Validation: An Empathic Approach to the Care of Dementia

Validation is a method for communicating both verbally and non-verbally with old-old disoriented populations. The goal of Validation is: (1) to stimulate communication in order to prevent withdraws inward; (2) to restore well-being; (3) to facilitate the resolution of unresolved issues to prepare for death. Validation also has the goal of reducing caregiver’s burn-out by teaching empathy skills.
Validation is now practiced in over three thousand long term care facilities, adult day care centers, and independent housing units in the United States, Canada, Great Britain, Norway and Australia. On a deep level of awareness, disoriented very old people know they are shutting out present reality. They restore the past to survive the bleak present. Validating their behaviors with empathy produces the following results: (1) dormant speech returns, (2) positive affect (smiling, sitting upright, reaching out to others) increases, (3) negative affect (biting, scratching, swearing) decreases, (4) social roles return in the group, (5) social interactions increase, (6) group members share common concerns and express common feelings (Fell, 1972).
When their struggle to restore the past is validated by a trusted caregiver, the very old do not withdraw inward. Buried emotions are shared and acknowledged. Disoriented old people begin to communicate with the trusted validator to the maximum of their ability. The Validation worker does not try to give insight, to insert new self-awareness or change the disoriented old person. To validate means to accept the disoriented old person where they are; to be non-judgmental; to share feelings that are freely expressed in order to lessen anxiety, restore self-worth, arid prevent withdrawal inward to vegetation.

HOW VALIDATION WORKS

There are four discrete stages that occur in the final Resolution phase of life. The Validation worker assesses the stage of confusion or disorientation by observing the physical condition, the social history, and through individual interviews.

Stage One: Malorientation

The Maloriented very old person is aware of present time, place, and person. Developmentally, the Maloriented have never faced losses. They are the blamers. When things go wrong, they cope by projecting their fears on others. These are the physical characteristics of a Maloriented very old person:
Eyes narrow; tight facial muscles; pursed lips; shallow breathing; chin juts out; lingers accuse; body movements are direct, purposeful; speech is clear; recent memory is intact with occasional lapses and repetitions of events; social controls are intact; voice is harsh or whining.
These are the psychological characteristics of a Maloriented old-old person:
Maintains tight control; hoards to hold onto present reality and to protect the self against future losses; does not want to reveal feelings; does not want to be touched; does not want insight into their behavior; confabulates; conforms to rules; is threatened by disoriented neighbors; projects fears onto others.
For example: When eyesight fails., the Maloriented blame their children for providing poor light bulbs; when dentures decay, they claim the meat is too tough; when they occasionally become incontinent, they claim the maids spill water. The Validation worker does not argue, aware that blaming is their only coping method. The following Validation techniques respect their defenses and build trust:

1. Listen with empathy. Use non-threatening exploring factual words: Who? What? Where? When? How? Avoid feeling words or intellectual analyzing. Avoid asking Why? Avoid confrontations.
2. Use the Maloriented person’s preferred sense (visual, auditory, kinesthetic). For example: If the person prefers their visual sense, use visual words: What does it look like? How do you see it? What color is it? In speaking the person’s language, the worker builds trust.
3. Repeat or paraphrase the Maloriented person’s key words.
4. Polarity. Help the person express extremes by asking: When was it the worst? When was it the best? How often did it happen? How bad was it? The worker respects the Maloriented person’s lifetime defenses, enabling the person to safely couch feelings in facts.
5. Life Review. Help the person explore the past by asking: Was it always like this? What was it like when you were….?
6. Imagine the opposite. This technique can lead to a creative solution. Although the Maloriented person continues resolving – old business is rarely resolved – anxiety lessens and they may find a way to solve the problem. Example: Was there ever a time when there was no man under the bed? The Maloriented person may answer: “When I have company, he doesn’t come. Maybe I’m lonely. Maybe I need to find friends.’’

Feelings are expressed in a factual way, shared and validated by a trusted listener. The rage, hurt, sexual feelings or guilt lessen when brought out into the open and acknowledged. Kept inside, the buried feelings fester. By listening with empathy, the worker does not buy into a delusion. Behavioral principles do not apply with this very old Maloriented person. They do not wish to change their blaming behaviors. Blaming is their only defense against loss. When ignored, the Maloriented person’s blaming gets worse. By listening, the worker helps the Maloriented relieve the burdens of a lifetime.

Stage Two: Time Confusion

In Time Confusion, physical damage to brain, eyes, ears and mobility increase. Physical characteristics of Time Confusion are:

Eyes blurry, unfocused; muscles loose; ,movement indirect, wanders; speech unclear, word-doodles; forms unique word-sounds; loss of sensory sell-awareness or body parts; loss of metaphorical thinking capacity — loss of the as—if, the ability to analyze and compare.

The psychological characteristics of Time Confusion are:

Raw emotions spill; the person moves back and forth in time; the person uses vivid imagery to restore people from the past; use of body parts or people in present time to represent people from the past; loss of social controls of motivation to conform to social rules.

These Validation techniques help the Time Confused:

1. Touch. Gentle pressure on the cheek with the palm of the hand often triggers a mother-relationship. Gentle touch on the back of the head can trigger a father-relationship. Cupped fingers on the back of the neck can stimulate a child-relationship, etc. The worker becomes a significant other through touch.
2. Genuine, close eye-contact.
3. Match the raw emotion. Verbalize the emotion. Use short, one-syllable feeling words.
4. Link the non-verbal behavior to unmet human needs. Basic human needs are: (1) Love or safety, (2) Usefulness, identity, (3) To express gut feelings. Example: A former carpenter who pounds his fist may be visualizing his hammer. He cannot see his hand. Damaged brain cells no longer inform him of his hand’s position. He can restore his past work via movement. Motion triggers emotion. His hand-movement is his ticket to his past. This way he restores his life’s work to gain self-worth.
5. Use Ambiguity. When Time-Confused cannot verbalize, the worker uses a vague pronoun, “he,” “it,” “someone,” “something,’’ in order to communicate. Example: 99-year-old Mrs. G. cries: “I HAVE TO FIND FILLATURE IN THE CAPS.’’ The worker, knowing that Mrs. G. has lost the dictionary words, uses the vague pronoun, ‘‘them.’’ The Worker asks with empathy, matching Mrs. G’s affect: ‘‘Did you lose them? Are you afraid something terrible happened to them?’’ Mrs. G. answers with relief at being heard: “OH Yes! Phillip fell in the well. See his cap on top.’’

Stage Three: Repetitive Motion

In Repetitive Motion, speech disappears and is often replaced by movements and repetitive sounds such as humming, clucking, moaning. Primary movements and rhythms often appear. The worker mirrors the movements, using music and non-verbal media to gain trust and stimulate dormant verbal behaviors. The goal is to keep communication open and to prevent withdrawal inward to Stage Four.

Stage Four: Vegetation

In Vegetation, movements lose their purpose. Disoriented old-old stimulate themselves minimally, to barely stay alive. Repetitive touch can evoke some response, but there is rarely any communication. Once the person reaches Vegetation, withdrawal inward is complete.
Validation does not restore cognitive functioning. But, Validation does prevent withdrawal to Vegetation. Validation does restore feelings of dignity and human communication.

Naomi Fell, MSW ACSW
Cleveland, Ohio

REFERENCE

Fell, N. (1972). A New Approach to Group Therapy with Senile Psychotic Aged. Unpublished paper presented at The International Gerontological Conference. Puerto Rico, 1972.