Validation therapy

Validation therapy is a method of therapeutic communication which can be used to connect with someone who has moderate to late-stage dementia ¹. Validation therapy places more emphasis on the emotional aspect of a conversation and less on the factual content, thereby imparting respect to the person, their feelings and their beliefs. Validation therapy focuses on accepting the reality of the person living with dementia. By focusing empathically on the emotional content of a person’s words or expressions, the aim of validation therapy is to alleviate negative feelings and enhance positive feelings ². Validation therapy is implemented through a number of communication techniques, including using nonthreatening words to establish understanding; rephrasing the person’s words; maintaining eye contact and a gentle tone of voice; responding in general terms when meanings are unclear; and using touch if appropriate ³.

Validation therapy was developed by Naomi Feil between 1963 and 1980 for older people with cognitive impairments ⁴. Initially, this did not include those with organically‐based dementia, but the approach has subsequently been applied in work with people who have a dementia diagnosis. Feil’s own approach classifies individuals with cognitive impairment as having one of four stages in a continuum of dementia: these stages are Mal orientation, Time Confusion, Repetitive Motion and Vegetation. The therapy is based on the general principle of validation, the acceptance of the reality and personal truth of another’s experience, and incorporates a range of specific techniques. Validation therapy has attracted a good deal of criticism from researchers who dispute the evidence for some of the beliefs and values of validation therapy, and the appropriateness of the techniques. Feil, however, argues strongly for the effectiveness of validation therapy.

Validation therapy is based on the general principle of the acceptance of the reality and personal truth of another person’s experience and incorporates a range of specific techniques ⁵. Validation therapy is intended to give the individual an opportunity to resolve unfinished conflicts by encouraging and validating the expression of feelings. The specific interventions and techniques are based on a synthesis of behavioral and psychotherapeutic methods to meet the needs of individuals with different stages of dementia. The approach can be used as a structured therapeutic activity in a group setting, usually lasting several weeks, or it can be conducted individually as part of an ongoing approach to facilitate communication as a supplement to group work. The validation therapy techniques comprised non-threatening, simple concrete words; speaking in a clear, low and empathic tone of voice; rephrasing and paraphrasing unclear verbal communication; responding to meanings through explicit and implicit verbal and non-verbal communication and mirroring verbal and non-verbal communication.

This method of communication often prevents argumentative and agitated behaviors. Validation therapy may require you to agree with a statement that has been made, even though the statement is neither true or real, because to the person with dementia, it may actually be both true and real. Additionally, the principles of Validation Therapy attempt to help you determine the underlying cause behind the actions taken or words spoken, and, to discover how those actions or words are true for the person with dementia.

Validation Therapy advocates that, rather than trying to bring the person with dementia back to our reality, it is more positive to enter their reality. In this way empathy is developed with the person, building trust and a sense of security. This in turn reduces anxiety. Many families and carers report increased benefits for themselves, as well as for the person with dementia, from a reduced number of conflicts and a less stressful environment.

Validation therapy is based on the idea that once the person has experienced severe short term memory loss and can no longer employ intellectual thinking or make sense of the present, he or she is likely to go back to the past. This may be in order to resolve unfinished conflicts, relive past experiences or to retreat from the present over which they have little control. Some people will go in and out of the present.

Some family members and carers express concern that validation involves lying to the person with dementia about reality. However a more accurate description is that it avoids challenging their reality. For instance, if a person with dementia believes that she is waiting for her children, all now middle aged, to return from school, family members and carers who use validation would not argue the point or expect their relative to have insight into their behavior. They would not correct their beliefs. Rather, the validating approach proposes acknowledging and empathising with the feelings behind the behavior being expressed. In this way the person’s dignity and self-esteem is maintained.

The basic principle behind validation therapy is to communicate with respect, showing that their opinions and beliefs are heard, acknowledged, valued and esteemed, rather than dismissed or marginalized. It may require you to do so even when you don’t agree with or believe what has been shared. Because this technique’s emphasis is on empathy and listening, it’s generally comforting and calming to a person who has dementia.

The evidence base for validation therapy is small and shows mixed findings. One Cochrane review ⁶ that evaluated the effectiveness of validation therapy to reduce behavioral and psychological symptoms in dementia. The review included only randomized trials of participants over 65 years of age, diagnosed with Alzheimer’s disease, dementia or other forms of cognitive impairment. The outcomes of interest were cognition, behavior, emotional state and activities of daily living. The review, updated in 2005, included three randomized trials (n=155 participants). Another systematic reviews ⁷ that evaluated the effective characteristics of residential long-term care settings for people with dementia identified one trial that was included in the Cochrane review ⁶. The Cochrane review concluded there is insufficient evidence from randomized trials to allow any conclusion about the efficacy of validation therapy for people with dementia or cognitive impairment ⁶.

A recent review of personalized psychosocial practices for behavioral and psychological symptoms of dementias ⁸ identified two validation therapy studies: one study of validation therapy and sensorial reminiscence therapy conducted twice weekly for 12 weeks, with each session lasting 45–60 minutes, found significant improvements for behavioral disturbance compared to controls ⁹; the other study, which included both individual (20 min, three times per week) and group sessions (45–60 min weekly), found decreased agitation, apathy, irritability, and night-time disturbance ¹⁰. However, several other reviews found insufficient evidence for the efficacy of validation therapy in reducing behavioral and psychological symptoms of dementias ¹¹.

Although the evidence base for validation therapy is underdeveloped, the concept of honoring the feelings of the person living with dementia has face validity as part of person-centered dementia care ¹². Validation therapy is a low investment practice, as it can be integrated into care by usual care providers after modest investment in communication training. Negative effects appear minimal, although there may be risk that an individual’s feelings of distress could be exacerbated through validation therapy if care providers are not sufficiently prepared to both honor and alleviate those feelings.

Validation therapy techniques

Validation therapy is described by Naomi Feil 1993 ⁴ as a discrete form of “therapy for communicating with old people who are diagnosed as having Alzheimer’s disease and related dementia”, which can be clearly distinguished from other types of intervention. The validation therapy approach attempts to address the shortcomings of other approaches, such as reality orientation, used with individuals who have more advanced dementia. Feil developed a model that 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; it was not developed from a theoretical basis in the way that some other newer psychological therapies have been developed.

Feil’s Validation Institute trains and accredits therapists wishing to practice validation therapy.

Validation, as a general term, can be defined as the acceptance of the reality and personal truth of another’s experience. This, in itself, is a central element of all humanistically‐oriented therapies, and a key aspect of person‐centred approaches to dementia care. Validation, in this general sense, can be considered as a kind of philosophy of care. Within a person‐centered approach ¹³, validation is identified as providing a high degree of empathy and an attempt to understand a person’s entire frame of reference, however disturbed that might be. It is therefore important to try to distinguish between the concept of validation in general and the specific application within validation therapy.

Important features of validation therapy are said to include: a means of classifying behaviours; 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 type dementia, who are struggling to resolve unfinished business before they die; and acceptance of the person’s reality ⁴. These features are not, however, unique to validation. Feil 1993 identifies a number of beliefs and values that underlie the validation approach, although again many of these are shared by other person‐centeredd approaches ⁴:

1. All people are unique and must be treated as individuals.
2. All people are valuable, no matter how disorientated they are.
3. There is reason behind the behavior of disorientated older people.
4. Behavior in old age is not merely a function of anatomical changes in the brain, but reflects a combination of physical, social and psychological changes that take place over the life span.
5. Old people cannot be forced to change their behaviors. Behaviors can be changed only if the person wants to change them.
6. Old people must be accepted non‐judgementally.
7. Particular life tasks are associated with each stage of life. Failure to complete a task at the appropriate stage of life may lead to psychological problems.
8. When more recent memory fails, older adults try to restore balance to their lives by retrieving earlier memories. When eyesight fails, they use their mind’s eye to see. When hearing goes, they listen to sounds from the past.
9. Painful feelings that are expressed, acknowledged, and validated by a trusted listener will diminish. Painful feelings that are ignored or suppressed will gain strength.
10. Empathy builds trust, reduces anxiety, and restores dignity.

The way in which these values are applied to provide specific interventions depends on the severity of dementia in each individual case. Feil has taken an idiosyncratic approach to the diagnosis, classification and staging of dementia and this does not map directly onto medical classification systems. Early work by Feil stated that validation therapy was not applicable to organic dementia ¹⁴, although she later included Alzheimer’s disease within the remit of validation. Feil classifies individuals with cognitive impairment as reflecting one of four stages in a continuum of dementia: these stages are Mal orientation, Time Confusion, Repetitive Motion and Vegetation. Each stage is identified by specific cognitive and behavioral characteristics. Specific validation therapy interventions address the different cognitive and behavioral features manifested by people with dementia at each of these stages.

The specific interventions and techniques used within the validation approach are based on a synthesis of behavioral and psychotherapeutic methods. The approach was developed through a process of adopting interventions from a variety of sources, to meet the needs of individuals with different stages of dementia. Feil 1982 ¹⁵ initially identified the group who most required an alternative approach as being those individuals who were over 85; she described these individuals as the “old ‐ old”. Over recent years the approach has been applied to younger individuals with dementia and the term “old ‐ old” is no longer in use in this context. The approach can be used as a structured therapeutic activity in a group setting, running usually for several weeks, or it can be used on an individual basis as part of an ongoing approach to facilitate communication, so supplementing group work.

Validation therapy has at its center 14 techniques ⁴:

1. Centring in order to focus upon the individual who is to be validated.
2. The use of non‐threatening factual words to build trust. These include words such as “who”, “what”, “where”, “when”, and “how” ‐ but not the word “why”.
3. Rephrasing the person’s speech to them.
4. Using polarity ‐ asking the person to think about the most extreme example of their complaint.
5. Imagining the opposite.
6. Reminiscing.
7. Maintaining genuine, close eye contact.
8. Using ambiguity, as in the use of non‐specific pronouns such as “they”, “he”, “she”, or “it”, in order to respond to the demented person’s conversation when they are using non‐dictionary words or when what they are saying is not understood.
9. Using a clear, low, loving tone of voice.
10. Observing and matching the person’s motions and emotions in order to create trust and establish verbal and non‐verbal relationships.
11. Linking behavior to the unmet human need.
12. Identifying and using the person’s preferred sense.
13. Touching ‐ noting that people in the first stage, mal orientation, do not respond well to being touched.
14. Using music in order to trigger early memories and thoughts.

Full explanations of these techniques are given by Naomi Feil ⁴. However, the extent to which some of the techniques are directly relevant to, and appropriate for, the subjective experience of people with dementia has been questioned ¹⁶. In a thorough and critical review of validation therapy Morton described both the theory and the techniques of validation therapy as dubious in formulation and utility (Morton 1999). He also comments on the fact that some of the psychotherapeutic approaches that are adopted within validation are theoretically incompatible. Goudie 1989 similarly find the theory incoherent and unconvincing. They dispute the evidence for some of the beliefs and values of validation therapy, and are critical of the techniques. Nevertheless, the development of the validation approach has been described by some as putting its creator into the ‘forefront of the focus on the experience of dementia’ ¹⁷, and others have viewed it as another means to address the ‘paucity of nurse‐patient interaction’ in dementia care ¹⁸.

Some suggestions which line up with the validation therapy techniques Feil outlined for communicating with a disoriented person include:

• To prepare yourself to listen empathetically, set your own emotions and anger aside to be dealt with and acknowledged later. Concentrate fully on what they are sharing, making sure you’re able to pick up on any little nuance they exhibit or share.
• Reminisce with them, especially talking about how they were able to solve a problem. A person with dementia cannot learn new coping skills; but, remembering how they handled problems in the past may help them rediscover a way to deal with problems they currently face.
• If the person with dementia enjoys physical contact, and would not consider you to be violating their space, use touch to establish a relationship with them. Gently stroking their cheek or hand may remind them of pleasant times from the past, such as times when their mother did the same. Remember, people who have problems with others being in their personal space will continue to have those issues, disoriented or not. Respect for their boundaries is important.
• Maintain close eye contact. Gazing into their eyes will help them feel secure and loved.
• Music is a great tool. Music and songs often transport us to another place and time. Think how many times a song reminds you of other people, places or events. Non-verbal people with dementia can even sing songs they once knew when they are otherwise unable to speak.
• Do not argue with them. Arguing with a confused person is rarely productive and leads to frustration and agitation.
• Don’t ask them why they did or said something or tell them they’re wrong. Instead, ask about the more basic facts of the situation. They’ll likely be more comfortable telling you the who, what, when, where and how than the why.
• Use a clear, low (but not quiet) and loving tone. High-pitched tones and soft tones are difficult for someone with impaired hearing to understand. Plus, an overly loud voice can come across as harsh or angry; therefore, do not talk louder than necessary just because they are hard of hearing.
• Use non-threatening, factual words. A person with dementia is not the least bit concerned in discovering why they behave the way they do. Rather than asking why something was done, focus instead on the more concrete questions of who, what, where, when and how.
• Turn the conversation toward a positive memory from their youth that’s related to something they’re doing or saying in the present.
• Try to set your emotions aside so you can really focus on what they’re saying, what they’re doing, the ways in which those things may reflect issues they’re struggling with, and how you can respond in a way that makes them feel heard.

Various observational studies have indicated that there are positive effects in using validation therapy in terms of the amount and duration of interactions that participants are able to make during validation groups ¹⁹. However, other studies ²⁰ have found no significant effects of validation therapy. Feil 1993 argues strongly for the benefits of validation therapy. She sees the benefits for people with dementia as including:

1. restoration of self worth.
2. reduction of the need for chemical and physical restraints.
3. minimization of the degree to which patients withdraw from the outside world.
4. promotion of communication and interaction with other people.
5. reduction of stress and anxiety.
6. stimulation of dormant potential.
7. help in resolving unfinished life tasks.
8. facilitation of independent living for as long as possible.

Possible benefits for families are said to include reduced frustration with their relative, more effective communication, relief in terms of the improvement made by their relative in relation to speech and social functioning, increased visiting, and increased awareness of their own ageing process. Possible benefits for professional caregivers are said to include reduction in frustration, prevention of burn‐out, promotion of joy in communicating and increased job satisfaction ⁴. A systematic review of non‐randomised studies ²¹ noted that there might potentially be other, more indirect benefits from validation therapy for both patients and staff; for example, validation therapy might help to promote a person‐centred approach, thereby improving patient care. Such benefits would, of course, be highly desirable, but there is a need to demonstrate their presence on the basis of rigorous research yielding strong evidence across a number of well‐designed studies.

References

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