What is Validation Therapy?
This post has been a long time coming.
Back in October 2017, I attended the 17th Alzheimer’s Australia National Dementia Conference in Melbourne, Australia. Wanting to get the most out of my attendance, I enthusiastically enrolled in a pre-conference workshop with American Social Worker Naomi Feil, the developer of the therapeutic approach called ‘The Validation Method’. I first came across Naomi Feil’s work when I was working on my honours thesis. I was ‘procrastaYouTubing’ one day, and came across this video. You will likely have seen it if you work in aged care, or nursing roles:
I discussed my intent to attend Naomi Feil's workshop with a colleague in dementia research, and they somewhat skeptically giggled, and told me, “None of it is research-informed”. I thought that this was a harsh criticism, given the obvious connection I had seen Naomi forge with Gladys Wilson in the video above. Clearly, something was going on. So, I maintained my enthusiasm and suspended my judgement.
Naomi's father was the director of an aged care home back in the days when the director would live on site. Naomi told us of her childhood, growing up with the older people as some of her closest friends. She would go off to school, and run home to tell her friends what she learnt that day. Having started this work in 1956, she has dedicated much of her life to development and dissemination of her therapeutic method.
Naomi is an excellent presenter. She told us that she once had a dream to become an actor. She now puts her acting skills into her passionate and engaging public talks. She calls this approach 'performative storytelling'. Her therapeutic method is founded on validation and acceptance of the reality of another individual, and was designed to assist with management of repetitive motions and behaviors associated with disorientation in older adults. This method contrasts directly with reality orientation therapy (as discussed by Spector, Davies, Woods, & Orrell, 2000), in which cues are used to redirect or reorient the individual with dementia to some ‘true’ or objective reality.
Built on the assumption that reality as it is experienced by an individual with dementia differs to some extent from that of the general population, Validation Therapy encourages the partner without dementia to suspend their own reality in order to validate the personal reality of the person with dementia (I like to think of this as a partner without dementia adventuring on an ‘epistemic holiday’ with the person with dementia to their reality). In doing so, the individual with dementia is made to feel honored and valued, and this is thought to create a sense of trust and ease.
Below I have shared a couple of my personal thoughts about this method, both praises and concerns:
The overall outcome of the approach, of assisting older people to “live and die with integrity” resonates with me greatly.
I absolutely love the way Naomi connects with Gladys Wilson, a woman with Alzheimer's dementia, in this video. I think back to when my Nanny was in her nursing home, towards the end of her life, and reflect on the difficulties we as a family had in connecting with her. We would often give Nanny hand massages whilst talking to her about what was happening in our lives. Naomi’s approach, of being with the person with dementia, of joining them in their reality, really resonated with me when I first saw this video... and it still does!
She emphasises 'empathy not sympathy'. She suggests that we really need to feel with others, rather than feeling for them. I think this is a lesson we could take beyond aged care and apply in all contexts. It really is all about genuine connection. I can definitely get behind that philosophy.
As the presentation progressed, I became more and more uneasy about the assumptions underlying this approach. When it comes down to it, the approach rests on the (what I would call shaky) assumption that all behaviour and communication by an older adult is an expression of some sort of unresolved grief. She described how unresolved grief makes an older adult become more and more withdrawn socially. She described the phases that an older person will go through as a result of unresolved grief:
- Saying things that are not ‘true’- like a child
2. Time confusion
- Separate the seconds, minutes and hours
3. Repetitive motion
- Emotional learning stays- go back to mum
- How words feel
- Revert to child-like state
4. Becomes non-verbal/ movement replaces speech, vegetation- “the living dead"
There are many things that I do not agree with here. Firstly, many of these described behaviours are typical of people with dementia, but not of older adults with no neurological pathology (or disorder of another kind). The approach infers that 'the longer the grief is "bottled up" the further an individual goes into a reclusive state'. This does not account for the progression of symptoms that occurs over time, as dementia is, by it very definition, the progressive death of brain cells. In many individuals with dementia, changes in speech and other movement abilities occur as a result of the degradation of tissues required to perform those actions, not as a result of unresolved grief.
Secondly, some of these claims are indeed unsubstantiated. For example, the approach claims that people adopt repetitive behaviours, particularly oral or vocal behaviours, because they are somehow connected to the way words feel.
Thirdly, I always cringe at the inference that older people revert to a child-like state as they age. I have a whole blog-post in me about this... and it will come... but, in short, we desperately need to stop using this analogy. Older people are not children. They have a life history, a biography. They have long-established personalities, preferences and identities. They may adopt behaviours that are similar to what we associate with a child-like state, but they are very different from children.
And finally, the inference that the inevitable end is the 'living dead' is so damaging. Please see my earlier post about how the words we use affect the way people with dementia and their families see themselves. I will continue to talk about this.
Despite my concerns described above, and some significant concerns about the overall therapeutic effectiveness of this method in day-to-day care (Neal & Barton Wright, 2003), I think that concepts and strategies stemming from this approach could conceivably be applied in research with individuals with dementia. Often people with dementia are excluded from research, as they are widely thought to be unreliable reporters of their own history. Perhaps the reality of individuals with dementia, whatever that might look like, can be validated by using the methods described by Naomi Feil, thereby allowing for ongoing knowledge contributions from the individuals with dementia in the research process. We can use the methods Naomi describes to gain access to the realities of people with dementia. In doing so, we can begin to learn what it like to live with dementia, and in doing so, design systems and services to attend to these unique needs of people with all types of dementia.
Lets consider that :)
Further information about 'the Validation Method' can be found [HERE]. The Validation Training Institute provides training in the method and certification in its use, with branches established internationally.
Many thanks to Prof. Anne Kinsella, who provided comments on text that informed the development of this blog entry.
Feil, N. (1992). Validation therapy. Geriatric Nursing, 13(3), 129-133.
Feil, N. (1993). The validation breakthrough: Simple techniques for communicating with people with "Alzheimer's-type dementia". Baltimore, MD: Health Professions Press.
Neal, M., & Barton Wright, P. (2003). Validation therapy for dementia. Cochrane Database of Systematic Reviews(3). doi:10.1002/14651858.CD001394
Spector, A., Davies, S., Woods, B., & Orrell, M. (2000). Reality orientation for dementia: A systematic review of the evidence of effectiveness from randomized controlled trials. The Gerontologist, 40(2), 206-212.