Validation Therapy and Dementia

Validation therapy was designed by Naomi Feil, a social worker who primarily worked with older adults. She specifically designed this therapy for use with adults over 80 years old with Alzheimer’s or other types of dementia and cognitive impairment.

Feil states that there are four stages of cognitive impairment ^[1]:

1. Malorientation: orientation to time and place is beginning to decline, but communication is still effective
2. Time confusion: sense of reality and memory are further declining, and able to communicate but in a simpler manner
3. Repetitive motion: very little orientation to time and place, and using repetitive actions to communicate, rather than words
4. Vegetation: inability to communicate or orientate

Validation therapy focuses on the needs of the person in each of these stages, informing caregivers how to use empathetic and helpful communication to allow the patient to express their needs and emotions. The idea behind this approach is to promote dignity, independence, and self-awareness, improve communication and self-worth, and reduce stress, withdrawal, and the need for physical restraint ^[2][3].

How does Validation therapy work?

Validation therapy is designed to improve trust between the person with dementia and the caregiver, to improve communication and understanding. If the caregiver can understand the intention behind speech and actions, and what is trying to be expressed, then they can effectively attend to the needs of their patient ^[3].

Validation therapy provides the caregiver with the tools required to accept their patient’s reality and respond with empathy, validating their experiences.

The premise of this therapy is based on 14 verbal and non-verbal techniques that can improve communication and understanding, helping the caregiver acknowledge and empathize with their patient’s feelings ^[1]. This then allows the patient to express themselves freely, thereby helping to reduce painful emotions.

The overall aim of this therapy is to increase self-worth, alertness, communication, social skills, sense of reality, and sense of humor, by reducing negative emotions and experiences. This then also helps to reduce behaviors such as crying, pacing, withdrawal, and aggression ^[2].

Validation therapy techniques

A summary of the 14 validation techniques outlined by Naomi Feil ^[1] are as follows:

1. Centering: Use a breathing exercise to bring attention to the self.
2. Nonthreatening and factual language: Rather than asking why something happened, ask who, what, how, when, to allow the patient to communicate about the experience rather than the feelings behind the experience. This helps to build trust and openness.
3. Rephrasing: Repeat in your own words what the patient has said, to show that they are being heard, validated, and understood.
4. Use polarity: Ask the patient to tell you the worst- or best-case scenario relating to their expressed concern, so that they can feel free to express extreme emotions and vent frustrations.
5. Imagine the opposite: When the patient states a concern or complaint, ask if there is a time that this issue does not occur. This allows them to try and find a solution for themselves, by considering the circumstances in which their issue does not arise.
6. Reminiscing: Use the words ‘always’ and ‘never’, such as ‘does this always happen?’, to prompt thoughts and memories of the past. (This can be used with technique 5.)
7. Eye contact: Maintaining eye contact during communication shows your patient that you are interested in what they are saying, helps to build trust, and encourages time and reality orientation.
8. Use ambiguity: If the patient says a word or phrase that is difficult to understand, rather than dismissing this as incomprehensible, ask vague or ambiguous questions to maintain communication and help them to express themselves.
9. Tone of voice: Always use a calm and clear tone of voice, avoiding harsh tones, to prevent responses such as anger or withdrawal.
10. Mirroring: Mirroring or imitating the behavior, actions, or emotions of the patient helps to build trust and orientate them to reality, particularly if they are unable to communicate verbally.
11. Link behavior to unmet needs: Often, people with dementia will give objects a symbolic meaning, acting behaviors toward this object that relate to love or the desire to be useful, or expressing an emotion. Understanding what they are trying to convey can help with meeting their needs.
12. Use preferred sense: Communication can be improved by understanding if your patient prefers to use sight, smell, touch, hearing, or taste as their preferred sense. When patients may not be able to express a preference, the therapist may observe their habits and surroundings for
13. Touching: Using therapeutic touch, such as touching the hand, face, or shoulder, can help to demonstrate compassion and caring, or aid in reminiscing about a loved one. Physical contact must always be appropriate and respectful, and it’s important to get consent fir However, some patients with dementia may not be able to give verbal consent, so proceeding with caution is the best route.
14. Music: Even people in the final stages of cognitive decline may still remember the songs from their past, and this may be the only way in which they can communicate. Music can be therapeutic in all stages, helping to lift mood, encourage social interactions, express emotions, and improve the relationship between the caregiver and patient.

How successful is validation therapy for dementia patients?

Research suggests that the use of Validation therapy has helped many dementia patients to cope with emotional distress, particularly with reducing agitation, which then reduces the need for medicinal intervention ^[4].

Similarly, it has been found to improve the ability for professional caregivers to respond to the emotional needs of their patients, which reduces patient’s feelings of depression and unwanted behaviors such as aggression ^[5].

The use of Validation therapy improves the relationship between the caregiver and their patient, which reduces feelings of caregiver burden and potential abuse towards patients, as well as expressions of anxiety and aggression from patients ^[6].

Other therapies to treat dementia

There are several other therapeutic activities and interventions used in the treatment of dementia, each of which focuses on individual aspects of cognitive decline. Some of these therapies are as follows ^[7]:

Cognitive stimulation therapy

Cognitive stimulation therapy involves the use of social, physical, recreational, and cognitive activities to stimulate the brain and promote social engagement.

Reminiscence therapy

Reminiscence therapy involves the use of either a structured or simple conversation with the person with dementia, to encourage them to recall their long-term memories and experiences from their past. This can help improve mood, communication, and cognitive abilities.

Reality orientation

Reality orientation can be an individual or group therapy, designed to help the person with dementia orientate to time, place, and person, helping to reduce confusion. This should be done carefully and should avoid countering any fixed delusions, since this can cause anger and frustration.

Cognitive rehabilitation and training

Typically, cognitive rehabilitation and training is only utilized in the earlier stages of dementia, as it can be distressing for those who are severely impaired. It is designed to assist in the improvement of functioning and provide strategies to cope with distress, by practicing various techniques. It can be provided by speech-language pathologists, psychotherapists/counselors, occupational therapists, and neurofeedback providers.

Family intervention

Family intervention can help to provide support for families caring for a loved one with dementia, by providing a clearer understanding of the condition, symptoms, and behaviors, techniques to manage and support their loved one, and reduce their feelings of caregiver burden.