Using Validation Therapy to Manage Difficult Behaviors

by Jan Allen, CSW, MSE
More About Jan. . .

REFLECTION

As a caregiver, you have been introduced to a new and different world - the world of dementia. People who inhabit the world of dementia are in a very different place than those of us who live in "Reality" (whatever that is).

1. Time in the world of dementia operates completely differently than time does for the rest of us. First, time is not sequential in the dementia universe. Time can be present at one moment, past at another and future at another. Time has absolutely no continuity.

2. Memory is very different in the world of dementia. Past may be confused with present. Memory may be there one moment and gone the next. The mind plays hurtful tricks in the world of dementia - making a known and loved child or spouse into a stranger to be feared. Family may no longer be family. As much as we in the "Real" world know that this is our mother or wife or husband, the person in the dementia world does not know these "Realities". S/he only knows what they know at any given moment. It is so hard to accept their dementia world.

It is so different from what we know in the "Real" world. Yet, there is no successful alternative but to accept whatever the dementia person claims as their reality - no matter how untrue it is to us. There is no successful way to "force" a person with dementia to join the "Real" world. In my experience with older persons, the most frustrated caregivers I have observed are the ones who have not accepted this simple fact: the world of dementia is defined by the dementia victim. We in the "Real" world do not define it. We can only hope to live in it somewhat peacefully IF AND ONLY IF we accept this dementia world on the terms of the person with dementia. If they "see" a rabbit on the couch, they see it. If you are not their spouse, you are not. If it is breakfast time, it is breakfast time (even at 6 p.m.).

Telling the dementia person that "I am too your wife" or "No, John, it IS NOT Friday. It is Sunday." Or saying, "Sally, you don't have any little babies. You are 85. Your babies are all grown up" - these kinds of statements from the "Real" world almost always serve only to upset and distress the dementia person. However, if you say something like, "If you say so, but I'd like to be your friend. . ." or "It's your Friday, huh? What do you do on Fridays?" or "Sally, tell me about your babies."

3. Emotions are also very different in the dementia universe. First, consider that the dementia person's reasoning abilities are very limited or perhaps gone completely. There are actual changes in the brain that affect a dementia person's ability to think. So, they are somewhat like a pre-schooler in their ability to assess, judge, make decisions, etc. Most dementia folks have some difficulty in understanding the spoken language. However, almost all dementia folks can easily pick up on the FEELINGS being expressed. It is very true that in the dementia universe, it is NOT so much what you say, but HOW you say it. When frustration, anger, and loudness creep into your voice, the dementia person is going to feel that much more strongly than the actual words being said. I tell caregivers that if you want to be less stressed, then try to literally become a part of the world of dementia.

Obviously, you have to limit your involvement to safe activities. If your loved one is engaged in some activity that might be harmful to them, you will have to step in and take direct action. However, in most cases, that is not where the frustration comes in for the caregiver. What I have observed is the frustration comes in with more mundane, every day sorts of activities that just don't happen logically, sequentially or "on time" any more. Even if you have never been late to church in 49 years, in the dementia universe, you may arrive at church during the sermon. You may leave before the final hymn. You loved one may "dine" while walking around the house, rather than at the table. Your mother may think you are HER MOTHER! As a caregiver, can you accept these events in the dementia universe? If you can accept that time is different, memory is different, and emotions are different, YOU as a caregiver will be much happier than constantly trying to squash the dementia person into the "Real" world mold that s/he now knows little or nothing about.

VALIDATION THERAPY

A very popular form of conversation with dementia persons is the use of a program called validation therapy. It was originated by Naomi Feil and she has trained many professionals in nursing homes and other health care settings to use the techniques with clients. I think validation therapy can be very helpful to caregivers as well. Here is my modified version.

First, the idea behind validation therapy is to "validate" or accept the values, beliefs and "Reality" of the dementia person - even if it has no basis in your reality. So, if a 67 year old man says that he is a sophomore in high school has to go to the high school so he can run the 100 yard dash in the track meet - validation therapy says, "OK." Here is an example of how a validation therapy conversation might go with a person with dementia.

Chuck: "I have to find my car keys."
Me: "Your car keys..." ( I don't tell him he doesn't have a car and he hasn't driven for years)
Chuck: "Yes, I need to get home - lot's of work to do, you know!"
Me: "You are busy today?" (I don't tell him he is at adult day care and isn't going home for hours)
Chuck: "Hell, yes. I'm busy every day, girlee."
Me: "You like being busy?" (I'm trying to find a topic of conversation that he might accept discussing)
Chuck: "What planet do you live on? I didn't say I LIKED it. I just have to work - like most of the rest of the world, ya know?" (He's getting a little frustrated, but seems to have forgotten the keys.)
Me: "I know about work, Chuck. I do some of that myself. In fact, I'm getting ready to fix some lunch for us. Care to join me?"
Chuck: "Lunch, huh? What are you having?"

Or:

Agnes: (cheerfully) "Well, goodbye everyone." (And she heads out the door)
Me: "Goodbye, Agnes... (I DO NOT tell her "no" or try to stop her right away. I have found that if you give dementia folks just a little room, they will sometimes stop and turn around on their own without a fight. I wait a moment, knowing she will wonder which way to go when she gets out the door), then I say very cheerfully, "Oh Agnes, just a minute... you forgot your craft!"
Agnes: "My craft???" (I walk toward her smiling with her half painted soda bottle/vase)
Me: "Yes, this one has your name on it. Too bad, though, it seems to be not quite finished"
Agnes: "Is that mine?"
Me: "Yes, the colors you selected are just wonderful.. Would you like to finish painting the other side?" (I make a point of looking at my watch.) "We have time, I think?"
Agnes: "No, I have to go."
Me: "Well, ok. Where are you headed?"
Agnes: "Home, of course."
Me: "Home. Isn't it great to have a place to call home. Let's see, I think you live in Amboy. That's about 15 miles from here...."
Agnes: "How do I get out of this place?"
Me: "Well, you usually get out of here when you husband comes to get you. He knows you are here."
Agnes: "Lonnie knows I'm here."
Me: "Sure, he brought you here to this club so you could have some fun time out of the house. He thought you might like being here. In fact, he told me that you really like to paint."
Agnes: (looking out the door that she has slowly been walking toward) "It looks cold out."
Me: "Yes, it is" (I open the door so she can feel the cold air coming in if I had tried to block the door, she would most likely try to walk past me; but when I open the door for her, she "realizes" that I am not trying to keep her against her will - even though that is exactly what I am trying to do because I know it would not be safe for her to try to walk 15 miles home in the cold. There have been times I have actually walked outside or around a building with the person - if it gives them some comfort that I am not going to "make" them stay with me. Usually, after a brief time outside, they will come back in on their own as if it's their idea) "Brrr..."
Agnes: (pulls back when she feels the cold air.) "I guess I need my coat..."
Me: "Agnes, I am sure I saw Lonnie with your coat. He'll bring it to you when he comes to get you. And, he'll have that car all warmed up. That will be nice, huh? To get into that nice warm car when Lonnie comes."
Agnes: "When is Lonnie coming?"
Me: "He said about 2. Let's see (I look at my watch again), it's 11:30 now. So, he'll be here pretty soon. After lunch. Shall we head back to the lunch room?"
Agnes: (she has already turned around and begun walking away from the door)

The key is to "agree" with what they want but by conversation and "steering" get them to do something else without them realizing they are actually being redirected. This is both validation and redirection therapy.

Does this always work? NO! But it has a pretty high success rate because it is so non-confrontational. If you can avoid direct confrontation, you will be much happier and so will the dementia person. I know that sometimes a direct confrontation is needed; but I see those confrontations occur far more often than they need to.

For example, one caregiver told me that her spouse loves to re-arrange the cupboards and it was driving her crazy trying to stop him. My question was, "Why are you trying to stop him?" It sounded like a relatively safe and benign activity to keep her spouse busy. I realize that opening a cupboard and seeing the toaster in a different place every couple of hours might be a little unsettling; but think of all the stuff you can be doing while the cabinets are getting re-arranged! So, maybe it's a reasonable trade-off to have to look for a few things every day.

One caregiver I know was really getting frustrated with her spouse "underfoot" all day long. She knew he had once loved woodworking; but could no longer safely use power tools. So, she had her son set up a "safe" wood shop for his dad. They put it in the garage where the wife could easily keep an eye on him, and the son put all sorts of "safe" tools, sand paper, tape measures, hammers, screws, etc. out on the workbench. Every morning, the wife would pack a lunch for her spouse, and give it to him and tell him he had to go to work. She sent him to the garage where he had pencils, paper, markers, brooms, shovels, dirt, seeds, tools, etc. to mess around with. She made sure he ate his lunch. Sometimes she even "came to his work" and joined him for lunch. This made a huge difference in her tolerance level - and helped her spouse as well.

There is a proven link between boredom and agitation. It is sometimes very challenging to keep a person with dementia busy; but it is worth thinking about how to do that so that they have some opportunity for "failure free" activities that will alleviate boredom and help them to have some meaningful "work" to do.

REDIRECTING

Redirecting is a simple technique of appearing to agree with the person; but getting them to go in a different direction (physically or conversationally) without them thinking they are being pushed into it.

Chuck: "Is there a phone here I could use?"
Me: "Yes." (But I don't show it to him or indicate where it is)
Chuck: "I need to call my daughter. She seems to have forgotten me."
Me: "Oh. You know, Chuck, I spoke with your daughter this morning."
Chuck: "You did?"
Me: "Yes. She said that the bus was going to bring you here today - and it did! Isn't that great the way those busses go all over the county?"
Chuck: "But she's late."
Me: "Well. I think the bus will take you home. At least that's what your daughter told me. Did you know she arranged this lovely bus for you?"
Chuck: "She did?"
Me: "Yes, she did. What a great gal that daughter of yours is."
Chuck: "I think I should call her."
Me: "Say, which way were you headed? I think they are getting lunch ready over here. Are you hungry?"
Chuck: "No. I want to call my daughter."
Me: "Ok. Well, say, let's eat and then we can see if she’s around."
Chuck: "I really want to go home."
Me: "You want to go home."
Chuck: (by now he is at the lunch table and looking at the nice meal) "What?"
Me: "That lunch sure looks good. Did you want to sit here or here? Good, I’ll sit next to you here."
Eventually Chuck has forgotten the phone in light of the sight and smell of lunch.

Validation Therapy Resources (off-site links):
- About Naomi Feil (from the Validation Training Institute)
- The Validation Training Institute
- Principles of Validation (adapted from Naomi Feil's book)
- The Validation Breakthrough: Simple Techniques for Communicating with People with Alzheimer's-Type Dementia (link to Amazon.com with 23 pages of excerpts and indexes)

Related Articles (from ElderCare Online and ALZwell):
- Management of Agitation Behavior
- Managing Behavior Problems
- When Your Loved One Resists Care
- Maintaining Selfhood and Dignity in Patients With Alzheimer's Disease
- Edyth Ann's Caregiving Tips

Recommended Reading (from our Bookstore):
- The Alzheimer's & Dementia Care Bookshelf
- The Validation Breakthrough: Simple Techniques for Communicating with People with Alzheimer's-Type Dementia (link to Amazon.com with 23 pages of excerpts and indexes)
- Therapeutic Caregiving: A Practical Guide for Caregivers of People with Alzheimer's Disease by Barbara Bridges
- Alzheimer's Early Stages: First Steps in Caring and Treatment by Daniel Kuhn
- The Complete Guide to Alzheimer's-Proofing Your Home by Mark Warner

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