People with Alzheimer’s disease and other types of dementia often come to live in an altered reality that doesn’t mesh with ours. Their memories become garbled and their hallucinations and delusions may not make any sense to us, but their perceptions are as real to them as ours are to us. Dealing with this stark contrast can be difficult, but learning what is behind the feelings of our loved one, or simply by joining them in their world is often the kindest, most respectful way to handle the beliefs and perceptions that a loved one’s brain creates.
Sadly, this is a tough concept for many adult children and spouses of people with dementia to absorb. Most people’s initial reactions to an off-the-wall remark are to refute or correct the remarks or behaviors. Years ago, this kind of “reorientation” was widely accepted, but the downfall is that it only works on individuals who are capable of rational thinking. Dementia patients lose this ability as the disease progresses and can become agitated or upset when their concept of reality is challenged. Thanks to the work of one woman, jarring reality orientation techniques gave way to the gentler practice of validation in dementia care.
A Dementia Care Pioneer
Naomi Feil MSW, ACSW, 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 and then began her own career with the elderly. Between 1963 and 1980, Feil grew increasingly dissatisfied with the traditional methods used to work with severely disoriented elders, so she developed a new technique aimed at acknowledging and accepting their irrational perceptions of reality.
Her first book, “Validation: The Feil Method,” was published in 1982. Although validation was slow to catch on with medical practitioners, by the mid-nineties Feil’s method began to gain popularity. Since then, her technique has gradually become accepted by most geriatricians, geriatric psychiatrists, social workers, nurses and other health care providers as a crucial tool in dementia care.
My approach is not "Validation Therapy" with a capital "V" as Feil practiced it. Rather is an off-shoot of Feil's compassionate understanding that reorientation is not only fruitless, but it's upsetting and even demeaning to our loved ones who live with dementia. Validation in the way that I'm presenting it can work well for most family caregivers. It's easier when we remember that no one can thrive when they are continually told that they are wrong.
My Experience with Validation
I personally witnessed this transition of medical thought as I struggled to care for my father after he was suddenly thrown into dementia due to a botched brain surgery.
My family was completely caught off-guard by this new development and we initially just tried to muddle through. I quickly 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 his thinking 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 and prevented him from realizing this dream. I even 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 to play in a stereo. He was thrilled. Dad watched the Welk reruns, merrily directing the band whenever he felt up to it. I made him a certificate of thanks from Welk for Dad’s “services” and hung that on his wall as well.
And on it went. What I did was try to determine what emotions were behind Dad's feelings and then help him in whatever way made sense. Sometimes, that meant reminiscing about an event so that I could determine what he was feeling. Other times, it simply meant joining in with what he thought was right.
I knew nothing about dementia during these early years, but I did know my dad. I could not put this intelligent, well-read man through the horror of correcting his thinking daily when he was no longer able to comprehend why he was wrong. I knew that I needed to transport myself into his world, which was instinctive to me, perhaps because I’m a rather whimsical person by nature.
Years later, I learned that there is a word for my approach to Dad’s altered realities: validation. Different forms of validation are now accepted by most clinicians as a practical way of working with people who have dementia. Validating our loved one's sense of self helps reduce stress, improve communication, reinforce self-esteem and infuse dignity into dementia care. It increases a sense of happiness for people living with dementia because they aren’t continually being told that they are wrong and confused by truths that they cannot understand.
The idea of validation stems from an empathetic attitude toward our loved ones and a holistic view of them as individuals. We learn to effectively validate their thoughts and experiences by making ourselves see the world through their eyes.
Isn’t “Lying” to Our Elders Demeaning?
Understandably, my mother had difficultly validating Dad’s altered beliefs about himself and the world. This was the man to whom she’d been married for over half a century. She felt that she was being disrespectful when she placated him by agreeing with his delusions.
I understood why Mom had trouble joining Dad in his world, but I also witnessed the agitation and emotional pain he went through as Mom valiantly tried to make him rejoin reality when he simply couldn’t. She eventually gave up and tried to “play along,” but she was never very convincing. I can’t fault her for that.
Validation Lends Dignity and Respect
Some of us have been told by our parents to never treat them like children when they get old. No one believes more than I do that treating an elder like a child is unacceptable. There is, however, a big difference between raising and educating a child and validating an elder who has dementia.
Children with normal developmental abilities are able to learn and grow intellectually and emotionally. As they gain experience, they gradually understand more and more about people and the world around them. Therefore, gently correcting a child is our job as parents who strive to help them develop and become well-adjusted.
The reverse is true of someone who has dementia. These individuals gradually lose their ability to understand the world as others see it and interact with it appropriately. The disease changes how the brain works and processes information, creating warped perceptions that they cannot differentiate from “true” reality. This is just one way that caring for our elders is different from caring for children.
If we, as dementia caregivers, continually “correct” their thinking, we are chipping away at any self-esteem they have managed to retain throughout the course of this disease. A caregiver’s commitment to honesty and accuracy often comes from a good place, but it can be demeaning, even cruel, for an aging loved one to endure.
Validation is not about treating someone as a child. It’s about respecting the person with dementia and how they see the world. It’s about overcoming our own bias. It’s about adding some dignity to the last years of our elders’ lives by accepting that maybe there is more than one way to look at things.
Yes, there are times when validation doesn’t work, so we lean on redirection and distraction instead.
“No, Dad, you can’t drive right now because I misplaced the keys. Let’s go see if there’s some music on TV.”
“No, Mom, there isn’t a war happening here in town. That is going on far away from us and we’re safe. Let’s change this news channel to Discovery and see what’s on.”
“I’m sorry you’re seeing bugs crawling on your bedroom walls. That must be very upsetting. I’ll call the exterminator and we can go have a cup of tea in the living room while we wait for them to show up.”
Dementia presents countless challenges that call for stellar patience and every tool at our disposal. It may seem backwards at first, but validating your loved one, rather than correcting them, is life-enhancing for both of you. It’s an expression of kindness and respect that will help them feel heard and prevent you from starting unnecessary arguments you will never win.