Should you enter your client’s world and agree with their reality?
I actually remember the day I asked myself this question. I witnessed an incident that forever changed the way I approached the issue of Orient vs. Validate.
I was working as a staff OT in a nursing home and a gentleman who lived in the home came up to the nurse’s desk and sat down. He was dressed in his best suit, tie, and hat.
A staff member asked him why he was dressed up and the gentleman responded, “I’m waiting for my sister to come pick me up for lunch.”
The staff member proceeded to orient the gentleman, with very direct language, to the fact that his sister had died five years ago and he would be having lunch in the dining room.
The gentleman looked shocked, walked slowly back to his room, and went to bed for three days. He wouldn’t eat or respond to anyone. He only got out of bed to use the bathroom. He was grieving his sister’s passing and the fact that he had forgotten such a significant event in his life.
The two camps
If you talk with staff and family members about this issue, there seem to be two camps. One camp believes that to not orient
the person to reality is to lie, and we all know that lying is wrong.
The other camp believes that living in the moment with the person is okay and a gentle way of providing comfort and security.
Studies on validation therapy
What does the evidence say? Luckily there have been research studies conducted that can guide our thinking on this important question.
Results of some studies indicate that validation therapy has significant positive effects, such as decreasing symptoms of agitation, apathy, irritability, and nighttime behaviors.
A qualitative study
also found favorable results using Integrative Validation Therapy (IVA) and revealed not only a decrease in behavioral and psychological symptoms of dementia (BPSD), but a decreased need to use drugs
such as benzodiazepine and neuroleptics. The study also drew the conclusion that IVA supports person-centered care because with IVA, professionals react to typical needs people with dementia have: Comfort, inclusion, attachment, and identity.
In my research, I noticed that some studies rate the efficacy of validation therapy as low because cognition didn’t improve.
However, Naomi Feil
, who created the concept of validation therapy, never intended it to be used to improve cognition. And we know from our own Dementia Care Specialists training that we are not going to be able to improve cognition in a person with dementia because it's a progressive, neurodegenerative disease.
Instead, our goals in creating a Dementia Capable Society are to enable a person with dementia to live to their functional and emotional potential.
Naomi Feil’s goals in creating validation therapy were to:
- Stimulate verbal and nonverbal communication in order to help restore feelings of dignity and well-being.
- Help persons resolve the meaning in their lives.
Sounds like she’s trying to meet the person at their best ability to communicate and to restore emotional well-being. Does that fit with the idea of a Dementia Capable Society?
The purpose of reality orientation is to disrupt cognitive decline by stimulating the confused individual with repetitive activities on an individual or group basis by reinforcing name, date, time, and other facts of orientation.
Unfortunately, I think it may have been applied in a negative way when the gentleman’s spirit and sense of well-being were shattered.
I am also not sure how much well-being is restored by being able to state the day of the week or time of day. Does that fit with the idea of a Dementia Capable Society?
Should we enter our client’s world and agree with their reality?
Naomi Feil’s work says we accept the person wherever they are at the moment.
We don’t necessarily have to affirm the person’s false belief
if we truly feel that would be lying. But if we’re using validation therapy correctly, we are simply validating the feelings
behind the person’s behaviors.
I think the argument that not correcting the person’s reality is a form of lying is forgetting the process and effects of dementia. It’s as if we think orienting someone will automatically process in the person’s brain and bring them back to the present.
However, if we appreciate the process of dementia, the cells that housed the present reality may be gone. With reality orientation, we’re asking the person to do something that they’re not capable of, which only causes distress or other behavioral and psychological symptoms of dementia.
So for the gentleman dressed up to go out to lunch with his sister, would it have been a better approach to try to discover what this behavior was trying to communicate?
- Was he trying to recapture an old role of big brother and/or an important man going out for lunch (Role identity)?
- Was he trying to attach to someone in his world that he knew loved and cared for him (To be loved)?
- Would it not have maintained his dignity and well-being to talk with him about his sister and what she meant to him?
- Could we not have created a special table in the dining room for him to sit with friends and enjoy a special lunch or even plan a lunch outing for him?
I can’t answer these questions for you, but I can answer them for me and my understanding of dementia. I would use therapeutic touch to establish rapport and feelings of being loved, I would talk with him about his sister and his past roles in life that were important to him, and I would validate his feelings—
such an important part of the human need to be recognized as valuable and to be loved.
For me, that fits with creating a Dementia Capable Society.