Validation Therapy

Validation Therapy, developed through clinical practice with Alzheimer-type nursing home residents, is based on a developmental theory that in old age, when controls loosen, disoriented, very old persons need to express buried emotions in order to die in peace. This final life struggle is called "Resolution."

Validation techniques are based on the principle that when emotions are suppressed they fester and can become toxic. When emotions are expressed to someone who listens with empathy (Validation), the person is relieved. Validation Therapy uses fifteen verbal and nonverbal techniques to communicate with those very old elders diagnosed with an Alzheimer-type dementia and includes a method for forming Validation Groups with time-confused elders. Validation Therapy assumes an attitude of respect for old people diagnosed with a dementia.

Validation is an interdisciplinary helping method. The goal of Validation is to improve the quality of life. Nonverbal Validation techniques such as "music" and "mirroring" often restore dignity and well-being for early onset Alzheimer populations. Administrators, nurses, social workers, psychologists, physical and occupational therapists report significant improvement after six months of Validation Therapy with late onset Alzheimer populations. Results include decreased staff burn-out, increased communication between nursing staff and disoriented residents, decreased agitation, increased family visits, less movement to "Vegetation," fewer tranquilizing medications, and increased communication within Validation Groups (Blumenthal, 1999; de Klerk-Rubin, 1994; Feil, 1993; Fine & Rouse-Bane, 1995: Lewis & Feil, 1996; Sharp, 1999).

Verbal Validation Techniques

Verbal Validation techniques restore well-being to older people in Phase One of Resolution, "the Maloriented." These individuals are mostly oriented to time and place, have no history of mental illness, are verbal, but repeat things that are not true in present time and often accuse others, projecting their frustration. The Maloriented use present day people to vent emotions that they never could express to important people in their lives in the past. In response, the Validating caregiver recognizes that the older person must use symbols (people or things in present time that substitute for people from the past) to express emotions. The Validating caregiver must accept the Maloriented where they are, and let them heal by venting to someone who listens with empathy.

A caregiver full of hurt cannot listen with empathy. Step One in Validation means that the caregivers free themselves from their own emotions, so as to enable them to accept the emotions of the older person and feel what they feel. The caregiver must step into the older person's shoes by "Centering." Verbal validation techniques for the Maloriented include:

Breathe deeply, inhaling from the nose and exhaling from the "Center" (a spot about three inches below the waist).
Avoid "feeling" words. Ask non-threatening factual questions: Who? What? Where? When? How? Avoid asking "Why."
Rephrase, repeating their key word, picking up their tempo.
Reflect the look in their eyes.
Listen to their verbs. Use their preferred sense. Speak their language.
Ask the extreme: "How bad?" "How often?"
Reminisce.
Help the person find a familiar coping method.

The following is an example of an interaction using verbal validation techniques:

The nurse examines a 90 year old who is physically not hurting, but always complaining: "My back hurts. I have a pain in my chest. My neck hurts. I wish I were dead."

The Validating nurse builds trust, and helps this old woman express her psychological pain.
The woman is terrified of dying alone. Using the kinesthetic sense the nurse asks, "Does it feel like a hammer pounding on your head, or is it more like a dull ache?"

The woman responds (loosening her grip on the nurse s and relieved to be understood), "Yes. Just like a hammer. That s right."

The nurse (asking the extreme), "When is the pain the worst?"

The woman responds, "It hurts all the time, but at night, when I m alone, the pain is horrible."

Rephrasing and reminiscing, the nurse asks, "When no one is with you, does the pain get worse? Have you ever had this terrible pain before?"

As the 90 year old woman begins to trust, her voice becomes less harsh and shrill, demonstrating that she feels safe. "When my husband died, I had the same pain in my head."

The nurse then attempts to find a familiar coping method: "How did you stand it when he died? What did you do?"

The woman responds, "I listened to the Strauss waltzes we danced to. We loved to dance. That s how I got through the night."

The nurse provides an answer, "I can get you some Strauss waltzes. When the pain gets bad, turn on your tape recorder. If you need me, I ll be here."

The woman responds, relieved, "You re a sweet girl. You can go now, honey. I know you have other people to take care of. But you ll come back with the waltzes?"

The nurse keeps her promise and the older woman complains less. She is not cured, but she trusts the nurse and is no longer so afraid to be alone. This Validating communication took five minutes. Validation does not take much clock-time, but it does take energy, focus, and caring. These techniques have been documented in videos (Fell, 1997).

Nonverbal Validation Techniques

Those in Phase 2 of Resolution, "the Time Confused," are very old people with more physical deterioration. They can no longer tell chronological clock-time. They go by memories, not minutes. Their emotions spill. They lose social controls. They retreat to the past, partly because they are no longer able to tell present time and partly because they need to restore the past to resolve it before they die. The Validating caregiver accepts the physical deterioration and psychological needs, using both verbal and nonverbal Validation.

Actions involved in nonverbal validation include:

Observe the emotion.
Say their emotion with the same emotion.
Genuinely minor their movements.
Use close, genuine eye contact.
Touch the patient using soft movements, for example the "Mother's touch" is a gentle, circular motion on the upper cheek.

The following conversation is an example of an interaction using nonverbal validation techniques:

An 88 year old woman screams, "Get out of my way. I have to see Mother."

The physical therapist, mirroring the woman s anxiety and moving with her responds, "Has something happened to your mother?"

The older woman responds, "Yes. She is sick. She s all alone. I have to help her."

The physical therapist, while gently touching the old woman on the upper cheek, using close eye contact, mirroring her fear, responds, "Are you afraid that you ll lose her?"

The older woman, in response, stops moving, looks close into the physical therapist s eyes, nods her head and cries, "I lost her. She died."

On a deep level of awareness, the old woman knew that her mother was dead. She had buried that knowledge. Now, in old old age, she restores her mother to express her grief. The physical therapist shares her grief. Crying brings relief. Within four minutes, the time-confused woman smiles at the physical therapist, "You're a nice girl. I like you."

Each time the time-confused woman needs to see her mother, she is Validated. After three weeks, she no longer looks for her mother. Her feelings have been expressed and she is relieved.

In Phase 3, "Repetitive Motion," older Alzheimer s patients may have lost speech, but still retain the human needs to express emotions and feel safe and useful. They use movements of lips, tongue, teeth, jaw, and body to express needs despite the inability to communicate those needs in a way that is understandable to caregivers. Nonverbal techniques that can assist in the Validation process with older adults in Phase 3 include music and ambiguity. Music, especially childhood songs with emotional memories, can help those in Repetitive Motion to express emotions. Ambiguous responses including vague pronouns and numbers can provide safe options for patient-caregiver interactions.

The following is an example of an interaction using nonverbal Validation techniques with an individual in Phase 3:

A 94 year old says, "He titled on the beetlebum."

The caregiver responds using ambiguity. "Did it hurt him?" (him is an ambiguous pronoun).

The 94 year old responds laughingly, "No. We twiddled all the time."

The older adult and the caregiver laugh together, singing, "A Bicycle Built for Two."

The 94 year old communicates until she dies.

Using vague pronouns to substitute for unique word combinations in Phase 3 stimulates interaction and prevents withdrawal inward. As a result, the individual s emotions and human needs are met resulting in a death with dignity.

—NAOMI FEIL

Article from The Encyclopedia Of Elder Care: The Comprehensive Resource On
Geriatric And Social Care; Mathy D. Mezey, RN, EdD, FAAN,Editor-In-Chief

Barbara J. Berkman, DSW Christopher M. Callahan, MD, Terry T. Fulmer, PhD RN, FAAN. Ethel L. Mitty, RN, EdD, Gregory J. Paveza, MSW, PhD, ACSW, Eugenia L. Siegler, MD, FACP, Neville E. Strumpf, PhD, RN, FAAN, Associate Editors

Melissa M. Bottrell, MPH, PhDc, Managing Editor