American Journal of Alzheimer’s Disease and Other Dementias
Volume 19, Number 2, March/April 2004
To the editor:
It is always inspiring to learn that a professional journal is discussing the Validation Method,®1-4 and we appreciate the initiative and caring that inspired Barry Zeltzer’s recent editorial on the theory (November/ December 2003). However, we are writing to express concern over important inaccuracies in his article. Dr. Zeltzer states, “For me, the best approach [when a patient is regressing back to childhood] has been to adopt the principles of validation therapy, in which one agrees with the patient, even if that means telling a lie.” If he had explored the validation principles in more depth, he would have learned that what we practice is not “therapeutic lying” nor diversion. We do not believe that any kind of lying can be therapeutic.
The principles of validation are as follows:
- Clients should be accepted as they are.
- All people are valuable, including those who are maloriented or disoriented.
- There is a reason behind the behavior of very old, disoriented people.
- Very old maloriented or disoriented people are in the final stage of life resolution, and are trying to resolve unfinished life tasks, crises, or other business.
- When recent memory fails, older adults try to restore balance to their lives by retrieving earlier memories.
- When eyesight fails, the very old use the “mind’s eye” to see. When hearing goes, they draw on sounds from the past.
- When present reality becomes painful, some clients survive by retreating and accessing memories from the past.
- Painful feelings that are expressed, acknowledged, and validated by a trusted listener will diminish; painful feelings that are ignored or suppressed will gain strength.
- Listening with empathy builds trust, reduces anxiety, and restores dignity.
- People live on several levels of awareness, often at the same time.
- Feelings experienced in the present can trigger memories of similar feelings experienced in the past.
Validation theory tells us that it is normal and age- appropriate for the very old to return to the past to resolve unfinished business or life struggles before they die. The principles outlined above are supported by theoretical assumptions from behavioral, analytical, and humanistic psychology.
The principle related to being truthful to persons with dementia is that people experience several levels of awareness, often at the same time. This theoretical assumption is supported by Freud’s postulation that there are several layers of consciousness. This means we do not lie to persons with dementia, because we know that on a deeper level they will recognize it as such. Another principle of validation is that human beings see with the “mind’s eye.”
Older persons use this method to restore someone from their past in order to resolve an unfinished relationship or to fulfill an unmet need. In the moment, the old person may see a mother who has died. He or she may need to talk to the mother, perhaps to vent a strong emotion that has lain dormant or perhaps to simply feel nurtured, secure, and loved again. But on another, deeper level of awareness, the person knows his or her loved one is dead.
Consider the following interaction between a validation worker and an 86-year-old gentleman that takes place in an assisted-living dementia-care center. He is found walking down the hallway, crying and asking various people if they had seen his mother. The validation worker asks him,
“You miss your mother and want to see her?”
“I wish I could see her right now. Where is she?”
“Tell me about your mother. What does she look like?”
“She was beautiful and she was good to me. She took good care of me,” the resident answers. The validation worker continues asking factual questions: who, what, when, and how. “What kind of things did she do for you?”
“She did everything. She took care of me, and I need to see her now.”
“Was she a good cook?”
The resident’s crying becomes more intense. “You ask me if she was a good cook. She was a great cook, but all she ever made was oatmeal. My father, the no-good drunk, spent most of his pay every week on booze, and many times all she could fix for us was oatmeal. But she made the best oatmeal; it was sweet and buttery, and she knew how to make it many different ways.”
The validation worker continues to listen empathetically.
“She took good care of us, but he was no good.” The resident pauses. “You must think I’m crazy, an 86-year-old man looking for his mother. I know she’s gone.”
In this particular case, the resident not only knows his mother is dead, but after his search for her is validated, he verbalizes that knowledge. Although the intention of validation is not to bring a person back to reality, this sometimes occurs. The most important outcome is that the person is helped to express his feelings, and these feelings are acknowledged by an empathic, trusted caregiver. Acknowledging the older person’s reality in order to enter their world with empathy is not lying.
When a 90-year-old woman demands to see her mother, the validation worker does not agree that the woman’s mother is alive and say, “She’ll be here soon. Have some cookies while you wait.” The validation worker does not divert or redirect the woman, nor does he or she argue and admonish, “Your mother died long ago.” Instead, he or she helps the woman express her need for her mother: “Is something wrong with your mother? Is she sick? What do you want to tell her right now?” The validation worker gleans the facts, speaking in the same tense as the old person and going where the person is at that moment. Perhaps some people think validation theory condones lying, because validation workers often speak to those they’re assisting in the present tense.
For example,they might ask, “What is the color of your mother’s eyes?” rather than “What was the color of your mother’s eyes?” This is not lying; rather, it is accepting that the old person has returned to the past and sees his or her mother clearly in the mind’s eye.
Validation teaches that we never lie to persons who have dementia, because we need to establish their trust if we are to validate their feelings. When we lie, we lose that trust. To illustrate, an 80-year-old woman with early-stage dementia is admitted to an assisted-living facility. Her family tells her she is going to stay there for a few days until they return from vacation, then they will return to take her back home. The woman holds on to this statement, repeatedly asking caregivers when her family is going to return to take her home. If the family had been honest with her, the transition, although difficult, would ultimately have gone more smoothly, because the woman would have been treated with honesty and respect.
In another example, a resident asks for his wife, who is dead. The caregiver replies, “She’ll be here to see you later.” The resident may not be able to remember much, but he clings to this statement. Day after day, he asks, “When will my wife get here?” His caregivers continue to lie, and in time, he loses trust in them, because he knows what they say is untrue. If the caregivers in this example had been trained in validation, they would have encouraged the resident to talk about his wife, mirroring his emotions and encouraging him to express his needs. They would have accepted the fact that there was a reason behind his repeated requests for her, and it was not simply a matter of his “forgetting” his wife was dead. He needed to grieve for her, and he needed his caregivers to help him resolve that grief in an honest and empathetic manner.
When emotions are expressed and someone listens with empathy, the feeling is relieved. Don’t all people with dementia deserve to be treated with dignity and respect and to be listened to instead of lied to?
We hope this letter helps clarify the validation concept, which was misunderstood and misstated.
Sincerely,
Naomi Feil, MSW, ACSW
Executive Director, Validation Training Institute
Cleveland, Ohio
Rita Altman, RN, BSN
Director, Country Meadows Retirement Community
Hershey, Pennsylvania