Parsing Validation: Helping People Living with Dementia Maintain Self-Worth

Caregiver, patient expert
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Validation is a term often used to describe different approaches to helping improve the quality of life of people living with Alzheimer’s disease and other types of dementia. Webster defines the word as “recognition or affirmation that a person or their feelings or opinions are valid or worthwhile.”

I believe that all caregivers who practice any form of validation when caring for a person living with dementia aim for the same result. They want to help the person maintain their sense of self, and they want to lower the anxiety and stress that stems from the person living with dementia losing the ability to readily understand the world around them.

Many professionals and caregivers would strip down the above definition to the fact that caregivers and clinicians should never argue with someone living with dementia. The reason for this is that people living with dementia have a reality that is true to them. In my opinion, if this is all the caregiver learns, they’ve absorbed the core meaning of validation and will probably become a good caregiver.

Parsing validation as a general approach vs. a trained method

I engaged in an email discussion about this topic with Vicki de Klerk-Rubin, R.N. Certified Validation Master (CVM), and Executive Director for the Validation Training Institute. When I asked her for a definition of the Validation Method as taught by them, she wrote:

“Validation is a method for communicating with people who have late-onset Alzheimer's disease. It has three elements: a basic, empathetic attitude; a theory which gives principles for viewing the aging process; and both short-term and long-term goals for validation work, and verbal and non-verbal techniques that help us communicate.”

We then delved into the thick of the common misunderstandings that occur when the word validation is used loosely. De Klerk  objects to the terms that many professionals use when talking about validation, such as “fiblets” or “therapeutic lies.”  The purpose of this approach is to help the person living with dementia maintain self-esteem and not become agitated by arguments. My preference has always been to say that we are “joining them in their world,” but likely my own version is similar to what these professionals are teaching in workshops.

Validation with a small “v” or a capital “V”

It’s important to note that, in the following material, de Klerk uses a capital “V” when talking about the Validation Method. I use a small “v” for the other approaches frequently called validation.

When I asked de Klerk about “fiblets” and “therapeutic lies” she wrote:

“The most important misconception of Validation is that it has anything to do with the 'therapeutic lie.' Validation practitioners never lie. Period. One of the key principles of Validation is that people live on different levels of consciousness, often at the same time. This means that even when an old woman is searching for her mother, she knows on a deep level of consciousness that her mother has passed. The Validation practitioner accepts that this old woman needs her mother in that moment. Perhaps she needs love or security or comfort — basic human needs. This old woman calls out for mother to try to fulfill this need.”

Here is a scenario written by de Klerk:

Validation Worker (V/W) might ask: Where is your mother?

Mrs. Smith: She's at home. I need to go to her.

V/W: What does she give you? (moving close to Mrs. Smith's comfort zone)

Mrs. Smith: She takes care of me.

V/W: So you need someone to care for you right now?

Mrs. Smith: This place is terrible.

V/W: (matching Mrs. Smith's facial expression, body language, and voice tone, using empathy) What is the worst thing about this place?

“So as you can see,” de Klerk said, “Validation explores the personal reality of the client, never lying and never confronting.”

I can see this approach working wonderfully in the common circumstance where someone with Alzheimer’s continually asks to go home, even when they are home. The Validation Method is certainly something that I will point to when people ask me, as a columnist, about how to handle this situation.

However, not everyone with dementia has Alzheimer’s, and not every situation will be handled smoothly with the Validation Method, especially if the person isn’t trained in the approach.

Therefore, it seems to me that, as is usually the case, caregivers — and even clinicians — will need to receive all the training possible and then go with their gut when it comes to an individual situation.

An example of when the Validation Method is not likely to help

In our email exchange, I asked de Klerk about the following scenario. It stems from a discussion with some students in a gerontology class, where they use my book, “Minding Our Elders,” as a way to humanize caregiving. I found the student’s story interesting and told her I'd like to ask de Klerk how she would use the Validation Method to handle it.

Here’s the story:

The student was visiting a neighbor who had Lewy body dementia (LBD). The woman with LBD would look out the window at what was essentially a slough and see two men (who were not there). The woman's granddaughter had furiously told her no one was there. That response upset the woman, which is understandable. The visitor went and looked out the window and said: "Oh, I see them! What do you think they want?" The woman said, "They seem to think that this is a resort. They want to swim." The visitor said, "Well, that's silly of them!" The conversation went on and, by the end, both of them were laughing.

Obviously, the visitor "lied." In my opinion, she handled the situation exceptionally well because the woman who lived with LBD became relaxed, happy and felt "validated." I asked de Klerk if she could tell me how that scenario would have been handled using the Validation Method.

“Validation does not always work well with people who have LBD,” de Klerk said. “Their 'visions' come from a different place than when people who have late onset Alzheimer's see people and things from their past. People with late onset Alzheimer's often stimulate eidetic images to express emotions and needs. This is not true for people who have LBD.

“There is no one method that is effective with all people who have 'cognitive decline.' It is important to have many different skills and to know what works with which person.”

As a family caregiver who spent a decade trying to construct a better way of life for my dad, who had surgically induced dementia, I completely agree. Each situation is different. Alzheimer’s is only one type of dementia, and even then, I’m sure there are times when those who are well trained in the Validation Method are challenged. They would probably decide as they go which approach is most likely to work best at that moment. That is our common goal.

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