Validation Therapy for Dementia: Calming or Condescending?

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People with Alzheimer's disease and other types of dementia often live in an altered reality that doesn't mesh with ours; yet their perceptions are as real to them as our perceptions are to us.

That's a tough concept for many adult children and spouses of people with dementia to absorb.

Validation of our loved one's reality is very often the most kind, respectful response to their altered world that we can provide. In order to offer that validation without coming across as condescending, we need to understand the reason behind "therapeutic fibbing"—as validation therapy is sometimes called.

Years back, the accepted psychiatric thinking was that people who had dementia and strayed from reality were supposed to be reoriented to the real world, but that theory slowly changed, due to the work of one woman.

A dementia care pioneer

Naomi Feil was born in Munich in 1932. She grew up in the Montefiore Home for the Aged in Cleveland, Ohio, where her father was the administrator and her mother was the head of the Social Service Department.

Feil earned her Master's degree in Social Work from Columbia University in New York. She then began her own work with the elderly. Between 1963 and 1980, in response to her dissatisfaction with traditional methods of working with severely disoriented elders, she developed a protocol of validating the aging adult's reality.

Her first book, "Validation: The Feil Method," was published in 1982. Though validation was slow to catch on with medical practitioners, by the mid-nineties Feil's method began to come into its own. Since then, validation has gradually become accepted as an important dementia management tool by most geriatricians and geriatric psychiatrists, as well as social workers, nurses and others who work with people who had developed dementia.

My personal experience with validation therapy

I personally witnessed this transition of medical thought as I struggled to give my own father some quality of life after surgery that was intended to correct the effects of an old World War II brain injury backfired, leaving him with instant dementia.

Stunned, our family just tried to muddle through. I found that the only way to help dad relax and retain any sense of self-esteem was to agree with him—no matter how deluded he was.

I agreed with the "fact" that he'd earned his medical degree, even though a reality check would show that WWII had interrupted his studies. I went so far as to create a faux medical diploma to hang on his wall at the nursing home, which helped for a while.

Then he became convinced that he had received an invitation from Lawrence Welk to be a guest conductor on the TV show, which of course was airing as reruns on PBS since Welk was long deceased.

I bought Dad a conductor's wand and numerous big band CDs. He was thrilled. Dad watched the Welk reruns on TV, merrily directing the band when he was feeling up to it. I made Dad a certificate of thanks from Welk for dad's "services" and hung that on his wall as well.

And on it went.

I knew nothing of the validation theory, but I did know my dad. I could not put this intelligent, well read man through the horror of daily corrections of his thinking when he was no longer able to comprehend why he was wrong. I knew that I needed to get into his world, which, to me – maybe because I'm a rather whimsical person by nature – was instinctive.

Much later I learned that there was a word for what I was doing. Validation.

Validation is now accepted as a practical way of working with people who have dementia. Validation helps reduce stress and it enhances dignity by reinforcing self-esteem. It increases happiness because people aren't continually being told that they are wrong.

The idea of validation stems from an empathetic attitude toward our loved ones and a holistic view of them as individuals. We learn to validate as we make ourselves see the world from their eyes, or—as I often less elegantly put it—we get into their heads.

Isn't "lying" to our elders demeaning?

Understandably, my mother had a difficult time validating Dad's altered world. This was the man to whom she'd been married for over half a century. She felt that she was disrespecting and demeaning him when she agreed with his delusions.

I understood why Mom had trouble joining Dad in his world, but I also witnessed the agitation and emotional pain Dad went through as Mom tried valiantly to make him understand reality when he simply could not do so. She eventually gave up and tried to "play along," though she was never convincing. I can't fault her for that.

Don't ever treat me like a child!

Some of us have been told by our parents to never treat them like a child when they get old. No one believes more than I do that treating an elder as a child is disrespectful and unacceptable.

There is, however, a big difference between training a child and validating an elder with dementia.

Children with normal developmental abilities are able to learn and grow intellectually and emotionally. As they gain experience, they gradually learn to understand the world around them. Therefore, gently correcting a child is our job as parents since the child's proper development is an obtainable goal.

The reverse is true of someone who has dementia. These individuals are gradually losing their ability to understand the world as others see it. They can only understand the world as their disease allows them to see it. This is just one way that caring for parents versus caring for children is different.

If we, as caregivers, continually "correct" their thinking, we are chipping away at any self-esteem that they have managed to retain during their slide into dementia. Constant correction can be demeaning –even cruel—though it's generally not meant as such.

Validation is not about treating someone as a child. It's about respecting the person with dementia as he or she sees the world. It's about overcoming our own bias. It's about adding some dignity to the last years of our elder's lives by accepting that maybe there is more than one way to see the world. There is our way, of course. There is our neighbor's way. And there is our elder's way, even when dementia is present.

Yes, there are times when validation doesn't work, so we lean on redirection and distraction:

"No, Dad, you can't drive now. Maybe later. Let's go see if there's some music on TV."

"No, Dad, there isn't a war here in town – that is across the world and shown on television. Let's change this news channel to Discovery and see what's going on."

"No, Dad, you can't walk without your walker or you'll fall. Let's go for a stroll together and see what Mom's up to."

Those are hard times that call for every tool at our disposal. Yet, for most things, validating our loved one, rather than arguing with him or her, is life enhancing for the elder. It's an expression of kindness, and yes, respect.

Carol Bradley Bursack

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Over the span of two decades, author, columnist, consultant and speaker Carol Bradley Bursack cared for a neighbor and six elderly family members. Her experiences inspired her to pen, "Minding Our Elders: Caregivers Share Their Personal Stories," a portable support group book for caregivers.

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104 Comments

I recently visited a unit in a nursing home dedicated to dementia/alz. they had a most interesting way of validating the desire to return home exhibited by some of the clients. Here is what they did: in a corner of the lounge, near the nurses desk, they placed a nice bench, and a street sign painted yellow marked BUS STOP. They found that was all it took to calm their anxiety, to be understood and validated; and the client would sit down to 'wait for a bus' and usually after a short while, get up and wander to something more interesting to them. Nice!
Wonderful article and valuable. It reminded me of something I heard recently on npr, about an elder care facility in Germany that built a bus stop outside its entrance. When someone gets agitated and wants to leave, a staff member would say , why yes let's take the bus. They wait at the bus stop until the agitation passes.
Words of great wisdom! My favorite use of this approach was with a retired professor obsessed with his next book. I took him to the library for research (opening books for a few moments, moving his papers and pens around) and found a printer willing to spend time with him discussing options for binding and paper stock for the final edition. It brought this man so much purpose and joy, saved him from a world of boredom and feeling useless.