Dementia Insights: The Validation Method for Dementia Care - Practical Neurology (original) (raw)

Physicians and Caregiving

Both as trainees and in practice, physicians receive relatively little education on interacting with and managing the health care of elderly individuals living with cognitive impairment and often find themselves inadequately prepared.1 Nurses, social workers, gerontologists, health care administrators, and allied health care professionals are more likely than physicians to enroll in the advanced clinical dementia practice educational programs that have been developed.2

Medical education, being rather insular, includes little to no training from the fields of nursing, social work, gerontology, or the allied health professions. As a result, the theory, methodology, and practice of caregiving is not part of the educational experience of most physicians. Disease-focused, evidence-based paradigms that are the primary pathway to learning and proficiency across traditional medicine, may undervalue the clinical experience of physicians and nonphysician health care professionals, and, thereby, the art of healing, marginalizing qualities of caregiving that could foster patient well-being.3

Dementia Care

Physicians’ resulting limited acumen related to the more human aspects of dementia care becomes more problematic considering that cures and effective treatments for Alzheimer disease (AD) and other dementias remain elusive. This, coupled with increasing rates of burnout and career dissatisfaction,4 contribute to situations in which neurologists may, for reasons of self-preservation, unintentionally avoid engaging with dementia patients, thereby missing opportunities to help them live as well as possible and to provide adequate support for their caregivers.

Atul Gawande, physician author of Being Mortal,5 writes that, for a clinician, “nothing is more threatening to who you think you are than a patient with a problem you cannot solve.” For this reason, Gawande notes that often, “medicine fails the people it is supposed to help.”⁵ Acknowledging that solutions are lacking for clinical problems is difficult for physicians, and places them in the often-unfamiliar territory of vulnerability. Yet, such a state can clear a space for presence, defined in this context by Kleinman as “the intensity of interacting with another human being that animates being there for, and with, that person, a calling forward or a stepping toward the other.”3 Presence, asserts Kleinman “is built out of listening intensely, indicating that the person and their story matter,” the ongoing practice of which, he posits, “sustains clinical work over the long and difficult journey of a career in medicine,” and defines the essence of caregiving.3

In the case of persons living with dementia, this both requires and increases empathy as well as understanding the complex ways dementia manifests in the lives of patients. Required skills include effectively communicating with persons whose language may have diminished and a grasp of the essential elements of personhood and life story. With those skills, it becomes possible to find the meaning in often misunderstood responses of people with dementia to the inner and outer challenges with which they are confronted.

The Validation Method

Development of the Validation Method

Such a seasoned, thoughtful, nuanced approach requires access to the wisdom, experience and knowledge of a master teacher. Naomi Feil, iconic founder of the Validation Method (Box), is just such a teacher. Physicians, in general, and neurologists, in particular, should become familiar with the principles and practice of the Validation Method as a means to improve the quality of care they are able to provide elders living with dementia as well as support for their caregivers.

Evidence for the Validation Method

Throughout the 1980s, Feil’s presentations of the Validation Method and its positive impacts gained attention in the US and Validation Therapy was becoming more widely known. During that period, research by Alprin, Peoples, Babins, Fritz, Dietch, and Sharp demonstrated that validation in elders with dementia increased communication and positive affect, reduced aggressive behavior, and lowered use of psychotropic medications.7-14 Additionally, caregivers were noted to feel more capable of handling difficult situations and experience more pleasure in their work.

In more recent research, the Validation Method combined with sensorial reminiscence found significant improvements for behavioral disturbances compared to controls in one study,¹⁵ and another found that Validation was associated with decreased agitation, apathy, irritability, and night-time disturbance.¹⁶

Ongoing research on the Validation Method adds to an emerging body of evidence that eye contact and physical touch, 2 elements of engagement that build trust in caring relationships, and essential components of Validation, have neurochemical effects that are conducive to neuroplasticity and resiliency.¹⁷ A new international research project at sites in The Netherlands, Australia, Israel, and Germany will measure dopamine, cortisol and serotonin before and after Validation sessions, to further elucidate the biological underpinnings of the Method’s observed effects.

Principles of the Validation Method

The Validation Method principles have essentially remained the same since Feil wrote them in 1982:

1. All very elderly people are unique and worthwhile.

2. Disoriented elders should be accepted as they are; we should not try to change them.

3. Listening with empathy builds trust, reduces anxiety, and restores dignity.

4. Painful feelings that are expressed, acknowledged, and validated by a trusted listener will diminish, whereas painful feelings that are ignored or suppressed will gain in strength.

5. There is a reason behind the behavior of very elderly adults with cognitive losses.

6. Basic human needs underlie behavior of disoriented very elderly people and include:

• to resolve unfinished issues, in order to die in peace;
• to live in peace;
• to restore a sense of equilibrium when eyesight, hearing, mobility, and memory fail;
• to make sense out of an unbearable reality by finding a place that feels comfortable, where one feels in order or in harmony and where relationships are familiar;
• to be recognized for status, identity, and self-worth;
• to be useful and productive;
• to be listened to and respected;
• to express feelings and be heard;
• to be loved and to belong;
• to have human contact;
• to be nurtured and feel safe and secure, rather than immobilized and restrained;
• to have sensory stimulation: tactile, visual, auditory, olfactory, gustatory, as well as sexual expression; and
• to reduce pain and discomfort.
  In order to satisfy their needs, people are drawn to the past or are pushed from the present to resolve, retreat, relieve, relive, and express.

7. Early learned behaviors return when verbal ability and recent memory fail.

8. Personal symbols used by disoriented elderly are people or things in the present that represent people, things, or concepts from the past that are laden with emotion.

9. Disoriented elders live on several levels of awareness, often at the same time.

10. When the 5 senses fail, disoriented elderly people stimulate and use their ‘inner senses,’ seeing with their ‘mind’s eye’ and hearing sounds from the past.

11. Events, emotions, colors, sounds, smells, tastes, and images create emotions that trigger similar emotions experienced in the past. Elders react in the present as they did in the past.

If these 11 principles are embodied, contact and communication with elders has been shown to become easier and more joyful for the caregiver and the person receiving care. Persons who are living with cognitive decline gain benefit through this kind of loving contact.

Mindfulness

Mindfulness is inherent to the Validation Method and can build the proper framework for implementing the Validation Method most effectively. Mindfulness has been defined by John Kabat-Zinn as the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.18 When the principles of the Validation Method are applied, attention is focused nonjudgmentally on another person, bringing them fully and deeply into the present moment. By acknowledging another person in this way, a trusting relationship is built.

Putting the Validation Method to Use

As shown in the Figure and demonstrated in the Case Studies, the Validation Method can be seen as a tripod of theory, techniques, and attitude. Each leg of the triangle is dependent on the others. If only the basic attitude is used, there will be good contact but little communication. If techniques are used without the validating attitude, they are sterile and often ineffective. Likewise, if attitude and techniques are used without goals, the method often goes wrong. It is only when all 3 elements are in place that contact and communication can easily flow.

Figure. The Validation Method requires a basic nonjudgmental, empathetic, honest, and respectful attitude in combination with theoretical understanding and application of specific techniques.

Practitioners of the Validation Method do not judge or correct false attributions and enhancement of memories. These are believed to be expressions of needs and feelings that are validated. Such validation enhances the individual’s sense of identity and acceptance. If an elder says they are hungry just after eating a large breakfast, we understand that ‘hunger’ is understood to represent something other than physical insatiety due to desiring food. A practitioner might ask, “Where do you feel the hunger? Is it a pang or an ache? What would fill that empty space?”

Techniques

The following techniques should be learned as prerequisites for effective and empathetic communication.

Centering. Clear away thoughts and feelings that interfere with making contact with others. Centering will help one find moments of peace, gather energy, and clear away the emotions of self and others that a person, themselves, may be experiencing.

Observation and Calibration. Exquisitely observe others, picking up clues about their current emotional state (ie, taking their “emotional temperature”). The next step to finding empathy is to match or calibrate yourself to these observations.

Respectful Tone of Voice. By using an adult-to-adult vocal tone, respect is given, helping to build a trusting relationship.

Respectful Eye Contact. Staying at eye-level, approaching from the front or slightly diagonal (if that is most appropriate) and using as much direct eye contact as the other person needs in the moment also conveys respect and builds trust.16

Appropriate Distancing. It is important to discover an appropriate distance because getting too close can create anger or fear, whereas staying too far away can block good communication. Finding the appropriate spot builds a warm connection.

The other verbal and nonverbal validation techniques are drawn from many different sources and are used like herbs when cooking. Recognizing and using the most appropriate techniques for each individual at the moment of contact is the skill set developed in Validation Method training courses.

Conclusion and Additional Resources

The principles and techniques of the Validation Method can help physicians and other health care professionals provide better care to elderly persons who are living with dementia, and also give physicians a helpful resource that may be shared with caregivers and families. Additionally, making use of the Validation Method’s attitudes, theories, and techniques may improve relationships with elderly individuals who are living with dementia and their care partners, thereby bolstering physicians’ satisfaction with their work and helping to combat burnout.

For those interested in learning more about the Validation Method or who are seeking educational or training opportunities, the following resources are available.

• Validation Training Institute (VTI)
• VTI YouTube channel
• Interview with Naomi Feil by neurologist, Daniel C. Potts

VdKR and DCP report no disclosures