Validation Therapy

What is validation therapy?

Validation therapy allows the caregiver to see, perceive, and understand the world through the older adult’s eyes and thereby reduce the senior’s anxiety by allowing them to become accepting of the reality of their condition and situation.

Communicating with an elderly adult who has dementia is challenging. It is doubly challenging when the senior citizen is agitated or upset. Often, trying to reason with him or her or pointing out his or her mistakes may feel like your best way to address the challenging situation. Often, caregivers want to correct or re-orient the older adult to reality. Unfortunately, for an elderly adult with Alzheimer’s disease or dementia, this avenue of approach may often make the situation worse.

Alzheimer's disease and other dementia-related conditions are debilitating conditions. The disease process destroys the cells housing memories. Thus, asking an elderly loved one with Alzheimer's disease to recall memories that he or she is not capable of remembering may only serve to frustrate him or her. You may also feel yourself starting to become frustrated and perhaps letting out your caregiver burnout or fatigue by unintentionally subjecting your older adult to elder abuse or neglect.

If you find that perhaps correcting or re-orienting a senior citizen with dementia may not be the effecting approach, then how should a caregiver communicate with an agitated aged adult who has dementia?  One option to consider is validation therapy.

History of the Validation Therapy

Validation therapy was developed by a social worker named Naomi Feil, who worked primarily with the elderly adults during the era of the 1960s.  Working with the senior citizens has been a lifelong career for Naomi. She grew up around the elderly as she was nurtured by the administrators, staff, and older residents in the Home for the Aged in Ohio, a senior living facility that also doubled as a memory care facility. Her father was the administrator for the home, and her mother headed the social services department. Literately growing up among the elderly, Naomi developed insight into the aging process and the unique needs of the elderly population who age in place in assisted living facilities.

Her interest in the elderly adult cohort continued into her adulthood. After obtaining a Master's degree in Social Work from Columbia University, she followed her mother's footsteps as she transitioned into becoming a social worker for the elderly adults.

As a social worker, she observed a large communication gap between the severely disoriented elderly and their caregivers. She compiled what she noted were the most effective methods of communication during her time working with the older adults into books published in 1982 (“Validation: The Fiel Method”) and 1993 (“The Validation Breakthrough”). Naomi Fiel went on to develop workshops and videos aimed at educating elderly adult caregivers on how to relate to the elderly population.

Validation Theory

Naomi Fiel aimed to bridge the gap between caregivers and senior citizens diagnosed with Alzheimer's disease and other dementia-related conditions through validation therapy. She began by teaching caregivers a more compassionate and calming way of engaging patients with severe dementia, Alzheimer’s disease, and other neurogenerative conditions. Naomi had observed that caregivers, striving to correct or re-orient the older person back to reality, would often end up increasing the anxiety and frustration of both parties involved. The older person would become more confused after they were corrected as they struggled to come to terms with the reality of their situation and the frustration they were causing loved ones.

Rather than correcting the older person or trying to establish a definite sense of reality, validation therapy allows the caregiver to step into the older person's existence by agreeing with what the older person is experiencing.

To fully understand how validation therapy for dementia works, it's best to review how Alzheimer's disease and other dementias progress.

The disease process for Alzheimer's disease is different for every individual, but the stages remain consistent throughout the process. It is essential to understand the progression of Alzheimer's disease to appreciate how validation therapy works and how to utilize validation therapy techniques effectively.

Alzheimer's disease is progressive, and the older person with the disease will not "get better" only because we keep reminding them of what is real. It is important for caregivers to understand the person who has Alzheimer's disease is continually dealing with a world that becomes increasingly disorienting, a world that disappears more and more each day without their approval or consent. Asking our loved one to retain their memory is asking to behave and take actions that or she may not be not capable of and may only lead to frustration, senior isolation, loneliness, and depression. Validation therapy is a practice that can help the caregiver better understand and support the older adult.

It is important to utilize validation therapy techniques and understand how Alzheimer’s disease destroys the brain’s cells through the creation of plaques that build up throughout the mind, causing loss of memory, cognition, and, eventually, a decreased ability to perform bodily functions. This condition can become particularly frustrating for elderly adults who may no longer be able to remember their identity and independently perform activities of daily living, such as tending to personal hygiene. As Alzheimer’s disease progresses, so do the symptoms. The elderly adult may not be able to display symptoms at first, they may first experience subtle symptoms, then cognitive impairment, and then full fledge Alzheimer’s disease. 

Validation Therapy

Validation therapy takes into account the progressive nature of Alzheimer's disease. This therapy method does not ask the person to try to remember lost information or correct the person when he or she may be inaccurate about the surroundings. Validation therapy, instead, asks the caregiver to "step inside the shoes" of the person with Alzheimer's disease and accept his or her point of view, without judgment.

When a caregiver practices validation therapy, the caregiver may begin to understand the mind, mental functions, perceptions, and attitudes of a senior citizens with Alzheimer's disease. By being accepted with compassion, the afflicted elderly adult becomes calmer and feels more secure.

The Eleven Principles of Validation Therapy

The “Eleven Principles of Validation Therapy” were developed by Naomi Fiel to guide caregivers who want to practice Validation Therapy. They are as follows:

1. People who are very old are unique and worthy. Western society tends to place more value on youth and vitality. However, when helping older people, it's best to remember that older people are worthy and vital also. Their unique experiences bring a different perspective to the table.

As the older adult struggles to recall memories and may experience difficulty with making decisions, it is important they are shown care and encouraged to maintain their sense of dignity.  The older adult may become entirely dependent on another person for care. They can no longer perform activities of daily living for themselves, such as cooking, bathing, or cleaning. As the body shuts down, he or she may spend more time in his or her bed. Their symptoms may include lack of bladder and bowel movement control, a hard time swallowing, weight changes, difficulty communicating, and increased grunting or groaning. The older person with Alzheimer's disease may no longer be able to recognize immediate family members or recall personal information about himself or herself. These times can be trying and it is important for the caregivers to continue to understand, ensure the independence of the elderly adult, and encourage a sense of dignity.

2. People with dementia should be accepted for who they are at that moment. Caregivers should not try to change them or make them be who they were before.

For instance, the older adult with Alzheimer's disease may start to show trembling of "clumsiness" with their hands, and they may begin to stumble or trip when they walk. It is the responsibility of the caregiver to understand. Although people in the beginning stages of Alzheimer's disease may still be able to function independently, they may take longer than usual to finish tasks they could do efficiently before.

When someone has dementia, they can not be expected to behave in a way that they can no longer act. They don't have the ability anymore to perform the tasks they did before. They need to be respected and accepted for how they think and feel at the moment. They should not feel pressured to function the same way they did in the past. 

3. To reduce anxiety and build trust, caregivers should listen to older adults using empathy. For people with dementia, rather than trying to calm them down with medication or reason, it's better to listen and empathize with how they are feeling.

Alzheimer’s disease may interfere with the elderly adult’s daily life and personal relationships, and therefore result in a host of emotions. Alzheimer’s disease can

be a frightening time for both the afflicted individual and their loved ones and caregivers. The person who has Alzheimer's disease becomes unable to complete tasks requiring multiple steps, like cooking a meal or playing a board game. Their ability to recall phone numbers or directions becomes unreliable, and they will tend to repeat the same questions over a short period. The older adult with Alzheimer's disease may become angry or lash out at others to mask their confusion or fear and may refuse to accept the diagnosis.  It is important for caregivers to express empathy and to understand through validation therapy.

4. If painful feelings are ignored or suppressed, they will only become more painful. If painful feelings are acknowledged, expressed, and heard by someone trustworthy, then the painful feelings will diminish. Providing an Alzheimer's patient with a safe environment to talk about painful feelings and acknowledge their hurt can lead to less pain-filled outbursts in the future. By engaging them on their level and with their point of view, caregivers can help older people work through their emotions.
5. Although the person may be disoriented, there is still purpose and meaning behind their behavior. The Alzheimer's patient may not know exactly where they are or who they are with, but the pain and fear are genuine to them. By empathizing with them, caregivers can discover what the motivation is behind their behavior, or they can validate their feelings and allow them to express those emotions. 
6. The meaning behind the behavior of a disoriented person stems from one or more of the following basic human needs:

-wanting to resolve issues so they may die in peace

-to have a life lived in peace

-to restore a sense of balance when their thoughts and memory begin to fail

-to makes sense of their environment and establish comfort and familiarity

-need to be recognized and feel self-worth

-need to feel useful and productive, need to be loved, belong, and have human contact rather than be restrained

-need to feel safe and nurtured: need stimulation such as sensory or sexual

-need to feel less pain or discomfort

The behavior of a person with Alzheimer's stems from the same needs that everyone else feels, except Alzheimer's prevents them from filtering their emotions.

7. When verbal ability and memory fail, early learned behaviors come to the forefront. When we see a person with Alzheimer's perform a childlike behavior, it's not something that is shameful or should be corrected. They are only doing what's left of their memory to self-sooth. 
8. People with dementia may use symbols that represent people or concepts from their past that have a lot of emotion attached to them. When they become repetitive or become focused on a symbol, it's because it represents something meaningful in their past. It's better to allow them the comfort of that symbol because, in a frightening world that is becoming more unfamiliar every day, it provides them with an anchor.
9. People with dementia are living in several different levels of time and awareness, sometimes all at the same time. Time is no longer linear for people with dementia. For them, they could be living in multiple periods in numerous places. It can be confusing and frightening. By pressing the issue of "correct" time, it may only serve to frighten them even more.
10. When the five senses fail, the inner senses become stimulated, and they hear sounds from the past. Sometimes, caregivers can become unnerved by some of the things that a patient with dementia says. Because Alzheimer's can change people's perception of space and time, people with Alzheimer's will sometimes say, hear, or see things that will scare or upset their caregivers. They aren't upsetting their caregivers on purpose, but are only expressing the things they observe in their time.
11. Colors, sounds and events from the past can trigger present emotions as if the person were there. Unlike people who are not ill with dementia, people with Alzheimer's may be transported into the past merely through a sound, color, or smell. For them, they can travel in their minds from one area of time into another quickly, which can be confusing both for them and for their caregivers.

Basic Validation Therapy Techniques

Before spending time with an Alzheimer’s patient, caregivers should prepare themselves mentally by setting aside their own judgments and emotions. To be able to listen empathetically and without bias, they need to be open to experiencing whatever the person with Alzheimer’s is suffering and not carry any firm expectations with them. Their feelings need to be set aside and managed another time, not while they're with the person they are caring for.

Caregivers should give the person with Alzheimer's disease full attention. This way, they can pay attention to any nuances in behavior or changes in emotions in the person they are caring for and adjust their approach.

When caregivers reminisce with the person with Alzheimer's disease, they may be able to process with them regarding their present-day situation. Although the person with Alzheimer's may not be able to learn new coping skills, they may be able to apply whatever worked for them in the past into the present.

Creating an environment of safety and calmness will help make a person with Alzheimer's feel nurtured. A caregiver can also create a personal connection by maintaining eye contact and saying the person's name.

Caregivers need to find a way to agree with what the person with Alzheimer’s disease is experiencing rather than correcting them. Often correcting or attempting to “re-orient” the person will only upset them instead. For instance, telling an elderly adult with Alzheimer’s disease, who insists that their deceased daughter is in the room, that “their daughter can’t be in the room because they passed away years ago” will only re-traumatize the person and start the grieving process all over again.

Although it may feel like lying to the person with dementia, if a caregiver agrees with something, they know is not real...to the person they are caring for, it is true. They don't experience the present as everyone else does. Time and space are fluid for them. By agreeing with their experience and by validating their perception, the caregiver is showing kindness and compassion. 

Music can help provide stimulation and help a person with Alzheimer’s disease feel relaxed. Caregivers can try to find music that’s familiar to the person they are caring for. A song can transport someone to a happy time.

Arguing with a person who has Alzheimer’s disease only leads to frustration and agitation for both parties. Do not argue. Do not argue with them because it is counterproductive.

Use low and nurturing tones. Tones that are too soft or high pitched are challenging for someone with impaired hearing. Caregivers should try not to speak too loudly because loud voices may come across as angry, bossy, or arrogant.

Validation Therapy – Summary:

Validation therapy works best if there is a rapport between the caregiver and the person with dementia. Family members and close friends will find that sharing everyday experiences and history will make validation therapy easier to utilize. Being able to recognize familiar names and events with caregivers can help the person with Alzheimer's disease feel more comfortable. Hired caregivers can also use validation therapy by developing a rapport first, then attempting to engage the patient.

Using validation therapy takes practice, but in the end, it's beneficial for all parties involved. By creating an environment that allows an elderly citizen with Alzheimer's disease to be accepted with respect and empathy, it not only helps them, but it helps the caregivers also.

Validation therapy provides an elderly adult with Alzheimer's disease the dignity that the disease takes from them. It provides them with a sense of ease and peace that they deserve to have during their final stages of life.