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 as a result of 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.
Feil’s model sought to classify the stage of dementia that an individual has reached according to cognitive and behavioral signs. Its development was the result of an attempt to provide practical solutions for difficulties experienced by patients and caregivers. Important features of validation therapy include: a means of classifying behaviors; provision of simple, practical techniques that help restore dignity; prevention of deterioration into a vegetative state; provision of an empathic listener; respect and empathy for older adults with Alzheimer’s disease who are struggling to resolve unfinished business before they die; and acceptance of the person’s reality (Takeda et al., 2012).
Validation therapy teaches that the experiences and personal truth of a person with dementia should be accepted and validated. Validation therapy states that:
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 the caregiver. A combination of validation and reminiscence helps confused clients experience joy from their earlier life and contributes to their overall quality of life (Zeman, 2015).
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 day care center, was wheeling her client Charles down the hall 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 might have stopped, kneeled down beside Charles, offered her hand, and introduced her colleagues. She might have asked Charles if she could talk for a moment with her co-workers or 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 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.
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, 2015).
Reality orientation can be taught to caregivers and family members; it can be performed in the home and should be structured around the area in which the patient spends most time. For example, access to a window is recommended to facilitate orientation to the time of day and the weather. Other than environmental cues, familiar objects to the patients (family scrapbooks, flash cards, Scrabble games, a globe, and large-piece jigsaw puzzles) can be used to stimulate their memory in reality orientation (Takeda et al., 2012).
For most of us, being oriented to reality is essential. But reality orientation isn’t helpful if the person has mid- to late-stage 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, 2015).
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 of the individual by fostering trust in the caregiver and reducing dependence on medications to manage negative behaviors.
Validation therapy and reality therapy differ in a number of 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. This in turn can improve self-esteem and reduce problem behaviors (Takeda et al., 2012).
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, a little creativity is required.
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 Peggy 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
Individuals’ 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 needs of the person with dementia, not just the dementia in the person we care for (Zeman, 2015).
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), recommends the following guidelines when working with a person with dementia: