how these experiences could be conveyed through
performance.
Finally, the composite narrative of Dave presents the advantage of condensing sig-
nicant experience into a short narrative. However, this brings the limitation of losing
the opportunity to represent a wider range of experiences that were narrated by all par-
ticipants. This limitation could be mitigated by future outputs, such as a multi-actor
performance that engages with a number of participantsnarrated experiences and
allows to observe their distinctive experiences.
In conclusion, this methodological paper discusses the benets of a narrative por-
traiture approach and how to create a portrait based on one study of experiences of
PwD. We argue that this approach offers an alternative, creative output for qualitative
research that tends to be dominated by textual outputs and should be further utilised.
Declaration of Conicting Interests
The authors declared no potential conicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding
The authors received no nancial support for the research, authorship, and/or publication of this
article.
ORCID iD
Tharin Phenwan https://orcid.org/0000-0003-0120-952X
Phenwan and Rodriguez-Dorans 13
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Author Biographies
Tharin Phenwan is a family medicine doctor and qualitative researcher. His main inter-
ests are dementia, Advance (Future) Care Planning, palliative care and quality of life.
Edgar Rodriguez-Dorans is interested in the study of LGBTQIA+lives, identities, sex-
ualities, and the use of performing arts in research. He works from an integrative approach
to counselling, and his work has centred on people living with chronic conditions.
16 Illness, Crisis & Loss 0(0)
Appendix 1.
Daves background and dementia background.
Phenwan and Rodriguez-Dorans 17
... Poorer oral health in people with dementia might be partly explained by symptoms of dementia which include fluctuating mental capacity and gradually declining cognitive functions (Phenwan & Rodriguez-Dorans, 2024;Phenwan et al., 2025b); these symptoms then affect executive functions, including the ability to maintain good oral health (Delwel et al., 2018;Geddis-Regan, 2023). That is, people with dementia may be unable to recognise a toothbrush or short-term memory loss may hinder their ability to maintain their routine oral hygiene, contributing to poorer oral health. ...
... Another consideration is to ensure that supporting mechanisms are in place for both people with dementia and carers and fully participate in the co-design policy development process with other stakeholders healthcare professionals and policymakers. This can be, but is not limited to, using creative participatory methods such as the world café' format (Monforte et al., 2023), art-based methods (Phenwan & Rodriguez-Dorans, 2024) or playful methods (Tsekleves et al., 2018). ...
Preprint
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Advance Care Planning (ACP) is an ongoing process that facilitates individuals to discuss and document their preferences for their future care in the event of terminal illness or incapacitation. In Scotland, the creation of ACP is encouraged, and integrated in current dementia policies as a means of safeguarding the human rights of people living with dementia (PwD). However, the uptake of ACP amongst PwD remains low. This may stem from PwD’s fluctuating mental capacity and symptom of forgetfulness. Moreover, the ACP process which is usually aimed at healthcare professionals (HCPs) may not be suitable for PwD due to the lack of appropriate support they might need. This study employed Fairclough’s Critical Discourse Analysis to explore how the discourses in Scottish dementia policies influence the initiation and revision of ACP for PwD. It examined the way in which the voices of PwD, family carers and HCPs shaped dementia policies regarding the initiation and revision of ACP. Three discourses were identified: Shifting Agencies; Formulaic Rightness; and Visibility and Voices. The analysis revealed that dementia policies inadequately supported the initiation and revision of ACPs for PwD. This is attributed to the responsibility for initiating ACPs being variously ascribed to different stakeholders, creating ambiguity regarding process ownership. The ACP process is presented in policy as formulaic, ignoring the nuances around PwD’s circumstances. The input and participation of PwD, family carers and HCPs to policy relating to ACPs was less visible thus making the legitimacy of those policies questionable. In light of these findings, the person (s) who should support the ACP process with and for PwD should be made explicit. The notion of ACP revision which aims to reflect PwD’s changing needs warrants greater emphasis within these dementia policies.
Preprint
Full-text available
Background Discussing Advance Care Planning (ACP) with people living with dementia (PwD) is challenging due to topic sensitivity, fluctuating mental capacity and symptom of forgetfulness. Given communication difficulties, the preferences and expectations expressed in any ACP may reflect family and healthcare professional perspectives rather than the PwD. Starting discussions early in the disease trajectory may avoid this, but many PwD may not be ready at this point for such discussions. Consequently, the optimal timing to discuss an ACP with and for PwD is undetermined. This study explored the changing needs of PwD and experiences of social contexts that influence ACP initiation and revision and aimed to identify the optimal time to discuss an ACP with PwD Methods Narrative online and telephone interviews were conducted with 13 PwD and 23 family carers. Participants were recruited via the Join Dementia Research (JDR) Platform. Narrative analysis was used to identify patterns in the data, generating three narratives: Shifting Expectations; Relational Interdependency and Trigger Points. Results The Shifting Expectations narrative indicated that PwD’s needs shifted to co-constructed needs with their family as PwD’s independence declined. This was reflected in the Relational interdependency narrative where PwD almost always co-created and revised their ACPs with trusted key persons who provided relational support. The Trigger points narrative indicated various points in time when PwD can effectively initiate and revise their ACPs, ranging from before the diagnosis to years afterwards, challenging the current suggestion of an early ACP initiation. Conclusions This study highlighted the changing co-constructed needs between PwD and their families that influence how PwD initiate and revise their ACP. The identification of ACP trigger points - the pivotal events throughout the dementia journey - that prompt PwD and family members to initiate or revise their ACPs were suggested, indicating that PwD can initiate and revise their ACPs throughout the disease trajectory provided relational support is available whereby key persons involved in their care are involved and agree with the decisions being made. Therefore, an alternative, relational approach to ACP with and for PwD is recommended.
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