People with Alzheimer’s disease or other types of dementia often come to live in an altered reality that doesn’t mesh with ours. As a senior’s memory loss and cognitive impairment worsen, they may struggle to maintain their senses of time and place. The disease process within the brain may even result in hallucinations and/or delusions that do not make any sense to us. However, a dementia patient’s perceptions are very real to them and can be downright frightening at times.
Dealing with this stark contrast can be frustrating for family caregivers and seniors alike, but there are ways of coping. Determining what is behind a loved one’s feelings and joining them in their world is often the kindest, most respectful way to handle the beliefs and perceptions that their broken brain creates.
Reality Orientation vs. Validation Therapy
Sadly, this is a tough concept to absorb. Most people initially react to off-the-wall remarks by repeatedly refuting or correcting dementia patients. Years ago, this approach called “reality orientation” was widely accepted, but the problem is that a person’s cognitive abilities, such as rational thinking and short-term memory, must still be somewhat intact for reorientation to be successful. Otherwise, they aren’t capable of understanding and/or retaining facts about their surroundings.
Dementia patients slowly lose these abilities as the disease progresses and can become agitated or upset when their concept of reality is challenged over and over again. Thanks to the work of a woman who pioneered dementia care, jarring reality orientation techniques gave way to the gentler practice of validation therapy.
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 working with the elderly. Throughout the 1960s and 1970s, she grew increasingly dissatisfied with the traditional methods used to interact 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, and her second book, “The Validation Breakthrough,” was released in 1993. Although validation was slow to catch on with medical practitioners, Feil’s method began to gain popularity by the mid-nineties. Since then, her technique has gradually become accepted by most geriatricians, geriatric psychiatrists, social workers, nurses, professional caregivers and other health care providers as a crucial tool in dementia care.
A Family Caregiver’s Experience With the Validation Approach
I witnessed this transition of medical thought as I struggled to care for my father after a botched brain surgery left him with dementia. My family was completely caught off-guard by his immediate and severe cognitive decline. Initially, we 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 became.
I must point out, though, that my personal approach is not “Validation therapy” with a capital “V” as Feil practiced it. Rather, is an offshoot of Feil’s understanding that reorientation may not only be fruitless in the moderate and severe stages of dementia, but it can also be upsetting and even demeaning to our loved ones who are struggling to make sense of their surroundings. 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.
So, I agreed with the “fact” that Dad had 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 the wall of his room 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 to watch The Lawrence Welk Show 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 behaviors and then help him in whatever way made sense. Sometimes, that meant reminiscing together about a person, place or event so I could get a better idea of 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 embracing Dad’s altered realities: validation. Different forms of validation are now accepted by most clinicians as a practical way of interacting with people who have dementia. Validating a loved one’s perceptions and emotions helps reduce stress, improve communication, boost 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 fully understand or remember.
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 a difficult time 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 she had trouble joining her husband in his world. But, I also witnessed the agitation and emotional pain Dad 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, though. Some of us just don’t have it in our nature to be dishonest or misleading, even if it may be in a loved one’s best interest.
Validation Lends Dignity and Respect to Dementia Care
Some of us have been told by our parents or spouses 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.
Most children 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. Alzheimer’s disease and other forms of dementia change how the brain works and processes information, creating warped perceptions that seniors cannot distinguish 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 a person with dementia and how they see the world. It’s about overcoming our own need to be “right.” It’s about infusing our elder’s last years with dignity by accepting that maybe there is more than one way to look at things.
Yes, there are certainly times when validation doesn’t work, so we lean on other non-pharmaceutical interventions for dementia like redirection and distraction.
“No, Dad, you can’t drive right now because I misplaced the keys. Let’s go see if there’s some music playing 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 turn off the news and check if there are any birds at the feeder in the backyard.”
“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 arrive.”
Dementia presents countless challenges that call for stellar patience, adaptability 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. These white “lies” are an expression of kindness and respect that will help them feel heard and prevent you from starting unnecessary arguments you will never win.