Florida: Specialized Alzheimer’s Adult Daycare, Level Two (345)Page 14 of 18

13. Validation Therapy and Reality Therapy

Validation therapy is a type of interactive cognitive therapy developed by Naomi Feil for use in older adults with cognitive disorders and dementia. It arose from Feil’s experience as a young adult watching what she felt was the failure of reality therapy in this patient population. She developed validation therapy as a method of working with patients she described as severely disoriented.

Validation therapy focuses on accepting the reality of the person living with dementia by focusing on the emotional content of a person’s words or expressions. The aim is to reduce negative feelings and enhance positive feelings. Validation therapy uses certain communication techniques, including a gentle tone of voice; nonthreatening words to establish understanding; rephrasing the person’s words; maintaining eye contact (where culturally appropriate); responding in general terms when meanings are unclear; and using appropriate touch (Scales et al., 2018).

Validation theory explains that many (very) old, disoriented people, who are often diagnosed with Alzheimer’s-type dementia, are in the final stage of life, trying to resolve unfinished issues to die in peace. Their final struggle is important, and caregivers can help them (VTI, 2023).

Validation techniques offer disoriented older adults an opportunity to express what they wish to express, whether it is verbal or non-verbal communication. When disoriented older adults can express the things that may have been suppressed for many years, the intensity of their feelings lessens, they communicate more, and are less likely to withdraw into further stages of disorientation (VTI, 2023).

Validation therapy states that:

  1. Very old people struggle to resolve unfinished life issues before death.
  2. Caregivers should use a basic, empathetic attitude that respects and values very old people without judgment.
  3. Caregivers should use specific techniques for individual as well as group work, based on the needs of the individual and his or her phase of resolution (VTI, 2023).

Gladys Wilson and Naomi Feil [5:46]


13.1 Situations in Which Validation Therapy is Useful

The use of validation in dementia care is a way of demonstrating to the client that their feelings, thoughts, and opinions are acknowledged and respected by a caregiver. A combination of validation and reminiscence helps confused or disoriented clients experience joy from their earlier life and contributes to their overall quality of life (Zeman, 2012).

Validation therapy is useful in any situation in which a caregiver, family member, or professional must interact with a person with dementia. Because validation therapy provides techniques for approaching and communicating with a person with dementia, it is particularly helpful in preventing a reaction in the person with dementia that might escalate into an unwanted behavior. It is also useful for calming and diffusing challenging behaviors.

Charles Lashes Out at Frances

Frances, a physical therapist working in a specialized adult daycare center, was wheeling her client Charles to the activities room. Charles was quiet and relaxed as they moved down the hall. About 50 feet from the activities room, Frances was stopped by two co-workers who engaged her in a conversation about another client. All three were standing behind Charles, talking animatedly. Frances placed her hand on Charles’s shoulder to reassure him and he angrily pushed it away, yelling in a loud voice “Stop that!” When one of Frances’s co-workers tried to calm him down, Charles yelled again and tried to hit the woman.

If Frances and her co-workers were familiar with validation therapy or another dementia-specific communication technique, they could have prevented this incident entirely. Instead of ignoring Charles and talking over him, the physical therapist should have stopped, kneeled beside Charles, offered her hand, and introduced her colleagues. She should have asked Charles if she could talk for a moment with her co-workers and included him in the conversation, while reminding her colleagues that nobody likes having people stand over them. If Charles seemed uncomfortable, she could have asked her colleagues to wait until she and Charles had finished what they were doing and continued the conversation after Charles was seated at the activities table.

This is a situation that didn’t need to cause Charles discomfort. If Frances and her co-workers had been respectful of Charles and validated his needs and preferences, they could have avoided upsetting him and modeled good practice for their colleagues.

13.2 Reality Therapy

Reality therapy or reality orientation is based upon the idea that a person who has lost contact with reality can be guided back to reality and that this process will help a person accept and deal with the reality of their situation. Reality therapy is intended to support a client’s own insights into the truthfulness of their situation.

For people who are confused or disoriented, reality therapy is designed to improve cognitive and psychomotor function. It is often employed to help clients focus on their immediate surroundings. With this technique, caregivers actively and repetitively present information needed to orient clients to the time and day, as well as their environment and the people around them. This process is most helpful for the person in early stages of dementia (Zeman, 2012).

Reality orientation isn’t helpful for a person in the mid- to late-stage of dementia. Short-term memory loss and cognitive deficits make it impossible to remember or even understand much of this information. Trying to get the individual to focus on reality when significant confusion and cognitive loss are present can increase confusion and cause agitation (Zeman, 2012).

13.3 Validation Therapy vs. Reality Orientation

Validation therapy and reality therapy differ in several ways. Validation therapy deals with a person’s feelings. It is not intended to improve a person’s cognition or to delay cognitive decline. It is intended to draw people out, encourage communication, and validate a client’s personal truth. When used consistently, validation therapy can reduce the number and intensity of challenging behaviors, decrease the use of drugs used to treat these behaviors, and provide comfort to the person with dementia.

Reality orientation on the other hand, is intended to reduce cognitive decline using repetitive activities that reinforce name, date, place, and time. It is based on the belief that continually and repeatedly telling or showing certain reminders to people with mild to moderate memory loss will result in an increase in interaction with others and improved orientation (Takeda et al., 2012).

13.4 Joining Clients in Their Own Reality

When a person with dementia has a delusion or hallucination or another type of challenging behavior, “getting into their reality” may allay fears, address a problem behavior, or help the caregiver figure out its cause. This often leads to simple, commonsense solutions. It also helps improve the quality of life for the individual by fostering trust in the caregiver and reducing dependence on medications to manage negative behaviors.

Getting into Polly’s Reality

Introduction: For older adults who are still able to participate in activities, specialized adult daycare is a good option. It provides respite for family caregivers while offering activities and socialization for clients with dementia. But, sometimes, success requires a little creativity.

Client Information: Polly is 75 years old and lives at home with her husband, Mel, who still works fulltime as a lawyer. She has moderate dementia, is independent in all basic activities of daily living but is no longer able to drive, shop, or manage complex tasks without the help of her husband. Polly had worked as a secretary in a law office for almost twenty years. When she retired, still wanting to keep busy, she took a part-time job at a nursery school and volunteered at the local animal shelter. Polly described herself as a “people person.”

Timeline: A specialized adult daycare center in Ohio did its part to help Mel when he called and asked about admitting his wife to their program. Mel believed Polly would do well there. Visiting the next day, he was impressed. Polly could stay at the center for the whole time he was at work, and professionals would make sure she was safe, had a good lunch, a nap if she needed one, and activities she would enjoy. It seemed like the ideal solution, and Mel thought it would allow him to remain employed for another year or two.

Polly, however, had other plans. She did not like the idea of a day care center, and especially the people she imagined were staying there. She told Mel she was “not one of them.” She refused to consider it and decided she wanted to go back to work instead. She told Mel she needed to be around people, enjoy her job, and have things “like they used to be.”

Intervention: Not knowing what else to do, Mel called the daycare center for suggestions, and they gave him an idea. That evening, Mel explained to Polly that her previous employer had hired another person. Her old job was gone, but if she was interested, he found another job for her. He told her he thought she would like it because she could be around a lot of other people.

The following day he took Polly to the daycare center. Mel explained that it was a place for people who had problems with their memory, and they were looking for help. The director greeted them and told Polly they wanted to hire her because they needed someone to help the staff keep the people there happy and engaged in activities. Her job would include talking to them, helping to set the table for lunch, handing out snacks, accompanying others to activities, and helping with pet therapy.

Polly was given a tour of the center and was treated as if she were a prospective employee. On the tour she saw the attendees in various activities including group exercise, a reminiscence circle, and flower arranging. She also met the pet therapist, who was bringing in two beautiful dogs that Polly admired.

Discussion: Mel was pleased that the center had recognized Polly’s need to “work” and their willingness to use that to encourage her interest in attending the daycare program. Of course, they knew that no real demands or expectations would be placed on Polly and that she would be encouraged to make friends and enjoy the activities. They waited to see what Polly’s decision would be.

Client Perspective: Polly did decide to take the “job” at the center. For a few weeks, she managed to hang on to the idea that she was there to work with the other people who had dementia. But gradually, Polly just enjoyed going to the center to see her “friends.”

Source: Adapted from Kisses for Elizabeth: A Common Sense Approach to Alzheimer’s and Dementia (2012), by Stephanie Zeman, RN, MSN. Used by permission.

13.5 Validation Therapy in Adult Day Care

An individual’s physical and mental condition is only part of what makes them tick. The roles they fill in contemporary life as well as their culture, ethics, spiritual beliefs, education, and the choices they made in earlier life are unique to each person. Commonsense dementia care addresses the needs of the person with dementia, not just the dementia in the person we care for (Zeman, 2012).

For healthcare providers working with a client with dementia, Stephanie Zeman, in her book Kisses for Elizabeth: A Common Sense Approach to Alzheimer’s and Dementia (2012), includes many commonsense recommendations. First and foremost, consider the whole person—not just the dementia. Practice good communication skills and encourage independence. If you can, imagine yourself in the person’s place, have a good sense of humor (and use it wisely). Most importantly, expect the unexpected. Additionally:

  • Avoid reality orientation except for early-stage dementia.
  • Validate the person’s feelings.
  • Avoid judgement, arguing or saying no.
  • Learn to use “feel goods” such as a hot bath, a cup of coffee, going to a movie, or offering a piece of chocolate.
  • Arrange for meaningful and important activities each day.
  • Remember that religion can be a comfort.

Joining Rose in Her Own Reality

Rose was upset at noises she heard during the night. She was convinced that animals were living in the ceiling of her room and would hurt her. Because she was so frightened by this, Rose started sleeping in a recliner by the nurses’ station.

When I heard about this, I asked a staff member “put yourself in Rose’s place and listen for the noise” by staying in her room for a while. Surprisingly, around midnight the staff member heard scratching noises from above.

An investigation of the noise discovered a tree branch was scraping the roof of the one-story facility when it was windy. It was removed the next morning, but Rose was still frightened and would not go into her room. No amount of explanation or “reasoning” with her would help. In her mind, she was in danger from the animal in her room.

Once again, we thought about what we needed to do for Rose. We even considered changing her room, but eventually the staff decided to “get rid of the animal.” They brought in a ladder and a paper bag. Removing a ceiling tile, one of the housekeeping staff climbed up and made some banging noises. Inflating the bag, and twisting the top, he came down the ladder with the “animal” in tow. Rose, who had been watching from the door, was relieved, and since the noise from the branch was gone, the “animal” never came back.