The Validation Breakthrough: Simple Techniques for Communicating With People With Alzheimer's and Other Dementias
Author: Naomi Feil; Vicki de Klerk-Rubin
Date: 2022-01-15T18:47:40.845606+00:00
Keywords: Family & Relationships; Eldercare; Health & Fitness; General; Diseases & Conditions; Alzheimer's & Dementia
Description: Since the 1980s, the Validation method has been recognized worldwide as a reliable and effective approach used by care staff and families to communicate with people experiencing memory loss and disorientation. Put into practice, it can relieve distress and confusion, promote dignity, improve engagement, and reduce conflicts. This easy-to-read book explains the essential principles and practices of Validation and illustrates them with compelling stories and photos. When a person's actions or expressions seem inexplicable, the Validation method is a tool to bridge the gap and connect with that p
Publisher: Health Professions Press

Health Professions Press, Inc.

Post Office Box 10624

Baltimore, Maryland 21285-0624
www.healthpropress.com

Copyright © 2022 by Naomi Feil and Vicki de Klerk-Rubin. All rights reserved.

The individuals described in this book are composites or real people whose situations are masked and are based on the authors’ experiences. In most instances, names and identifying details have been changed to protect confidentiality. Real names and identifying details are used with permission.

The information provided in this book is in no way meant to substitute for a medical practitioner’s advice or expert opinion. Readers should consult a medical practitioner if they are interested in more information on dementia. This book is sold without warranties of any kind, express or implied, and the publisher and authors disclaim any liability, loss, or damage caused by the contents of this book.

Permission to reprint the photographs on the following pages is gratefully acknowledged: p. 12, Edward Feil Productions; p. 26, Edward R. Feil; pp. 54 and 94, Validation Training Institute, Inc.; pp. 58, 70, 74, 82, 129, 173, 193, 211, 221, and 230, Edward G. Feil; p. 112, Rita Altman; and p. 138, Ann Gurnett and Pam Amos.

Library of Congress Cataloging-in-Publication Data

Names: Feil, Naomi, author. | de Klerk-Rubin, Vicki, author.

Title: The validation breakthrough : simple techniques for communicating with people with Alzheimer’s and other dementias / Naomi Feil and Vicki de Klerk-Rubin.

Description: Fourth edition. | Baltimore : Health Professions Press, [2022] | Includes bibliographical references and index.

Identifiers: LCCN 2022027479 (print) | LCCN 2022027480 (ebook) | ISBN 9781956801002 (paperback) | ISBN 9781956801019 (epub)

Subjects: LCSH: Alzheimer’s disease--Patients--Care. | Senile dementia--Patients--Care. | Validation therapy. | BISAC: HEALTH & FITNESS / Diseases & Conditions / Alzheimer’s & Dementia | FAMILY & RELATIONSHIPS / Eldercare

Classification: LCC RC523 .F454 2022 (print) | LCC RC523 (ebook) | DDC 616.8/311--dc23/eng/20220803

LC record available at https://lccn.loc.gov/2022027479

LC ebook record available at https://lccn.loc.gov/2022027480

British Library Cataloguing in Publication data are available from the British Library.

Contents

About the Authors

Preface, by Vicki de Klerk-Rubin

Prologue—Florence Trew 1872–1963: “I died,” by Naomi Feil

Part I

Alzheimer’s Disease, Dementia, and the Use of Validation

Chapter 1

Aging, Development, and Alzheimer’s Disease

Chapter 2

The Concept and Techniques of Validation

Chapter 3

Using Validation with People Who Are Mostly Oriented in Phase One

Chapter 4

Using Validation with People Who Are in Phase Two

Chapter 5

Using Validation with People Who Are in Phase Three

Chapter 6

Using Validation with People Who Are in Phase Four

Chapter 7

Using Validation with Young-Old People Living with Alzheimer’s Disease

Chapter 8

Who Benefits from Validation?

Chapter 9

How Validation Differs from Other Methods Used with Old-Old People

Part II

Communicating with People in Different Phases Using Validation

Chapter 10

Communicating with People Who Are Mostly Oriented

Chapter 11

Communicating with People Who Are Living in a Personal Reality

Chapter 12

Communicating with People Who Express Themselves Mostly Through Movements and Sounds

Chapter 13

Communicating with Disoriented People Living in the Community

Part III

Validation in Different Care Settings

Chapter 14

Validating Family Members

Chapter 15

Group Validation

Chapter 16

Validation in Different Care Settings—Case Studies

Appendix A

Frequently Asked Questions About Validation

Appendix B

Validation Learning and Training

Appendix C

Validation Summary and Assessment Tool

References

About the Authors

Naomi Feil, M.S.W., ACSW, is the Founder of the Validation Training Institute. She is the originator of Validation, currently recognized throughout the world as a state-of-the-art method for communicating with older adults diagnosed as having neurocognitive disorders (NCDs) due to Alzheimer’s disease or other forms of dementia.

Ms. Feil earned her master’s of social work degree from Columbia University and studied at the New School for Social Research, Case Western Reserve University, and the University of Michigan. In 1963, she became dissatisfied with traditional therapies for older people with dementia and began to develop her own methods for helping older people cope with the cognitive impairment that is sometimes part of the aging process.

In addition to her earlier book on Validation, Ms. Feil has published numerous journal articles and, in collaboration with her husband Edward R. Feil, a documentary filmmaker, has produced nine award-winning films on Validation. The Validation Breakthrough has sold more than 55,000 copies in the United States alone in previous editions. She is internationally recognized for her work with older people and was one of the most sought-after trainers in the field. More than 30,000 facilities in the United States, Canada, Europe, Australia, and Japan have adopted Validation, and nearly 90,000 professional and family caregivers have attended her workshops in North America, Europe, Australia, and Asia. There are 23 Validation centers that teach Validation certification courses in 13 countries.

Vicki de Klerk-Rubin, R.N., M.B.A., is a Validation Master Teacher and the Executive Director of the Validation Training Institute (VTI). As the daughter of Naomi Feil, she strives to continue the legacy her mother started by ensuring that the VTI remains strong and committed to spreading the method she developed with integrity, creativity, and love.

Ms. de Klerk-Rubin assisted in the development of Authorized Validation Organizations (AVOs) throughout the world. She is especially proud of her work with other Validation Teachers in developing the standardized curricula, the Quality Manual, and certification levels. More recently, she has focused on developing online Validation training as well as training for specific groups of people: Validation for Family Caregivers and Validation for First Responders. Each training is focused on the needs of the participant. Every online course follows strict quality standards for online pedagogy.

Ms. de Klerk-Rubin received her master’s degree in business administration from Fordham University (1983) and a nursing degree from Hogeschool Holland, Amsterdam (1997). She has published numerous articles on Validation in Dutch and British magazines and is co-author on revisions of Naomi Feil’s publications. Her book Validation Techniques for Dementia Care: The Family Guide to Improving Communication has been published in English (2008, Health Professions Press), German, Japanese, Swedish, and French. Her newest publication, Validation for First Responders (2019, VTI), is also available in German and French.

Preface

Vicki de Klerk-Rubin

The “breakthrough” referred to in the title of this book did not happen quickly, nor is it finished. Naomi Feil has changed the way most people in the field of gerontology approach disorientation, dementia, and Alzheimer’s disease. She was the first person to say that caregivers need to step into the shoes of the disoriented old-old person. In doing so, she became the “godmother” of person-centered care. Through her charisma and focused energy, she spread awareness of her method throughout the world by doing workshops. These full-day, one-woman shows inspired a generation of caregivers. Since the late 1970s, Naomi presented more than 1,000 workshops in the United States and 1,000 in Europe. She also held workshops in Australia, Asia, and Africa. Many of the Validation concepts have become accepted facts and have been integrated into the medical and scientific body of knowledge. Validation has inspired many other person-centered methods. And so, the breakthroughs continue.

Feil’s method also continues to develop and change with the times. The Validation Masters who make up the Education Committee listen to criticism and, informed by their wide-ranging experience, propose changes to the method, the philosophy, the language used, and how Validation is taught throughout the world. The Validation method is not static.

The most important change made to this edition of The Validation Breakthrough is the language used to refer to people in the Resolution Stage of Life. Many people have expressed discomfort with the terms Malorientation and Vegetation (in particular). After much thought and discussion, the Education Committee decided to discard the labels and instead provide descriptions of characteristic behaviors and ways of communicating.

The second major change in this edition is the section discussing dementia and Alzheimer’s disease. All information in this section has been updated to conform with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and this updated knowledge is carried through the rest of the book.

More recent research has been added to Chapter 8, although it must be mentioned that it is impossible to include all the studies that have been and continue to be done on the Validation method. There are more than 50 scientific papers uploaded to the Research page on the Validation Training Institute website (https://vfvalidation.org/resources/types/research/), and more continue to be sent to us for publication there. Please see this free resource for further information on research.

The closing chapters and appendixes at the end of the book have also been modified to make them more useful to readers. Case studies illustrating the implementation and efficacy of Validation in a wide variety of professional care settings (and countries) have been given greater prominence. The discussions of family caregivers using Validation and of group Validation experiences are updated along with helpful answers to common questions about Validation. Plus, a handy Assessment Tool and summary of Validation principles are added. You will also find information about how to learn more about the Validation method or receive formal training.

Finally, the many stories that make this book such a rich experience for the reader have been updated to remove anachronisms. Hopefully this makes it easier for the reader to identify with the caregivers described in the stories and learn the lessons they learn.

My mother and I wish you a fun and enriching reading experience that leads to better relationships with disoriented older adults, more joy in your interactions, and more communication. After all, the Validation method is quite simply a way to communicate with those living with cognitive decline.

I dedicate this book to my editor and friend, Lita Kohn, without whom it would never have been written. Her guidance, enthusiasm, and honest search for what makes life meaningful have helped me look forward to my old-old age.

—Naomi Feil

PART I

Alzheimer’s Disease, Dementia, and the Use of Validation

Part I includes nine chapters. In Chapter 1, I describe the normal process of aging and human development and identify the crucial social and psychological needs of the “old-old.” In Chapter 2, the concept of Validation is introduced, and I describe the characteristic phases of very old people who enter the final struggle—what I call the Resolution Stage of Life—and describe the Validation techniques that can help restore dignity in each phase.

Chapters 3, 4, 5, and 6 present vivid case histories of people in four progressive phases of Resolution. All of these chapters describe the physical and psychological characteristics typical of each phase of Resolution and reveal how Validation has helped both the disoriented old-old and the people who have cared for them. Chapter 7 deals with the special case of early-onset Alzheimer’s disease, which often begins before the age of 70. Unlike old-old, disoriented adults, people with early-onset Alzheimer’s disease deteriorate despite Validation. However, caregivers who work with people living with early-onset Alzheimer’s disease have found some short-term benefits of Validation, as described in Chapter 7.

Chapter 8 looks at some of the research that has been conducted on the effect of Validation on disoriented, old-old adults; on the professionals and paraprofessionals who have cared for them; and on the families of older adults. As this chapter demonstrates, positive effects for all three groups have repeatedly been shown.

Finally, Chapter 9 examines the differences between Validation and seven other interventions that are often used with disoriented older adults—reality orientation, behavior modification, psychotherapy, diversion, life review, reminiscence, and remotivation.

CHAPTER 1

Aging, Development, and Alzheimer’s Disease

How I Learned: The Case of Isadore Rose: “You Castrated Me with Words”

Isadore Rose was a tall, bony, good-looking man when we met. He moved with purpose and was oriented to present time and place, but he was not happily oriented. He was in Phase One. He was loaded with emotional scars from the past, suffering from feelings he had not faced earlier in life. When I first met Isadore in 1963, I did not know about an individual’s final struggle, what I came to call the Resolution Stage of Life. I judged Isadore by standards of behavior that apply to older adults who are not stuck with unfinished life tasks. I misunderstood him and the many people like him.

At the time I met him, Isadore Rose was struggling to tie up loose ends. Before we were even introduced, he whispered to me that his sister, Helen, was saving money by not feeding him enough. His sister amazed me with her compassion for her brother despite his bitterness. Together, after his death, Helen and I tried to understand Isadore. We began with his nursing home history.

His final record reflected his sad existence:

- Assets: 1 black suit, 3 shirts, 1 pr. pajamas, 1 pr. shorts, 1 Schick razor, 1 pr. shoes.

- Personal savings: None.

- Financial arrangement: Monthly veteran’s pension.

- Medical diagnosis: CVA with left hemiparesis. Paget’s disease of the bone. Osteochondroma right tibia. Bowel surgery 1955 for enteritis. Prostate surgery 1963.

- Psychiatric diagnosis: Chronic organ brain syndrome, senile dementia-type.

- Certificate of death: Isadore Rose died on 1/6/73 at 11:45 a.m. Approximate interval between onset and death: 5 minutes. Immediate cause: respiratory arrest.

Through Helen, I learned about Isadore’s earlier life. “He wanted so much to be loved,” she told me. Her voice was hollow; the deep circles under her eyes made her face puffy and ghostlike. “To be somebody. Our father never loved him. He punished Isadore by locking him in the attic. In my dreams, even today, I hear Father yell, ‘You are no good, Isadore. You’ll never amount to anything.’ Isadore never yelled back. I never saw him cry.”

“You know, Isadore was born at the wrong time. Our parents couldn’t afford another child. They had just come to America from Russia, without a penny. Mother hid me under her sewing machine in the factory where she worked. I was 2 years old. When the boss found me, he fired her, and she was pregnant with Isadore.”

Helen Wallace’s words rushed one on top of the other, spinning out her life. “I know it wasn’t Isadore’s fault that his wife divorced him. She kept saying that he was impotent. He wanted more than anything to have a child. Isadore was waiting for the day when he could get season baseball tickets for a son. Father never once took Isadore anywhere, not even to a ball game. When Isadore’s wife left him, he moved in with us. He helped us pay for our house, but he was never a successful lawyer.

“When he lost the Ephraim Gross case, his one big case, he gave up. He said the judge didn’t like him, so what was the use of trying? He barely earned a living after that. Poor guy! Every day, he walked up the hill to his law office on Buckeye and 116th Street. I don’t know what he did there all day. Then he fell. The doctor said he had a bone disease. He tried so hard to keep walking. He fell down our basement steps and said it was my fault. He said I didn’t feed him enough. Crazy! On top of that, he wouldn’t sign his Social Security checks. He said we would steal them. That’s when I called you, almost 11 years ago. My God! I can’t believe it’s been so long!”

Together, Helen and I reviewed Isadore’s sad later life, beginning in 1962, when he had begun attending a day program. With the benefit of hindsight, these excerpts from his history struck me as a chronicle of missed opportunities:

- 3/62: Isadore Rose, age 73, enrolls in day center. Client is mildly confused, usually continent. Claims his sister is stealing his pension. Staff instructed to use reality orientation with client.

- 5/62: Client accuses center director of abusing him and locking him in the attic. Appears agitated and swears angrily at staff. Staff assure client that nobody would hurt him. Reality orientation does not seem to be effective with client.

- 4/63: Client undergoes prostate surgery. Although surgery is successful, he accuses surgeon of castrating him. Seems more confused after surgery; seems to swear at staff more.

- 5/63: Client seen by psychiatrist, diagnosed with schizophrenia with hallucinations, senile dementia with chronic organic brain syndrome. Behavior modification recommended to deal with unacceptable behaviors. Staff instructed to ignore client when he becomes aggressive.

- 8/63: Behavior modification not working. Client becomes physically abusive when ignored. Staff unable to deal with client.

- 3/69: Client admitted to nursing home. Incontinent most of the time. Client blames incontinence on administrator.

- 4/69: Social worker sees client, reports failure to connect with him. Client turns head away, scribbles on legal pad—which he carries with him at all times—when social worker tries to provide insight into his behaviors.

- 10/70: Client refuses to talk, keeps eyes shut. Handwriting shows much deterioration.

- 3/71: Client restrained in wheelchair during waking hours. Engages in repetitive behaviors. Spoon-fed.

- 11/71: Psychiatrist prescribes medication for client to control repetitive behaviors. Client does not speak, appears totally unaware of surroundings.

- 12/71: Client transferred to acute care wing, where he is fed, toileted, and moved.

- 1/73: Today I close my file on Isadore Rose. Client deceased.

It took me 10 years to understand what had happened to Isadore Rose. I had never empathized with him, nor with the scores of very old people like him with whom I worked from 1963 to 1973. I judged them by standards that applied to much younger people, people who had not lived through the physical and social losses of very old age, people who had faced their emotions along the way, people who did not have to express unfinished feelings to die in peace. Isadore Rose’s eyesight and hearing were impaired. He had a weak bladder and damaged brain cells and could no longer control his anger in old age. He could not “listen to reason” and conform to my sense of reality. He was not motivated to calm down and modify his behavior. He needed to yell, to rid himself of his bottled-up rage. He had his own reality. He was using his mind’s eye to return to his law office and punish the judge who had ruled against him on his important law case. He wanted to re-affirm himself, to shout to his father, “I am a good person. You were unfair. You castrated me with words. I am worthwhile.”

I wanted Isadore Rose and others in their 80s and 90s to conform to my standards, to remain oriented to my middle-age conception of reality. I did not know that very old people face a very different struggle. It took Isadore Rose’s death to teach me to listen to older people who need to return to the past to resolve it.

I never listened to Isadore Rose. Only after he died did I realize that I should have looked at how he had lived his life, how he had faced his life tasks, how he had expressed his emotions, how he had dealt with his losses, how he had rolled with the punches. Isadore Rose was restoring the past to resolve it, to heal himself. His behavior was not pathological but age appropriate. He needed empathy. His life history revealed the reasons behind his “delusions.” He heard his father with his mind’s ear; he saw the judge with his mind’s eye. He used his vivid memories to relive the past to justify himself in his old age. He had shuffled through life, muttering under his breath, blaming others when life hurt.

Isadore had never expressed his rage until old age. At age 14, he was silent; at age 84, he finally expressed his hurt. He wanted to be loved. He begged for approval. But it was too late. An avalanche of physical deterioration exacerbated his feelings of inadequacy. Despite his strokes, Isadore Rose would not have withdrawn inward if I had listened to him. He would have communicated with me until he died.

Isadore Rose taught me that very old people who live to old-old age loaded with a backpack of unexpressed emotions must unload these emotions before they die. They enter the final stage of life: Resolution. In Resolution, very old people try to tie up the emotional loose threads of their lives before death. In very old age, they face tasks they should have faced years earlier.

A Theory of Life Development and the Need for Validation

Many developmental psychologists, most importantly Erik Erikson (1963), believe that different life tasks need to be completed at different stages of life. An understanding of people’s development across the lifespan is an important foundation for using Validation effectively.

The Stages of Life Development

In infancy, we learn to trust that Mother will never leave us out in the cold. Warm, safe, snuggled against her breast, we nurse, one with the world. A piercing noise jars our ears—the telephone. Abruptly, without warning, torn from Mother, we are alone. In infancy, we know only present time, NOW. In no time, we are abandoned. Hungry, cold, we shiver. Red in the face with fury, we wail. We face our first life task. We must learn to trust that Mother will come back. We will survive the cold, the hunger pangs, the fury, the fear. Mother proves again and again that she will return. The infant learns with constant repetition: I am lovable. Mother will never leave me. I can wait. I can survive the cold, the hunger, the anger, the fear. Mother will not reject me.

In childhood, our task is to learn control. We get a kick out of following rules. “Mom! Look what I did—I put everything in the potty. Look what I produced. I did the right thing at the right time in the right place…. Dad! Watch! I learned to ride my bike with no hands! Uh-oh! My bike hit a bump!” The child who learned to trust in infancy falls, cries, then gets up and starts riding all over again. “Hey! Look! I did it!” That child may fall again and again. But that child will never fall apart. In childhood, we put our infant’s trust to work for us.

But if our parents teach us over and over that we must be perfect—never soiling, never spilling, never falling, never crying, never hurting, never forgetting—we fail to master the task of control and add another load to our backpack. We carry with us to old age the need to keep tight control. We fear exposing our feelings. We keep our fingers wrapped tightly around the handlebars. We hold onto our possessions. We become hoarders.

In adolescence, our task is to cut the cord, to rebel. At age 15, we must fight to separate from our parents to discover our own values. We fight to come up with our own identity. We fight those closest to us. We fight to find out who we are. How are we unique? We’ve learned in infancy that our parents love us even when we fight them. We can risk rebellion. But if we do not have and hold unconditional love from our parents, rebellion is risky. If we fight and disobey the rules, our parents might not love us anymore. We will be all alone. So, we capitulate. We are good. We always do what our parents want. Who are we? We are the good child. We are the teacher’s good student, our spouse’s devoted partner, the boss’s good worker. We never learn who we are inside separate from an authority. The outside world gives us identity. Afraid of rejection if we assert ourselves, we never learn to be ourselves. To be worthwhile, we have to become somebody’s something. Without family, without work, we are nothing. The backpack gets heavier as we get older. We become martyrs.

In adulthood, our task is to get close to another human being. We search for intimacy. We want to whisper, “I love you.” We want to touch without fear of rejection. If we are clear about who we are, if our identity comes from deep inside, we can risk being hurt. We can say “I love you,” trusting that we will survive if our love is not returned. We can risk a fall. We won’t fall apart.

But if we have failed to accomplish our earlier life tasks, we will not reach out for intimacy. If we could never trust ourselves to take our hands off the handlebars as children, how can we trust ourselves to survive the bumps of adulthood? Haunted by the terror of abandonment in infancy, the agonizing embarrassment of failure as a child, the fear of rejection as a teenager, we must stay apart from others. We become isolated. We become recluses.

In middle age, our life task is to roll with the punches. We watch our wrinkles deepen, our hair thin; our creased skin doesn’t fit the bones, the bags won’t go away. We look in the mirror. Everything looks like it did 5 years ago, but it’s all a little lower. Some of us suffer an onslaught—an avalanche of losses. We lose a spouse, a breast, a kidney, a job. We face our losses. We grieve. We look in the mirror and accept that we will not live forever. We expand our repertoire for living. We add new keys to the piano of our lives. We move on. A spouse dies; we find a close friend. A job goes; we accept a volunteer job.

But if we have learned that we must be perfect, that we cannot lose control, then we cannot spill our feelings to anyone. Without our spouse, we are nobody. Without our job, we are nothing. To survive, we deny the impact of our losses. We cannot risk learning new keys. We bang the same key; hang onto outworn roles. A widower rejects a new relationship—nobody is good enough. A music lover refuses to buy a hearing aid—it’s too expensive. An executive ridicules a volunteer job—his time is worth money. We are stuck, unprepared for the next life stage. We cling to outworn behaviors.

In old age, we have to justify what we have done in our lives. It’s time to look backward, to sort out what we were. In old age, we prepare to die, feeling good about what we have accomplished in life. We die with self-respect, despite our failures, mistakes, and unfulfilled dreams. I wish that I had been a great actress, but I wasn’t. Instead, I used my acting skills to become a good teacher. I like myself. Despite my unfulfilled dreams, despite my mistakes, despite my losses, I am glad that I was born. I respect myself. I have integrity. I can compromise. I can accept what I am, what I was, and what I have never become. Life is worth living.

But if we cannot accept who we are and trust that we will be loved when our eyes blur, our hair thins, our recent memory fades, then we fall into despair. Without deep self-acceptance to outweigh an onslaught of losses, we become bitter.

Despair, if ignored, rumbles inside, turning into depression. Depression is an internal storm. Rage, rebellion, shame, guilt, love—emotions that have been stopped up successfully for a lifetime—fester. Bearing our backpack that becomes unbearable, we move toward old-old age.

Each life stage has its own unique task. Ignored, each incomplete task re-emerges later in life. The task challenges us to pay attention. The task gives us a second chance at a later time. The task persists, following us to very old age. If we continue to deny its existence, if we refuse to face it, the task finds the moment to take center stage. The task waits for old-old age, when our controls weaken. The task waits until we forget our lines. Then the task moves in.

The Need for Validation

Out of my experience with Isadore Rose and others like him, I developed a method of communicating with empathy that has helped old-old people regain dignity, reduce anxiety, and prevent withdrawal. My method—Validation—has helped thousands of caregivers of people like Isadore communicate and avoid burnout and depression.

From Isadore Rose, I learned the most crucial characteristic of very old age: developmental history and physical changes are inseparable. I had to look at the whole human being, not just the condition of the brain, to understand the reason behind the behavior. Behavior at every age is judged by physical, psychological, and social development. We listen to the teenager who vents rage. We do not judge the teenager by our standards of behavior. We know what it’s like to rebel against authority at age 15. It may be less intuitive to empathize with a person who has skipped important life tasks and has rebelled at age 90.

Very old age is still new.[1] For the first time in history, we are pressed to understand old-old people as medicine increases our lifespan. Caregivers face a new generation of very old people who must return to the past to resolve it before death. We must understand the blend of physical, psychological, and social changes that explain the behavior of very old people. A 3-year-old who talks to an imaginary playmate is not hallucinating. At this age, the behavior is considered appropriate. Young children use their imagination, simulate verbal behaviors, and model their parents. At age 33, talking to an imaginary person would be considered a hallucination. However, at 93, the very old person may be behaving appropriately when seeing someone from the past who is not there. To empathize with old-old people, we need to understand the complex interweaving of physical deterioration and developmental needs.

Unique tasks are associated with each life stage. People who achieve the life tasks associated with each stage of development learn to master their environments. They gain confidence that they can make mistakes and occasionally lose control without feeling guilty. They learn to express their most intimate feelings without fear of rejection or shame and to trust that they can survive hard times. People who fulfill their life tasks at each stage achieve integrity in late life. In old age, they are able to accept new roles; to grieve over deaths, failures, and unfulfilled dreams; to generate new activity when aging brings losses and familiar social roles change; to move on to new goals. These people do not need Validation.

An increasing number of people reach very old age with some unresolved life tasks that reappear in late life. People with unresolved life tasks carry heavy emotional burdens that they struggle to resolve when they are older. Buried for a lifetime, these feelings erupt in old age. Like Isadore Rose, these older adults use people in the present time to substitute for people from the past and to unload painful emotions. They enter the Resolution Stage of Life, the stage in which they struggle to complete unfinished tasks so as to die in peace. Validation is based on the premise that many old-old people enter into this final Resolution Stage and that certain techniques, described in detail in the next chapter, can be used to communicate with them and help them resolve the past.

In 1963, when I returned to work in the Montefiore Home for the Aged in Cleveland, Ohio, where I grew up, I found that most of the 170 residents were oriented, integrated human beings who had learned to compromise. They rolled with the punches of old age and still enjoyed living. Only 23 residents had become confused or disoriented. These residents were often labeled on the basis of their behaviors—they were known as the blamers, the martyrs, the moaners, the wanderers, the yellers, the pacers, the pounders, whom nobody wanted. I didn’t know it then, but each person had accumulated a load of festering feelings. These were the very old people with whom I worked in the Special Service Wing, separated from the oriented residents who resented their “crazy” behaviors. Staff, too, were not eager to care for the residents who could not or would not control their feelings and conform. These 23 old-old people might have died of pneumonia or heart disease, but modern medicine kept them alive. They outlived their bodies.

I also worked with the very old, oriented residents in the Montefiore Home for the Aged. Many of them had survived cancer; heart disease; stroke; and the loss of their recent memory, eyesight, hearing, and mobility. They stayed oriented. In studying their social histories, in talking with their families, in working with them day after day, I found that they carried with them very little excess baggage. They had faced most of life’s tasks along the way. They had learned to trust other people, to admit their mistakes. They did not fall apart when problems struck. They were able to express deep feelings. They had survived the losses of middle age and entered the Montefiore Home prepared for old age. They had compromised. When life wasn’t the way they wanted it to be, they accepted things the way they were. They were glad to be alive.

In 1963, the 23 residents who were confused were diagnosed as having “chronic organic brain syndrome, senile dementia-type, often accompanied with cerebral atherosclerosis.” By 1980, the number of disoriented residents had tripled to 69, and they were diagnosed as having “senile dementia of the Alzheimer’s type, with related disorders.” As people lived longer, the Special Service Wing for disoriented residents grew. These very old people gradually taught me that they must pack for their final move. They sort out dirty linen stashed in the storehouse of the past. They are busy, irresistibly drawn to wrap up loose ends. This is not a conscious movement to the past. It is a deep human need: to die in peace. Those who achieve integrity in very old age never enter the Resolution Stage. They face their tasks adequately along the way. But, as we live longer, there is a growing number of very old people who fall into the Resolution Stage of Life.

This woman is expressing feelings that were bottled up for decades. Now in old-old age, she can finally express herself to someone who is really listening.

Who Are Old-Old People, and What Is Dementia?

Social researcher Bernice Neugarten (1970) and many others distinguish “young-old” from “old-old” or “oldest-old” people. Young-old people are between the ages of 65 and 84; old-old people are 85 and older. Neugarten believes that the two groups of older adults have different social and psychological needs and therefore need to be considered separately. I often use the terms “younger-old and “old-old” to distinguish the two groups of older adults that Neugarten defined. There are also exceptions, as each person ages differently. Some 70-year-olds act as if they are 90; some 90-year-olds act as if they are 70.

Physical Changes Affecting Old-Old People

In my many years of working with older people, I have found that even the most physically fit people begin to experience some physical deterioration after the age of 75. Often, muscle strength decreases; the ability to control the bladder diminishes; arthritis, osteoporosis, and circulatory problems affect mobility; vision, hearing, and sensory acuity become impaired; and the blood flow to the brain changes, affecting cognitive function. Arteries that carry oxygen and nutrients to the brain sometimes become clogged, leading to small strokes that often go undetected.

When we reach our 30s, thousands of neurons in the brain begin to die. Unlike other cells in the body, many of these cells are not replaced. Neuron loss is a gradual process, and by the time a person reaches age 80, the cumulative loss of neurons can be significant enough to affect some cognitive processes, including the retrieval of recently learned facts, dates, and names. We should not medicalize normal changes in the body, including the brain, as we age. Normal aging includes memory loss; this is a change that occurs as we age, not a disease. Cognition can also be affected by Alzheimer’s disease and other diseases, a distinct phenomenon that is examined in the next section.

Dementia

The word dementia comes from the Latin dis, meaning away from, and mens, meaning mind. It was introduced in the 18th century by two French researchers, Philippe Pinel and J.E. Esquirol, who used the term to describe mental deterioration and “idiocy” caused by lesions in the brain.

Identification of Alzheimer’s Disease

In 1906, a German neurologist, Alois Alzheimer, examined the brain of a 55-year-old woman on autopsy. Observing “remarkable changes in the neurofibrils … and a peculiar substance in the cerebral cortex,” Alzheimer concluded that “we are apparently confronted with a distinctive disease process” (Alzheimer, 1907, p. 148). Alzheimer had identified the neurofibrillary tangles and senile plaques that are hallmarks of the disease that bears his name. Neurofibrillary tangles are twisted filaments, or threadlike structures, in the brain. Plaques are laminated deposits of a protein, beta amyloid, that is found on the surface membranes of neurons when they degenerate.

The neurofibrillary tangles and plaques that cause Alzheimer’s disease tend to develop over time. According to neurologist Dennis Selkoe, “most of us who live into our late 70s will develop at least a few senile plaques and neurofibrillary tangles, particularly in the hippocampus and other brain regions important for memory” (Selkoe, 1991, p. 68). Nobel prize winner Carleton Gajdusek reported that 90% of people older than 90 develop plaques in their brains (Gajdusek, 1985). This research has continued to be reconfirmed, for instance, in articles by St. George-Hyslop (2000) and Reas (2017).

Alzheimer’s disease was originally considered a form of pre-senile dementia. This distinction between senile and pre-senile dementia was abandoned after 1968, however, after the brains of very old people and younger people were found to be similar upon autopsy. “Senility was renamed Alzheimer’s disease, which became a common illness almost overnight” (Miller, 1988, p. 41). Today, the term organic brain syndrome is seldom used, and Alzheimer’s disease is the label used most often to describe older adults living with a dementia.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published in 2013, now uses the term neurocognitive disorders (NCDs) instead of dementia. There are many different forms of NCDs, including vascular NCD, NCD with Lewy bodies, NCD due to Parkinson’s disease, frontotemporal NCD, and NCD due to Alzheimer’s disease (American Psychiatric Association, 2013).

Alzheimer’s disease is still a diagnosis made by excluding other possible illnesses. According to the DSM-5, a diagnosis of NCD due to Alzheimer’s disease requires all of the following criteria to be present:

- Genetic testing or clear evidence of a decline in memory

- A decline in one other cognitive function

- A progressive decline

- No evidence of any other identifiable cause for the cognitive decline

Instead of using the terms early onset or late onset to describe NCD due to Alzheimer’s disease, the book talks about “possible” or “probable” NCD due to Alzheimer’s disease. Deficits are found in the following areas:

- Memory
- Orientation
- Judgment
- Logical thinking
- Abstract thinking
- Appropriate emotional response
- Attention span
- Performance of activities of daily living

These deficits begin gradually and continue with age. They disrupt functioning at work as well as on a social level. The decline is much greater than what normally can be expected during the aging process. The physical evidence of Alzheimer’s disease—the plaques and neurofibrillary tangles in the brain—are no longer the only criteria because we know that everyone over the age of 55 has them.

The Relationship Between Physical Changes and Disorientation in Old-Old People

Neurofibrillary tangles and plaques are found in the brains of all people with Alzheimer’s disease. They are also found in many people who do not exhibit any signs of disorientation, however. Therefore, these changes in the anatomical structure of the brain are not the sole cause of changes in behavior in very old people. Many people over 80 survive damage to these brain cells and remain oriented. Although they may have a visual impairment, a hearing impairment, and other physical disabilities, these people retain the ability to communicate verbally, are aware of present time and place, and are able to make appropriate judgments. They have found psychological balance by achieving the following:

- Faced the challenges and disappointments of their lives

- Tackled the problems of daily living with a sense of hope

- Forgiven themselves and others for their mistakes and failures

- Compromised when they could not fulfill goals

- Continued to respect themselves despite failures, mistakes, and dreams that were not fulfilled

- Survived physical and social losses

- Accepted their physical deterioration, loss of loved ones, and inevitable death

- Maintained a zest for living

- Avoided dwelling on the past but enjoyed reminiscing

- Established new relationships

- Prepared for death by making peace with their loved ones

Old-old people who are oriented do not need Validation. These people validate themselves. Since 1956, I have worked with oriented old-old people. Some of these people had physical impairments that damaged their recent memories and affected their control over their emotions. Nevertheless, the old-old people with whom I have worked who expressed their emotions—positive and negative—throughout their lives did not vent their anger inappropriately in old-old age. Despite strokes and other physical disabilities that affected their behavior, they remained whole.

Although the cause of NCD due to Alzheimer’s disease is associated with structural changes in the brain, psychiatrists and neurologists who work with older people have long recognized the effect of emotional influences on memory. “Some of what is seen as senile brain disease may be a massive defense against the reality of old age and death,” wrote V. A. Kral. “Stress itself may play a role.” (1977, p. 76).

With loss of friends, family, health, and social status, older people who are disoriented often lose their motivation to conform to social norms. Their failure to resolve important developmental tasks earlier in life catches up with them in old age. They return to the past to resolve these tasks. These old-old people no longer have the tools to cope with the ever-increasing changes of aging. As a result, they choose to retreat. Validating them helps them regain their dignity. With Validation, they often return to present reality and respond with focused eye contact, improved speech, steadier gait, and regained social controls.

Recognizing that disoriented old-old people are struggling with a legitimate life task may reduce the chance of misdiagnosis. Whereas confusion in a younger person may represent physical disease, disorientation in a very old person may represent the normal struggle of the old-old person who has lost recent memory and is surrendering present-day factual thinking to restore the past and heal old wounds before death.

Early-Onset Alzheimer’s Disease

Disorientation in younger people with Alzheimer’s disease is usually not exacerbated by loss of physical health, by changes in social roles, or by the death or illness of family and friends. I have been unable to find underlying psychological or social reasons behind the disoriented behavior of people with early-onset Alzheimer’s disease. Unlike older people with Alzheimer’s disease, people in their 40s, 50s, and 60s often fail to respond to the touch or eye contact of the caregiver. They stare blankly into space. Often, as the disease progresses, people with early-onset Alzheimer’s disease lash out without provocation. Although Validation often momentarily improves quality of life for people with early-onset Alzheimer’s disease (as shown in Chapter 7), I have not been successful in using Validation to slow the progression of the disease. People with early-onset Alzheimer’s disease have declined in their functioning despite my work with them.

Old-Old People, Disorientation, and Human Needs

Abraham Maslow (1908–1970) was a psychologist who developed a theory about human needs. He said that human beings must first fulfill physiological needs (e.g., hunger, thirst), followed by safety needs (to feel secure and safe), before striving to fulfill psychological and social needs (Maslow, 1954). He created a hierarchy of these needs, which not only seems to apply to oriented and healthy people, but also to disoriented older adults to some extent (see Table 1.1). Maslow’s pyramid of needs does not totally apply to very old, disoriented people, but much of the hierarchy makes sense and gives us a greater understanding of these individuals.

From 1963 onward, I worked with old-old nursing home residents who were disoriented and diagnosed with Alzheimer’s disease. I documented their social and psychological needs in gerontological literature and on film (Feil, 1967, 1972, 1973, 1974, 1978, 1982, 1985, 1989, 1991, 1992a, 1992b, 1992c; Feil & Flynn, 1983; Feil, Shove, & Davenport, 1972). I learned to understand why they behave the way they do, and I learned to communicate with them.

Table 1.1. Maslow’s hierarchy of needs and how they apply to disoriented older adults

Maslow’s

As applied to disoriented older adults

Self-actualization: To realize one’s full potential

Resolution of unfinished issues in order to die in peace

Aesthetic needs: Symmetry, order, and beauty

Need to restore a sense of equilibrium when eyesight, hearing, mobility, and memory fail

Cognitive needs: To understand and explore

Need to make sense out of an unbearable reality; to find a place that feels comfortable and where relationships are familiar

Esteem needs: To achieve, gain approval or recognition

Need for recognition, status, and self-worth; need to be listened to and respected

Need to belong and be loved: To feel affiliated with others

Need to be loved and to belong; need for human contact

Safety needs: To feel secure and safe

Need to feel safe and secure rather than immobilized and restrained

Physiological needs: Hunger, thirst, sex, and so forth

Need for sensory stimulation: tactile, visual, auditory, olfactory, gustatory, as well as sexual expression

Source: Abraham Maslow (1908–1970).

I found that a medical diagnosis of Alzheimer’s disease tells only part of the story, that it is impossible to understand a person’s behavior without considering the person’s age, social needs, and psychological needs. After working with hundreds of old-old people who became disoriented in late life, I realized that these older adults share certain psychological and social needs:

- Need to resolve unfinished issues in order to die in peace

- Need to live in peace

- Need to restore a sense of equilibrium when eyesight, hearing, mobility, and memory fail

- Need to make sense out of an unbearable reality: to find a place that feels comfortable, where one feels in order or in harmony and where relationships are familiar

- Need for recognition, status, identity, and self-worth

- Need to be useful and productive
- Need to be listened to and respected
- Need to express feelings and be heard

- Need to be loved and to belong: need for human contact

- Need to be nurtured and to feel safe and secure, rather than immobilized and restrained

To satisfy these needs, they use the mind’s eye to see; they recall familiar voices from the past, which sound real to them. To relive the sense of usefulness they experienced when they were working, they move their hands and feet in the same way that they may have done in their jobs. Once they lose the ability to communicate through speech, they blend sounds to express their emotions. Most important, despite disorientation, they keep the universal human need to belong, to find identity, to express themselves.

Across more than 50 years of caring about and working with disoriented old-old people, I found that when they are validated, when their psychological and social needs are met, they do not withdraw inward. They continue to communicate until they die. Often, dormant speech re-appears; eyes light; gait improves; well-established familiar social roles return; negative behaviors, such as crying, pacing, blaming, and pounding, decrease.

Old-old people who try to work through the anguish of Resolution while isolated suffer enormously. Their actions are often a source of frustration and pain to caregivers and family members, who are at a loss as to how to deal with their incomprehensible behaviors. As more and more people in the United States and elsewhere in the world reach old-old age, more and more families and long-term care organizations will be confronted with unexpected and upsetting behaviors. The need to find some way of understanding and communicating with this population is overwhelming.

If caregivers and family members only focus on the behaviors of very old people who are disoriented, they will be unable to validate these individuals. However, caregivers can learn to perceive each person as a human being who has deteriorated physically and lost the ability to cope with the assaults of aging. They can learn that many older people are involved in a final struggle to resolve the unfinished tasks of their lives. Armed with the simple techniques of Validation described in Chapter 2, caregivers learn to effectively communicate with disoriented old-old people who are struggling to survive.

VALIDATION AROUND THE WORLD

The Power of Empathy

Cinzia Siviero

Validation Master

Italy

ONE DAY MARIA TOLD ME, “Losing memory is like losing yourself, the remembrances of people you loved, the whole life! It is better to die!” Maria and I had been meeting twice a week for months. She waited for me, even if she didn’t realize it, closed in her loneliness and full of confusion. When she saw me, she would smile. Then she would launch into a soliloquy I could rarely interrupt. She would be busy looking for thoughts in her mind and things in her room. What was she looking for in her drawer, closet, and purse? It would be a piece of paper she had written on a little time before to remember. She would tease herself for having to use these memory tricks to survive, able as she still was to maintain self-control and see the irony.

Maria was in the first phase of Resolution—the phase of denial, tension, and accusations. Yes, accusations. She blamed someone for having stolen a Rolex she never owned. She said she had to hide her pens because somebody was stealing them. She declared that this place was a disgrace because money disappeared. Naomi Feil explains that people in Phase One express themselves through symbols. The Rolex that roused Maria’s claims of theft seemed to reveal the unease of someone who is feeling robbed of her own precious time. And what about the pens? They were the tools of a whole life spent working as a secretary for an important doctor. Old age was stealing away from Maria a job she had loved very much. She would keep herself engaged for hours writing a list of tasks she had to do and then blamed the facility for keeping her confined and not letting her go out. She would exclaim: “What a waste these places are, full of passages for aged people to get lost in! Who built them?” It was the architect’s fault, not her incapacity to find her way.

Maria was a product of old times and old values. She was educated and sophisticated. In her 90s, she was still very beautiful, always tidy, sharp, and perfectly appointed—a real lady. There was no danger of seeing her in shoes that mismatched the colors of her tailored suit. She never forgot what she called her “hangings,” her precious necklaces and earrings. She spent hours preparing herself. She would tell me how “polite” I was for addressing her properly and formally, and then would say, “Away with these jeans that you women wear today. How awful!”

At the beginning, mistrust separated us. As I nurtured an empathic relationship, Maria’s defenses softened and she became more trusting. She valued the truthfulness, genuineness, and sharing of our Validation talks, and she enjoyed those who devoted even a few minutes of their attention to her, only to her. It was not always easy; she was often repetitive, and her short-term memory was very damaged. She might ask me the same question a few minutes later. Sometimes she noticed and felt shattered. I was happy, however, to give Maria these small but precious spaces, made of respect and empathy. They made me feel good, too.

It is now 3 years since we met. I enter Maria’s room. It’s dark and she’s dozing in bed with a bathrobe draped over her. I always find her so in these last times I see her. She doesn’t get up and doesn’t dress anymore. There’s a foul smell, and it’s obvious that she doesn’t take care of herself anymore. I agree with her doctor’s decision to move Maria to a more suitable unit. I say hello to her. I turn on a light, and she tells me the light bothers her. I help her to sit so I can face her to talk. Her expression is lost, as if she doesn’t understand who I am and what I want. I tell her that I used to visit her sometimes and chat with her, but she doesn’t remember.

I read in Maria’s eyes sadness and confusion. She talks about her parents as if they are still here, but then she adds, “Probably they are dead.” She doesn’t remember if she had brothers. She admits she has some problem with her memory. We talk about the fact that she rarely gets up and she says that, on the other hand, nobody comes to pick her up. I know this is not true, but there’s no need to contradict her.

Surprisingly, Maria understands that she is going to be moved to another place. I was intending to tell her but wasn’t sure how to do it. Is it possible that she felt my unease? I often tell my students that very old people in Resolution seem to have antennae that can sense unspoken things. I have never been in a situation when I felt this more strongly. And again Maria surprises me by asking, “Is this thing already decided?” I reply, “I am afraid so.” “Not, ‘I am afraid so,’” she says. “I know it!”

Maria now looks angry with me, and rightfully so. Slowly, she grows outraged: “This is not right.” “Call my family.” “I really don’t understand.” “If it is true that I have been here all these years, I have the right …” She declares that there is no space for another person in her small room. But it’s clear that there’s no use in explaining to her that the room will not be this one anymore.

Maria is fighting and I let her express herself. Using Validation has taught me that she has a right to feel and express her emotions and that her reactions are a natural form of self-defense. My job is to try to share and help Validate her feelings whenever we are together to help relieve Maria of some of her anxiety.

[1]According to the Centers for Disease Control and Prevention (CDC), in 2020, the average life expectancy in the United States was 74.5 years for a man and 80.2 years for a woman. In 1950, men lived on average to 65.6 years and women to 71.1 years.

CHAPTER 2

The Concept and Techniques of Validation

What Is Validation?

Validation is a method for communicating with old-old people who are diagnosed as having Alzheimer’s disease and related dementias. It is a method that I developed over a period of many years. As a gerontological social worker, I worked for decades with disoriented nursing home residents. Over the years, I noticed that old-old people with Alzheimer’s-type dementia tended to engage in similar kinds of behaviors. Eventually, I identified different clusters of physical and behavioral traits that distinguish different groups of disoriented old-old people. Between 1963 and 1980, I formed a set of beliefs about why old-old people behave the way they do. From this understanding of their behavior, I developed techniques for communicating with them. Validation developed directly from my experience with old-old residents of nursing homes.

Validation is based on an attitude of respect and empathy for older adults living with cognitive decline who are struggling to resolve unfinished business before they die. Validation suggests a way of classifying the behaviors of disoriented old people and offers simple, practical techniques that help them restore dignity and avoid deteriorating into a withdrawn state.

Validation provides disoriented old-old people with an empathetic listener, someone who does not judge them, but accepts their view of reality. As the trust between the old-old person and the validating caregiver grows, anxiety is reduced, and the sense of self-worth is restored. Physical and social functioning improve, and withdrawal is prevented.

The Four Phases of Resolution

Very old people who have ignored or denied the need to address important life tasks in earlier stages of their life enter a period in which they feel the need to resolve unfinished business in order to die in peace. They generally progress through four phases of Resolution:

1. Phase One: Communicating well, mostly oriented; denying, confabulating (making up stories to cover their losses); energetically and fearfully clinging to what they have not yet lost. The person expresses past conflicts in disguised forms.

2. Phase Two: Communicating, mostly living in their personal reality; verbally expressing needs and feelings with few filters.

3. Phase Three: Still communicating, mostly internalizing needs and feelings; expressing needs and feelings through movements and sounds.

4. Phase Four: Barely perceptible communication; withdrawn and internalizing their needs and feelings.

Using Validation with a man in Phase Two, sharing his grief.

With each phase, physical deterioration worsens, and there is a progressive withdrawal inward (Table 2.1). Know that people often wander from phase to phase. Each person is unique; there can be no formula for categorizing human beings. A 90-year-old woman may be oriented at 7:00 a.m. At 8:30 a.m., she may be convinced that a man is under her bed. At 2:30 p.m., she may demand to go home to see her mother. Despite these fluctuations during the day, however, most people stay in one phase of Resolution most of the time. When necessary, the validating caregiver moves from phase to phase with the person, using the appropriate Validation techniques.

Caregivers working with people in Resolution learn to recognize the physical and psychological characteristics of each phase (see Table 2.1). Validation practitioners learn to adapt their approach to each individual in the moment, knowing how to shift easily as the older adult shifts.

Old-old people who are not validated can pass through all of these phases. However, as we shall see, people who are validated need not progress to the state of withdrawal in Phase Four and often die at peace with themselves.

The Principles of Validation

To understand a person’s behavior, his or her physical strengths, social needs, and psychological needs must be known. Behavior cannot be judged appropriate or inappropriate unless it is viewed within the context of these needs. For example, a 13-year-old is expected to rebel. At this age, an adolescent is experiencing the physical, emotional, and hormonal changes of puberty, making it difficult to control behavior. Teenagers swear at their parents, slam doors, and then become contrite. We know that such behavior may be a normal psychological, social, and physiological reaction for a teenager and do not automatically label it as a mental health problem. If a 45-year-old adult shows similar behavior, verbally abusing colleagues and exhibiting intense mood swings, then we would likely suspect a mental health condition. Our expectations of how a 45-year-old will behave are different from our expectations for a 13-year-old. All behavior must be viewed within the context of what is considered appropriate at each stage of life.

The top writing sample was written by an oriented 96-year-old woman. The writing is fairly clear and legible. The bottom writing sample is typical of a disoriented old-old person moving from Phase One to Phase Two. Families and staff can learn to recognize the change in handwriting as one way of assessing the phase of resolution.

Validation theory and practice are based on the following fundamental, humanistic principles:

•All older adults are unique and worthwhile.

•People should be accepted as they are: we should not try to change them.

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

•Painful feelings that are expressed, acknowledged, and validated by a trusted listener will diminish. Painful feelings that are ignored or suppressed will strengthen.

•There is a reason behind the behavior of very old disoriented people.

•Reasons underlying the behavior of very old disoriented people can be one or more of the following basic human needs:

Need to resolve unfinished issues in order to die in peace

Need to live in peace

Need to restore a sense of equilibrium when eyesight, hearing, mobility, and memory fail

Need to make sense out of an unbearable reality: to find a place that feels comfortable, where one feels in order or in harmony and where relationships are familiar

Need for recognition, status, identity, and self-worth

Need to be useful and productive

Need to be listened to and respected

Need to express feelings and be heard

Need to be loved and to belong: need for human contact

Need to be nurtured and to feel safe and secure, rather than immobilized and restrained

Need for sensory stimulation: tactile, visual, auditory, olfactory, gustatory, as well as sexual expression

Need to reduce pain and discomfort

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

•Personal symbols used by disoriented older adults are people or things (in present time) that represent people, things, or concepts from the past that are laden with emotion.

•Disoriented old people live on several levels of awareness, often at the same time.

•When the five senses fail, disoriented older adults stimulate and use their “inner senses.” They see with their “mind’s eye” and hear sounds from the past. Events, emotions, colors, sounds, smells, tastes, and images create emotions, which in turn trigger similar emotions experienced in the past. Older adults react in the present time the same way they did in the past.

A validating caregiver acknowledges the loss of eyesight, hearing, recent memory, and social controls of very old people. A validating caregiver understands that some very old people with a blurry present-day reality can easily return to the past to retrieve familiar faces. They need to go back to mend torn relationships. The validating caregiver does not judge them as behaving inappropriately. Viewed in the context of physical, social, and psychological factors, their behavior is healing; their retrieval of the past is functional.

An essential premise of Validation is that there is a reason behind all behavior. Understanding why disoriented old-old people behave the way they do and accepting the way they behave are key to validating them. The validating caregiver accepts the physical deterioration of the person; enters that person’s world; and becomes a nurturing, trusted authority. The old-old person then feels safe and begins to communicate, with or without words.

Disoriented old-old people respond to the genuine touching, nurturing, caring, and empathy they feel from the validating caregiver. Increased feelings of self-worth and well-being through Validation often lead to significant changes in behavior. Most importantly, older people in Resolution do not withdraw inward, but continue to communicate to the maximum of their potential.

The Techniques of Validation

The techniques of Validation are simple. They do not require a college degree but do require the capacity to accept and empathize with older people who are disoriented. Validating caregivers must be able to put aside their own judgments and expectations of behavior and learn to be sensitive to the logic behind the behaviors of very old people. Family members, nursing assistants, social workers, physical and occupational therapists, nurses, nursing home administrators, and anyone living or working with a disoriented old-old adult can learn to use these techniques. The techniques require no more than 8 minutes per day of genuine, open, nonjudgmental, empathetic listening. These techniques significantly reduce the anxiety of older adults. They are enormously helpful to families and to caregivers, who otherwise may experience burnout from working daily with older adults who are disoriented.

As Chapters 3 through 6 show, different Validation techniques are appropriate for different phases of Resolution. Some techniques, such as Centering, are used with old-old people at all phases; other techniques, such as touch, are appropriate only for particular phases (Feil, 1992b).

The techniques of Validation are simple to learn and can be performed within the course of a typical day. By using these techniques, caregivers can improve not only the lives of older people, but their own lives as well.

Technique 1: Centering

To Center, the caregiver focuses on his or her breathing to expel as much anger and frustration as possible. By releasing this anger and frustration, caregivers open themselves up to the feelings of the people with whom they are trying to communicate. Since it is crucial to release one’s own emotions to be able to listen empathetically to another person, all Validation sessions should begin with this technique. Centering takes about 3 minutes and is pleasant and relaxing. To Center yourself, follow these steps:

- Focus on a spot about 2 inches below your waist.

- Inhale deeply through your nose, filling your body with air. Exhale through your mouth.

- Stop all inner dialogue and devote all of your attention to your breathing.

- Repeat this procedure slowly, eight times.

Technique 2: Using Open Questions to Build Trust

People in Resolution do not want to understand their feelings. They are not interested in understanding why they behave the way they do. They retreat when confronted with their feelings. To effectively communicate with these older adults, the caregiver must avoid asking questions that force them to face their emotions. Instead, the caregiver should focus on factual questions—who, what, where, when, and how. Caregivers should avoid asking disoriented older people why something happened or why they did what they did.

An 80-year-old woman complains to her daughter that the housekeeper is stealing her jewelry. Rather than argue with her, the daughter concentrates on the factual. “Who is stealing your jewelry, Mother?” she asks. The mother is engaged by the question and responds to it. “That young mealy-mouthed know-it-all. You know—Gladys something or other. I can’t pronounce her last name. The one that thinks cleaning a house means moving dust from one room to another.”

“What does she take?” asks the daughter, continuing to focus on the factual.

“The last things she stole were my black earrings—the ones that Dad gave me.”

“Those were your favorite,” responds the daughter. “Dad gave you beautiful things. He knew just what looked good on you. When did he give them to you?”

“Right after we were married, on our honeymoon,” responds the mother. Her anger validated, the mother stops accusing the housekeeper and begins to reminisce about her husband.

Technique 3: Rephrasing

People in Resolution often find comfort in hearing their own words spoken by someone else. To rephrase, the caregiver repeats the gist of what the person has said, using the same key words. The tone of the voice and the cadence of the speech should also be used. When responding to a woman who speaks quickly, the caregiver should also speak quickly.

A 77-year-old man accuses his mechanic of damaging his car. “You broke my gearshift. This is the third time you messed up my car! I’m not paying you one red cent until you fix it! I want my car working the way it used to work.”

The mechanic knows that this man identifies with his car. The gears are wearing out, like the man. The man cannot accept his increasing night-blindness and the loss of his sense of direction. To validate the man, the mechanic rephrases, matching the man’s low tone with empathy. “You want your car to be shipshape. You want me to fix it so that it works the way it always did.”

“Damn right, I do—no ifs, ands, or buts. Those gears were working fine last week. Now, you fix them the way they were. I’m not buying any new parts for this car. It’s a great car.”

“You have a fine piece of machinery there, Mr. Simpson. And you say you want to keep it that way. You say those gears were working last week?”

“Well, I was beginning to have some trouble shifting into reverse. When I was driving last night, I almost backed into the wrong driveway.”

On a deep level of awareness, the older man knows he is losing his eyesight and that his sense of direction is failing. He trusts this mechanic, who does not argue or confront him with his losses. Validated, the older man feels stronger.

Technique 4: Using Polarity

The technique of polarity involves asking the person to think about the most extreme example of his or her complaint. By thinking about the worst case, the person being validated expresses his or her feelings more fully, thereby finding some relief. For example, to validate a woman who complains that the food is inedible, the validating caregiver asks, “Is that the worst chicken you ever ate?” The caregiver knows that the woman is venting her frustration over her poorly fitting dentures. She knows that the woman needs someone to listen to her anger. By letting her release this anger by complaining about the food, the caregiver helps relieve the woman’s anxiety.

Technique 5: Imagining the Opposite

Imagining the opposite often leads to the recollection of a familiar solution to the problem, provided the old-old person trusts the validating caregiver. An 85-year-old woman complains that a man enters her room each night. “That man came back last night.” To validate her, the caregiver asks her to think about times when the man does not appear. “Are there nights when he doesn’t come?”

“Well, come to think of it, when you visited me the other night, that man never once showed up. But as soon as you left, and I was alone, there he was—plain as anything.”

The caregiver rephrases the woman’s words. “You mean, whenever you’re alone, the man comes? If I were with you all the time, he would never bother you?”

“Well, I was never alone in my whole life. My husband was always with me. It was horrible when he died.”

“What did you do after he died?”

“I was so scared that I got all his pictures, and as soon as night came, I took out his favorite waltzes. I stayed up all night looking at his pictures and listening to his music. That’s how I made it through the night.”

By prompting her to think about a situation in which the man does not appear, the caregiver helps the woman recall how she dealt with a similar situation earlier in her life. Together, the woman and the validating caregiver find the pictures. Together, they reminisce about the woman’s husband. The woman restores her familiar way of coping with the fear of being left alone.

Technique 6: Reminiscing

Exploring the past can re-establish familiar coping methods that the disoriented person can tap to survive present-day losses. By the time a person reaches old-old age, it is too late to learn new coping skills. The validating caregiver can help the person retrieve old ways of handling stress, however. By using words such as “always” and “never,” the caregiver can trigger earlier memories. For example, by asking, “Did you always have a hard time sleeping, Mrs. Johnson? Even when your husband was alive?”, the caregiver may help trigger earlier memories of coping with a problem that the person had since forgotten.

Technique 5, imagining the opposite, and technique 6, reminiscing, are used together. One technique follows the other to help the old-old person restore familiar ways of overcoming stress.

Technique 7: Maintaining Genuine, Close Eye Contact

The very old person in Phase Two or Phase Three feels loved and secure when the nurturing caregiver shows affection through close eye contact. Even older people with impaired vision sense the concentrated focus of the validating caregiver who looks directly into their eyes. People who wander, looking for a nurturing parent, often stop wandering when the validating caregiver looks directly into their eyes. The validating caregiver can become a nurturing parent so those people can feel safe and loved. Their anxiety is reduced.

Technique 8: Using Ambiguity

People in Phase Two and some in Phase Three often use words that have no meaning to others. They often communicate nonverbally, in ways that are difficult to understand. By using ambiguity, caregivers can often communicate with the older person even when they don’t understand what is being said. For example, a person may cry, “These catawalks are hurting me!” The caregiver can respond by asking, “Where do they hurt?” The pronoun they substitutes for the unknown word catawalks. A person may confide, “I wirld with the woomets.” The caregiver asks, “Was it fun? Did they say anything?” The words he, she, it, someone, and something fill in for the nondictionary words. With encouragement of this kind, these people keep communicating, and withdrawal inward is prevented.

Technique 9: Using a Clear, Low, Loving Tone of Voice

Under neutral circumstances, harsh tones cause disoriented people to become angry or to withdraw. High, soft tones are difficult for many older adults to hear. It is important to speak in a clear, low, nurturing tone of voice. Often, a nurturing voice triggers memories of loved ones and reduces stress.

A disoriented 90-year-old man misses his wife. He cannot see, hear, or distinguish present from past time. Looking for his wife in the middle of the night, he finds a sleeping woman and climbs into her bed. The validating nurse understands that the man is returning to the past to fill his need to be with his wife. Although the man is deaf, the nurse nevertheless uses a nurturing, loving tone to ease both the longing of the 90-year-old man and the terror of the female resident.

“Mr. Jones, you miss your wife so much, you thought that Mrs. Drew was your wife. Does she look like her?” she asks in a low, nurturing tone full of respect. As the nurse talks, she gently helps Mr. Jones out of Mrs. Drew’s bed.

The old man begins to cry as the nurse takes his arm, helping him back to his own room. “You’re a wonderful woman, Molly. You’re the tops,” he says.

The validating nurse responds in a loving voice, “Molly was a wonderful wife. You love her very much. She is your sweetheart.” Together, in a soft voice, they sing, “Let Me Call You Sweetheart, I’m in Love with You.” His love for his wife expressed, Mr. Jones falls asleep without medication.

This technique should not be used when the person is expressing strong feelings and speaking in an emotional tone of voice. Using a warm, loving voice tone with someone who is angry, for example, will only create withdrawal or increased anger. In this case, the Validation worker should match the voice tone—see the following technique.

Technique 10: Observing and Matching the Person’s Motions and Emotions (Mirroring)

People who are disoriented often express their emotions without inhibition. To communicate with them, it is important to take stock of their physical characteristics and the ways in which they move. Caregivers should observe their eyes, facial muscles, breathing, changes in color, chin, lower lip, hands, stomach, position in the chair, position of the feet, and the general tone of their muscles to match these postures. When the person being validated paces, the caregiver paces. When the person being validated breathes heavily, the caregiver breathes heavily. Done with empathy, mirroring can be effective in helping to create trust. It allows the caregiver to enter the emotional world of the older person and to build a verbal and nonverbal relationship.

Mirroring the sometimes bizarre motions of the person can be a challenging experience for caregivers, and not all caregivers will want to try this technique. It asks that you be willing to enter the world of people who are disoriented and fully “walk in their shoes.”

Mildred Hopkins, a former legal secretary, never married. She worked for the same firm for 45 years. Now, at age 86, withdrawn inward to Phase Three, she must keep busy. Work was an important source of dignity. Her brain no longer informs her of her body’s position. Seeing her Underwood typewriter with her mind’s eye, she moves to the rhythms of her past, swiftly moving her fingers to complete her dictation so that her boss can go to court. The validating caregiver mirrors Mildred’s finger movements. Mildred sees the caregiver’s fingers matching her own rhythms. She looks up. Their eyes meet. They move together.

The caregiver smiles at Mildred with admiration. “You can type how many words per minute?” she asks.

With pride, Mildred responds, “92.”

This was the first word that she had spoken since she entered the nursing home 6 months earlier. In mirroring her movements, the validating caregiver established empathy with Mildred. Secure in the relationship, Mildred begins to look outward. Her speech improves, and she seems more aware of her surroundings.

Technique 11: Linking the Behavior with Unmet Human Need

Most people need to be loved and nurtured, to be active and engaged, and to express their deep emotions to someone who listens with empathy.

Lovingly, a 93-year-old woman folds her paper napkin. She smooths out each wrinkle, meticulously wrapping one fold into the other. Nothing is out of place. A waitress who does not understand Validation takes the napkin out of the old woman’s hand and shakes it. The woman begins to yell at the top of her voice: “Help! Help!” Instead of medicating or restraining the woman, the validating caregiver gives her the napkin. Together, they fold it carefully, lovingly, smoothing out each wrinkle.

“Does this make you feel safe and warm?” asks the caregiver.

The old woman smiles. She strokes the napkin moaning, “Ma, Ma, Ma. I love you.”

Somehow, the napkin has become a soft, loving mother for this old woman. The caregiver links the folding behavior to the human need for love. When old-old people pound or pace or rub or pat, the validating caregiver links the behavior to one of three human needs—love, usefulness (restoration of movements associated with work), or the need to express raw emotions.

Technique 12: Identifying and Using the Preferred Sense

Most people have a preferred sense. For some people, that sense is vision. For others, it is the sense of smell; for yet others, it is the sense of touch. Knowing a person’s preferred sense is one way of building trust because it enables the caregiver to speak the person’s language, to step into the person’s world.

To discover which sense a person prefers, the caregiver needs to listen and observe carefully, to try to key in on what the person is saying or trying to say. One technique for determining which sense a person favors is to ask that person to think about and describe an experience from the past. The first sense the person uses often reveals the person’s preferred sense. For example, a resident may describe a trip to the mountains she took as a young woman. “It was wonderful,” she may say. “We were in the mountains, and I could see the tips of the trees.” This resident probably prefers her sense of vision and may respond well to visually descriptive words.

Other people may be particularly sensitive to sound or touch and may favor hearing words (e.g., “This sounds bad,” “I heard it clearly,” “His voice was cruel”) or feeling words (e.g., “I feel terrible,” “I sense something,” “This hits me hard”). To build trust, the caregiver should try to use words that reflect the person’s Preferred Sense.

Technique 13: Touching

Touching is a technique that is usually not appropriate for people in Phase One, but it is often effective with people in Phase Two. In Phase Two, people have lost their defenses and often have poor vision and hearing. Cut off from visual and auditory stimuli, they need to feel the presence of another human being. They have lost track of clock time and are often unable to recognize people. They no longer distinguish between people they have known all their lives and people they have never met before. The validating caregiver can instantaneously become a loved person because people in Phase Two can incorporate strangers into their world.

People in Phase Three are no longer aware of where they are. They are encapsulated in their own space. To communicate with them, the caregiver must enter their world and touch them in the same way a loved one touched them. To use touch with a disoriented person, the caregiver should approach the person from the front, as approaching from the back or the side may startle them.

I have found that pleasant memories of early childhood are often evoked through touch. With people in Phase Three, the validating caregiver can often establish an immediate intimate relationship by using the following techniques:

- Use the fingertips in a light, circular motion on the upper cheek (mother-touch).

- Use the fingertips in a circular motion with a moderate amount of pressure on the back of the head (father-touch).

- Use the outside of the hand, placing the little finger on the ear lobe and curving along the chin with both hands; make a soft, stroking motion downward along the neck (partner-touch).

- Use cupped fingers on the back of the neck with both hands in a small circular motion (child-touch).

- Use both hands to rub the shoulders and upper back (brother/sister/friend-touch).

- Touch the back of the calf with the hand (reminiscent of working with large animals [e.g., a farmer]).

Naomi Feil demonstrating the “mother-touch,” which is good to use when a client is missing his or her mother.

Touching another human being is an intimate act, and caregivers—both professionals and families—must always respect that some people may not want to be touched. Any sign of resistance to physical contact should indicate to the caregiver that touching is not appropriate. The personal space of all people, whether they are disoriented or not, must always be respected.

Technique 14: Using Music

When words have gone, familiar, early learned melodies return. Stored forever in the brain’s circuits, early learning, reinforced through the years, remains. People in Phase Three who no longer retain the ability to speak can often sing a lullaby from beginning to end. When a former sailor, now 95 years old and in Phase Three, paces back and forth, his daughter validates him by singing “Anchors Away, My Boys.” The sailor stops, looks at his daughter, smiles, and sings with her. The sailor does not recognize his 60-year-old daughter, nor does he know the name of the song, but he sings each word. His daughter can now communicate with music. She sings with her father because he can no longer talk.

People in Phase Three will often say a few words after singing a familiar song. Music energizes many people who are disoriented.

VALIDATION AROUND THE WORLD

Using Mirroring to Make Contact

Vicki de Klerk-Rubin

Validation Master

Validation Training Institute

United States

A WOMAN CONTACTED NAOMI FEIL for some advice on how to help her mother, who was living in a nursing home in New York and having many difficulties. Naomi suggested that I contact her since I lived in New York at that time. When I did, it led to an extraordinary series of encounters with the mother, the daughter, and her husband.

The smell of urine struck me first, then the dinginess of the walls. As I walked from the elevator, I could hear a sort of screaming or chanting from a woman as I walked toward room 302, my destination. The whining “ma-mama” sounds were emanating from this room. This would be my first encounter with Mrs. W.

I knocked and entered when invited. Sitting by the window was a thin, very old woman who was gesticulating with great energy; making high-pitched, almost whining sounds and words; and yelling in a pulsating rhythm. As I approached, I could feel her energy, her drive, her need to communicate. After quickly introducing myself to the daughter and her husband, who were visiting, I approached Mrs. W and made easy eye contact. She drew me in with her eyes and tremendous need to get her point across, although I had no idea what that was.

I sat very close to her, facing her at eye level. Continuing the intense eye contact, I started to mirror her rhythms. Immediately we had contact. I introduced myself: “Mrs. W, I’m Vicki de Klerk. How are you?” She tried “speaking” to me. I tried putting words to what I was sensing: “You want to get out of here!” “This is no good.” And she answered, “Yes.”

Vicki:

Where do you want to go?

Mrs. W:

I want to go home.

Vicki:

Who do you want to see?

Mrs. W:

(sounds)

Vicki:

Do you want to see your husband?

Mrs. W:

Yes.

Vicki:

Do you miss being a wife?

Mrs. W:

(nods yes)

Vicki:

Is it that you want to go home or do you want to get out of HERE?

Mrs. W:

(no answer, but her eyes start to close)

Vicki:

Do you sleep a lot when things get too painful to handle?

Mrs. W:

(keeping her eyes closed, nods yes)

I visited several times and, with coaching, Mrs. W’s daughter and sonin-law started using elements of Validation in their daily visits. From that first visit, they saw that contact was possible and that there was a reason behind their mother’s behavior. They took her out of the nursing home on short trips, which gave them all great pleasure. Mrs. W responded to them more often and with less whining. They still struggled with their desire to make “Mom” feel better and accept her situation, but they also understood that they could keep communicating with her and share her feelings of frustration. They understood that the whining and complaining sounds were part of Mrs. W’s character and were behaviors that she had had her whole life. Mrs. W passed away some months later, still complaining, still resolving, but also still communicating with her children.

CHAPTER 3

Using Validation with People Who Are Mostly Oriented in Phase One

The people you will meet in this chapter—and all the people throughout the book—are composites of real people with whom I have worked since 1956. All of the people in this chapter are in the first phase of Resolution. The vignettes show that appropriate use of Validation can help caregivers communicate with older adults in Phase One and avoid stressful encounters.

The Case of Frances, the Accuser

Frances Blake was diagnosed with Alzheimer’s-type dementia. She was a blamer. She was 82 years old when I met her, and she knew where she was most of the time. She cradled her shiny black patent leather pocketbook under her arm. Frances’s pocketbook was stuffed with paper napkins. After cataract surgery and a broken hip, Frances had begun to forget names. It was then that she began hoarding. Hoarding helped Frances regain control. Her purse had become her personality. She filled it up to hold herself together and keep going.

At least once a week, Frances would march into my office in the senior housing complex, plunk herself down, and begin to blame. She would always accuse the same person.

“That Elsie Barker did it again!” she would shout angrily. “Last night she stole my pure silk lace panties. Raw silk! Then that hussy marched over to Sam Peltz’s room. You know, the good-looking young man across the hall with the mustache! He’s only 78.” Frances leaned close, cupping her hands to her lips. She whispered to me confidentially, “She stays in his room all night!” She paused for emphasis before adding, “With my panties.”

I checked out her story. There was not one shred of truth in her accusations. I showed Frances her raw silk lace panties with her name sewed in them, hidden under a napkin in her bottom drawer. The more I tried to convince her that no one was stealing her underwear, the angrier she became. Reality orientation made her abusive. Her voice became nasty. “Are you calling me a liar? I know my own pants, and those are not mine! Somebody sneaked those pants into my drawer,” she would say when I confronted her. Patiently, I tried to help her by giving her insight into her behavior, to help her understand her feelings, to help her understand why she blamed Elsie.

“Mrs. Blake,” I said. “Why do you think Elsie Barker steals your panties?”

“Because that woman is no good! There’s a word for her in the dictionary. It’s spelled ‘w-h-o-r-e.’ I don’t use that word because I am a lady! I don’t fool around with every new man that walks into the building.”

“Do you miss having a man around the house?” I asked. “Did you feel robbed when you lost your husband?”

“Just because my husband died, I don’t go around stealing other women’s underwear,” she retorted angrily. “I’m going to let Sam Peltz know what kind of woman that Elsie is.”

Frances Blake did not want to understand why she blamed Elsie Barker. She did not want to face her feelings of jealousy. After a lifetime of redirecting feelings that she found unacceptable, it was too late for her to change. Blaming had become her way of coping.

Life went sour for Frances after her husband’s death; she blamed to survive. Her blaming became so unbearable that her daughter stopped visiting her. “I can’t take Mother anymore,” she told me. “When Dad died, she blamed the doctor. When she got sick, she blamed the hospital. Now her memory is going. She forgot to turn off the stove and burned the food, so she blamed me. The older she gets, the worse she gets.”

Frances Blake never learned to trust herself. She skipped an important life task: to trust that she could survive losses. The deeper the fear, the more she blamed other people. In terror of losing her memory, she blamed her daughter. Out of loneliness after the death of her husband, she blamed Elsie. She ended up alone. At first, her friends tolerated her. They tried to modify her behavior by walking away whenever she began to rant and rave about Elsie. Behavior modification did not work, however; Frances got worse.

Frances Blake wanted to be heard. She needed someone to listen. In her old age, she had reached the Resolution Stage of Life. Loaded with feelings she had never expressed, she used Elsie to unload her baggage. She was finally struggling to patch up her life. But we ignored her. And the more we ignored her, the more she blamed and raged. Placed on tranquilizing medication prescribed by her psychiatrist, she shriveled up and was transferred to a nursing home.

Using Validation with Frances Blake

I learned through my failure with Frances Blake. I learned not to contradict, patronize, argue, or try to use logic or give insight. Had I known how to validate Frances, I might have prevented her transfer to a nursing home. When she told me about her stolen panties, I should have rephrased her words by asking “Your best silk pants? When did she steal them, Mrs. Blake?” Feeling my concern, Frances Blake would have begun to trust me.

“Who gave them to you?” I should have asked, to encourage her to reminisce. Mrs. Blake might have expressed her real grief—the loss of her husband and the loneliness of living alone. By validating her grief and anger, I would have helped to alleviate some of her stress. If Mrs. Blake had someone to listen to her, her blaming would probably have diminished, and she would have been accepted by her friends and neighbors.

The Case of George, the Loner

George Smith was another blamer. A fleshy, puffy, 86-year-old man with deep, pinkish circles obscuring his small brown eyes, he sat up nights in his overstuffed chair listening for the drip from the ceiling. He would not sleep in his bed. His scratchy voice was weary. “Can’t you patch up that hole? What kind of a man are you? I can’t sleep in a bed that’s full of water. It smells terrible!”

George’s son, James, checked the ceiling. There was no leak. The physician checked George. He found weak bladder muscles that caused George’s incontinence. James knew that his father could not accept physical weakness. George blamed a leaking roof to allay his fear of losing control. When his father raised the subject, James tried to divert him.

“Dad, there’s no leak in the ceiling,” said James. “How’d you like to go out for a cup of coffee and a doughnut? What do you say, Dad, just the two of us?”

“Don’t ignore me, James,” said George. “You don’t believe me. You think I’m making this all up. You don’t get dripped on all night. Your roof doesn’t leak. You don’t know what it’s like living here.”

George Smith saw through his son’s attempts to change the subject, to divert his attention, to ignore his needs. Like all blamers, on a deep level of awareness, George knew the truth. Like a sleeper who, without waking, slaps a mosquito, blamers know unconsciously why they blame. Deep down, George Smith knew that he could no longer control his urine at night. But he could not face this awful truth. The awareness that he was losing physical control over his body was too terrifying.

George Smith had never faced his fears. Throughout his life, he had controlled his feelings of anxiety. He was filled with fears of falling apart. He could not stop the physical deterioration that worsened as he grew older. The worse things got, the more he blamed his son.

At age 88, George was diagnosed by a gerontologist as having Alzheimer’s disease. He was sent to a nursing home, where he died after 2 years. He never adjusted to the change in environment and simply withdrew inward.

Using Validation with George Smith

I heard about George Smith only after he died. Had I met him earlier, I could have worked with his son to help him validate his father’s blaming, and James’s frustration might have subsided. By using Validation, James could have avoided confronting his father about facts and focused on responding to his emotional needs. The interaction could have been altogether different.

“James, not only did you do a lousy job when you plugged that hole in the ceiling, but you also did something to make the pipes spring another leak. I can’t tell where the water is coming from. What kind of a plumber are you?”

James would have Centered to free himself of his anger at his father’s unfounded accusation and then rephrased his father’s words. James would have realized that his father’s incontinence was at fault. “You mean there’s another leak? Where do you think the leak might be coming from, Dad?”

“If I knew where the leak was, I’d fix it myself. I wouldn’t ask you.”

To help his father express the full extent of his anger and fear at becoming incontinent, James would have used polarity. “How bad is it? How much water is leaking out of the pipe?”

“It’s pretty bad, son. And it’s getting worse. Do you smell it? The stench is from the sewer, I reckon.”

Picking up on his father’s use of olfactory words, James might have asked, “Is it a rancid odor? Like rotten wood? Or more like mold?”

“It smells more like mold. The same odor your mother complained about in the hospital. Remember? She used to complain about that old lady in the other bed in the hospital.”

James might have realized that his father feared losing control over his functions, the same way James’s mother had before she died. George Smith needed to verbalize his fear indirectly.

James could ask, “What did Mother say about the old lady?”

“That she couldn’t stand the stench another minute. So, I got her that lilac perfume, the one your mother liked so much,” said George.

“Do you think some lilac aftershave could help now?” asks James.

“Well, we could try it until we find out where the leak is coming from. I think the pipes are rusted out. We need new plumbing in this house.”

James would have understood that his father was afraid that his body was wearing out. George would probably not have stopped blaming the leaking pipes for his increasing incontinence, but with Validation, his son would have been able to help his father regain self-respect by validating him whenever he expressed his fear and anger. George Smith would not have withdrawn inward and shut himself off to the world.

The Case of Jenny, the Gardener

Jenny Fish’s blaming blossomed when she moved to her new apartment. Jenny was a kind, gentle, 81-year-old woman who worked in her garden every morning. Wearing pink slippers, she gracefully walked down to her rose garden each morning, bothering no one, soothing her bruised roses after a storm. Her problems began when the owners of her apartment building decided to eliminate the garden to extend the parking lot. Jenny was forced to say goodbye to her roses and move to a different unit. Six stories up, without even a patio on which to grow potted plants, she began to hear funny noises at night.

“That man next door is banging furniture,” she shouted indignantly. “He moves the bed around at night, and he breathes funny. He starts at midnight and goes on for hours so that I can’t sleep a wink.”

Jenny’s apartment faced the outside wall; she had no neighbors. A medical examination found her to be healthy. She had no history of mental illness, no vitamin deficiency, no tumor or kidney infection. Her eyesight, hearing, and recent memory recall were normal for her age. Her general practitioner diagnosed her as having “mild NCD possibly due to Alzheimer’s disease with delusions, but confined to an imaginary male,” and otherwise healthy. He recommended a tranquilizer to reduce her anxiety during sleepless nights.

Her niece, Rita, showed Jenny the wall outside her apartment. Walking up and down the hallway, Rita and Jenny knocked on doors and found no male tenants living nearby. Hoping that socializing might calm her aunt’s fears, Rita encouraged Jenny to attend the Garden Club meetings held at a nearby community center. Jenny refused, saying she was too tired to go anywhere because “that man” would not let her sleep. To modify Jenny’s behavior, Rita excused herself and walked away whenever Jenny began her tirades. Rita’s departure made Jenny’s accusations worse. The man next door became even more real, taking on a physical dimension. Jenny described him to her one-time friends in vivid detail.

“He’s tall,” reported Jenny, “with a long nose, huge nostrils, and dirty fingernails. He uses his nails to scrape the wrought iron bed to make that funny sound at night. Don’t ask me how he does it, but he breathes that fast panting sound so hard that I hear him right through the wall.”

One by one her friends left her. Her niece pleaded with me, “Can’t you make her stop? I don’t want to put my aunt in a nursing home.” That’s where Jenny ended up.

Using Validation with Jenny Fish

Had Jenny been validated—by a family member, by an adult day worker, by a neighbor, by a doctor—I do not believe she would have deteriorated. The scenario could have been entirely different. Jenny’s niece, Rita, suspecting serious problems but not knowing how to deal with her aunt, might have taken Jenny to a psychologist trained in Validation. The encounter might have gone like this:

“What does the man look like, Mrs. Fish?” asks the psychologist, focusing on visuals, Jenny’s preferred sense.

“He has thick black hair, all over his head and body,” she whispers.

The psychologist nods empathetically, acknowledging her fear without words.

“Is he tall?” asks the psychologist, again focusing on the visual.

“He has a long nose with big nostrils, like Jimmy Durante.”

“What is he wearing?”

“Doctor, sometimes he isn’t wearing anything at all,” replies Jenny.

“You mean he is all naked?” asks the psychologist, matching the tempo and pitch of Jenny’s voice.

“Not a stitch. Imagine his nerve. Staring at me all night long,” continues Jenny.

“What does he do?” asks the psychologist.

“He just looks at me through the crack in the wall. Laughing at me. I think he knows that I hate living in this place,” responds Jenny, sadly.

“How long has this been going on?” asks the psychologist.

“Wait a minute. I can’t remember the exact day, but I wrote it down in my diary. Here it is. Friday, October 17th.”

“Isn’t that the day you moved?” asks the psychologist.

“That’s right. That’s the day they tore up my roses for a parking lot!”

The psychologist, trying to help Mrs. Fish to imagine the opposite, asks, “Mrs. Fish, are you telling me that if you still lived in your old apartment and if you still had your roses to take care of, that man would go away?”

Jenny remains silent for a few minutes and then says, “You know, I never used to see a man staring at me. I was very happy in my own place. I lived there most of my life. And I always had roses, even when I was a little girl at home.”

“What kind of roses did you grow?” asks the psychologist.

Jenny replies, “They were the most beautiful Peace roses. Very rare in this part of the country. I always bought a special kind of soil for them. Very expensive, but my roses were gorgeous.”

The psychologist, suspecting that the fear Jenny felt when she lost her garden and her familiar home may have triggered her early fears, could have helped her find a creative solution. Jenny needed to grow roses to still her fears. She expressed her love and energy through her flowers.

“Do you think that the man might leave you alone if we found a little spot for you to grow your Peace roses again?”

“It’s very likely. Those thorns will frighten him. I think my roses always kept men away. That’s why this has never happened before.” Jenny feels relieved and brightens at the thought of gardening again. She begins to trust the psychologist, who helps her find a small garden. Jenny stops seeing her imaginary man. She is able to express her fears to the psychologist, who continues to validate her once each month.

The Case of June, the Blamer

June Simpson bloomed as a blamer when she lost her husband. Three years after her husband’s death, she tried to shoo away her neighbor’s dog and fell and broke her hip. She blamed her neighbor, who had been her friend. “If you had watched that dog, I wouldn’t have broken my hip!” she yelled. “It’s your fault!”

When her gums decayed, her bridge loosened and she had trouble chewing. She blamed the butcher in the meat department of the grocery store. “That meat is so tough, only a horse could chew it. Horse meat, that’s what you sold me! Now I have to buy a new bridge. I ought to sue you!” The butcher ignored her. Her neighbors avoided her. June, they said, had a loose screw.

June had led a productive, normal, neurotic life. When things went wrong, she pulled herself together by blaming and then went on with her life. She had been a bookkeeper in a large law office, where she had performed her job with great competence. Before reaching old age, she had never had to face many losses simultaneously. She hadn’t developed skills for coping with the multiple problems she now faced in old age, when her losses piled up. She had nothing to do to take her mind off her troubles. She had no one to love. She had lost her husband, had no children, had no job to which to turn. As the pains and losses of aging grew, she found herself unable to cope. Her only way of living through hard times was to blame. She lost her friends and died alone.

Using Validation with June Simpson

I wish I had met June Simpson’s neighbors before she died. By teaching them how to validate June, I might have kept her from dying friendless and alone. The brief but unpleasant interaction with the butcher could have been a validating experience for June rather than the bitter encounter it was.

“Horse meat, that’s what you’re selling me. It tastes terrible. No human being could swallow that meat,” screeches June, angrily.

“Does it taste that terrible?” asks the butcher.

“I’ll bet you wouldn’t eat that meat. It’s tough and terrible, so don’t try to pretend that stuff is the best steak,” replies June.

Encouraging June to reminisce, the butcher turns the conversation to June’s late husband. “You’re used to eating the best,” he says. “I remember your husband. He sure knew how to shop. He was a remarkable man.”

“He always shopped for me,” replies June, her tone already calmer. “Every Saturday. He knew just what to buy.”

“What a great man he was,” comments the butcher. “He always picked the best cuts. Only filet for him.”

“Well, I’ll try the same cut. Do you think I should use another kind of tenderizer?” asks June, forgetting her anger.

“It might help. How are you seasoning your meat right now, Mrs. Simpson?”

How to Read the Vital Signs of People in Phase One

I have introduced you to four very old people. All of them communicate well and are mostly oriented, but they are denying their losses, confabulating to hide their weaknesses, and clinging to what they have not yet lost. They struggle in the present time to express feelings they did not deal with in the past. The validating caregiver does not view their behavior as delusional or irrational, but seeks to ease the pain they feel over these unresolved conflicts. The losses that these older adults face in present-day reality trigger memories of earlier losses. They blame to cope with so many losses. Their behavior is functional.

What Does it Mean to Be in Phase One?

Older adults in Phase One are usually more than 80 years old, have no history of mental illness, speak clearly, and are mostly oriented to time and place, with occasional recent memory lapses. They are oriented, but not happily so. They are unhappy because they need to address unresolved issues, and they use people in the present to express emotions they have not expressed in the past. Here are some commonalities among older adults in Phase One:

- They cannot accept the increasing physical and social losses that inevitably accompany very old age.

- They have never faced important life tasks. These tasks include establishing one’s identity; achieving intimacy; learning to establish appropriate emotional and behavioral controls; learning to trust other people; learning to accept losses, especially the losses that come with aging; becoming involved in new activities; achieving integrity; and accepting what is, what was, and what can never be.

- They are able to function in most areas of daily living but repeat or fixate on an idea or theme that is often untrue of present-day reality.

Physical Characteristics of People in Phase One

Older people in Phase One share similar physical traits and may express themselves in distinct ways. The following characteristics are often observed in older adults who are in Phase One:

- Their eyes are clear and focused.

- Their muscles are tight.

- Their chins jut out.

- They sit or stand with their arms folded.

- Their body movements are purposeful.

- Their voices may be shrill, whiny, or harsh.

- Their speech is clear.

- Their recent memory is largely intact, although occasional lapses occur.

- They retain the ability to read and write.

- Their cognitive abilities, including the ability to tell time, remain intact.

- They experience occasional urinary incontinence.

The woman pictured here has an expression associated with Phase One. People in Phase One often have tensed muscles, make direct eye contact, and gesticulate to make a point. This woman is expressing anger to someone who is listening. We can see the tension in her lips and narrowing of her eyes.

Psychological Characteristics of People in Phase One

In old-old age, people face a final life task. They must express the emotions and fears they have buried for a lifetime. Present-day losses trigger vivid memories of past losses; today’s fears stimulate memories of similar fears of long ago. The little boy who was punished and felt ashamed and bad for wetting his pants becomes the old man who blames his roommate for spilling water all over the floor because he is too ashamed to admit that he can no longer control his bladder.

Older adults in Resolution often use people or objects in the present time to express feelings that they should have expressed at an earlier life stage. For example, an 80-year-old woman who never expressed her bitterness and grief when her husband died at 40 claims that her roommate has stolen her wedding ring. She hides her wedding ring, a symbol of her marriage, so that she can accuse others of robbing her of her husband. In doing so, she finds a way of expressing her anger and grief without coming to terms with her feelings. She does not want to be made aware of the reason behind her behavior. She rejects insight, which frightens her. She does not want to be confronted with her loneliness, which she prefers to deny. These denied emotions cause pain, which she deals with by getting angry at her roommate.

People in Phase One share certain psychological characteristics:

- They have no long-term history of mental illness.

- They have generally led relatively productive lives.

- They have failed to complete certain life tasks and have entered the final Resolution Stage of Life.

- They need to express certain emotions that have been bottled up throughout their lives.

- They are unwilling and unable to face unpleasant reality and thus deny their losses.

- They avoid intimacy and do not like being touched.

- They cling to present time and place.

- They are fearful of losing control of their physical and mental functions.

- They fear change and adapt poorly to new surroundings.

- They do not want to change familiar behaviors and consequently do not respond to behavior modifications.

- They hold on to familiar coping methods.

- They try to maintain control and deny the loss of control.

- They resist change.

- They are threatened by confrontations.

- They do not want to be analyzed.

- They do not want insights.

- They seek approval from caregivers.

- They feel relief when validated.

Frequently Seen Behaviors of People in Phase One

The behaviors often seen in Phase One are triggered by physical changes that occur during the aging process and are tied to the psychological ways in which people have dealt with crises throughout their lives. Blaming, accusing, and complaining are some of the familiar ways in which people in Phase One cope when things go wrong. When they reach old age, they cling to these well-established coping methods like a drowning person clings to a life preserver. They are afraid of aging. As more and more things go wrong, their blaming, accusing, and complaining get worse.

People in Phase One accuse others of acts that may include stealing from them, poisoning them, and spying on them. They accuse to relieve themselves of anger, hurt, or sexual fears. They may hoard and clutch items, such as pocketbooks, canes, or newspapers. In an attempt to regain control over their lives, they often hoard objects that symbolize their losses. They hoard toilet paper to express their fear of incontinence; they hoard pencils and paper to conceal a fear of losing their ability to write; they hide keys to cover their worry of losing their home or their ability to drive.

Understanding People in Phase One

I worked with scores of people who were blamers. I spoke with their relatives, their neighbors, their friends. I reviewed their medical and social histories. I began to find clues to their behavior. Similar threads appeared again and again when I pieced together the fabric of their lives.

What clues are revealed in these four vignettes that might help us understand the behavior of these people? All four of these people shared the following characteristics:

- They were diagnosed as being in the early stages of Alzheimer’s disease, with hallucinations.

- They had no history of mental illness.

- They did not want insight into the reasons behind their behaviors.

- They did not want to change their behavior and were not helped by behavior modification.

- They accused others in order to express emotions they had long suppressed.

- They experienced shame, guilt, and feelings of inadequacy as a result of present-day losses, which triggered similar feelings from the past.

- Without the benefit of Validation, they all deteriorated.

“Helping” Techniques That Make Matters Worse

People who live or work with older adults in Phase One and want to help them must recognize what will make this population worse. I have found that people in Phase One respond poorly to the following:

- Insight-oriented therapy, such as psychotherapy or counseling

- Behavior modification

- Being confronted with reality when they blame or accuse

- Being helped to get in touch with their feelings

- Being asked to analyze their own behavior

- Being patronized in order to be placated

Validation Techniques for Communicating with People in Phase One

People in Phase One are often well adjusted in most areas of daily living. Their combative or confused behavior is often triggered by specific fears induced by aging losses. For example, the woman who sees a man under her bed may behave perfectly rationally until she is overwhelmed by unwelcome sexual thoughts that she could control in the past. A man who is ashamed of his incontinence may behave rationally until he realizes that he has soiled himself. He is ashamed and blames others for his faulty plumbing.

A Validation practitioner approaching the client from the front, at eye level, making eye contact, and seemingly at a distance that is comfortable to the client. This is a good example of a “validating approach.”

People in Phase One respond very well to Validation. A validating caregiver listens with empathy, knowing that these people are bringing the past to the present to wrap up their lives. When older adults express their feelings of pain, and when these feelings are validated, they experience relief and become less anxious. When they are heard, the repetitive behaviors lessen. Listened to with respect by a nurturing caregiver, people feel more adequate. After about 6 weeks of consistent Validation, their accusing and complaining lessen and often cease altogether. Most importantly, people in Phase One who are validated continue to communicate and do not deteriorate and withdraw.

As the cases of Frances, George, Jenny, and June reveal, many of the Validation techniques presented in Chapter 2 can be used effectively with people in Phase One:

1. Centering: Centering is crucial for working with people in Phase One, whose accusing and blaming behavior is often hurtful to friends, families, and caregivers. Acknowledge your hurt, anger, or frustration over their behavior, and then put these emotions in the closet so that you can tune into the world of the other person.

2. Using nonthreatening, factual words to build trust: Use words that get at facts rather than emotions. People in Phase One are not interested in understanding why they behave the way they do. They are not interested in exploring their emotions. When talking with people in Phase One, use words like who, what, where, when, and how— but never why—to get at the facts of the situation. Validate feelings only when the person expresses them.

3. Rephrasing: Repeat in your words what the person says using his or her key words. Adopt the pitch and tempo of the person’s voice, the look in the person’s eyes, and the person’s facial expression. This genuine expression of empathy helps the older adult feel understood by a caring person. Their anger subsides. Rephrasing must be genuine. The validating caregiver corroborates the feelings of the individual and builds trust through rephrasing.

4. Identifying the person’s preferred sense and emphasizing this sense: By listening to the other person, you can identify which sense he or she prefers. If the person tends to use a lot of visual words, focus on visual perceptions (e.g., “What does it look like?” “How do you picture it?” “What color is it?” “How tall is he?”). If the person reveals that he or she hears noises at night, focus on aural perceptions (e.g., “What does it sound like?” “What kind of noise was it?”). If the person complains about feeling pain, use kinesthetic (i.e., feeling) words (e.g., “Is it a sharp pain?” “Is it pounding in your head?”).

5. Using polarity: Often, people respond to being asked to describe the extreme form of their experiences (e.g., “How bad does it hurt?” “When is it the worst?”).

6. Helping the person to imagine the opposite: Ask the other person if there are times when the behavior he or she has described does not occur (e.g., “Is there a time when the man does not hide under your bed?” “Is there a time when your roommate doesn’t steal your clothes?”).

7. Reminiscing: Explore the past to establish trust and re-establish familiar coping methods that the older adult can use to handle present-day crises. People in Phase One can no longer learn new ways of coping, but they can tap into well-established, familiar ways of coping with crises.

To establish a trusting relationship with a person in Phase One, Validation sessions must take place in a private room. The amount of time the validating caregiver spends with the older adult depends on the person’s verbal capacity, the length of his or her attention span, and the amount of time the caregiver has available. Three 5- to 10-minute validating sessions a day should be sufficient for people in this phase of Resolution. To establish a trusting relationship, validating interactions between the caregiver and the older adult should take place at least once a week. It is very important that sessions not be missed, as many people in Phase One fear rejection and abandonment. They need to feel wanted.

The results of these sessions should be noticeable. After 5–10 minutes, the caregiver should note the following physical changes to indicate that the other person’s anxiety has diminished:

- The lower lip will be relaxed.

- The voice will be steadier.

- Breathing will become more even.

- The muscles will relax.

- The eyes will be calmer.

- The blaming and accusing stop or lessen.

When ending a validating session, the caregiver must remember that most people in Phase One retreat from intimacy. Hugs often make them feel uncomfortable. A handshake or a gentle touch on the forearm is a better way to end.

VALIDATION AROUND THE WORLD

The Case of Mrs. Hara

Fumie Inatani

Validation Teacher

Kurume University

Japan

MRS. HARA WAS 88 YEARS OLD when I first met her at a nursing home in Minami Kyushu (Japan). Her husband had passed away in his 40s, leaving her to raise their five children by working as a farmer as well as a construction worker. From youth, Mrs. Hara was no stranger to hard work, and even when she was older, she went out into the fields to work and also took care of her grandchildren. She was proud of her family.

According to her medical history, Mrs. Hara had fallen and sustained a lumbar compression fracture, causing lower back pain. Before being admitted to a hospital, she operated a farm with her third son’s family. Although Mrs. Hara could recognize that she was in a hospital, she would say that she had arrived one month earlier, when in fact she had been there for a considerable period of time. After being admitted to the hospital, she started to develop symptoms of dementia, was diagnosed as having dementia, and was moved to a nursing home where her third son’s wife would often visit her.

When Mrs. Hara was moved to the nursing home, she often woke up at night to wash her eyes and would go to the nurses’ station to ask for eye drops or a wet compress for her leg, which she claimed hurt. When she was taken to a doctor’s office to see an ophthalmologist and a surgeon, she looked a little relieved. She again, however, started to express feeling pain at night. Mrs. Hara often spent time in another unit that had a telephone, saying that her family might call her. She volunteered to help the staff during the daytime, but she stayed awake alone at night. One night, she became upset and scattered water in the room next to hers, saying, “My neighbor poured water on my bed.” She would sometimes sneak out of the unit.

The staff sought my advice. As Mrs. Hara was usually oriented, it seemed that she was in the first phase of Resolution. When I met Mrs. Hara, she was helping the staff in a unit of the nursing home. Her lower back was a little bent, but she was working briskly and skillfully folding towels.

Mrs. Hara:

(focuses her attention and diligently folds towels)

Fumie:

Good evening.

Mrs. Hara:

(silent)

Fumie:

You are quick at folding towels.

Mrs. Hara:

(continues to fold towels in silence, then speaks) I am not quick. I am old. I am not quick!

Fumie:

Yes, you are quick. (attempts folding a towel in the same way) Mrs. Hara, is this good?

Mrs. Hara:

(nods silently)

I had recently come to learn about the techniques of Validation and chose to focus all my energy on understanding the meaning behind what Mrs. Hara had said when we first met. I visited her every Saturday. One day Mrs. Hara asked me, “Have you already eaten?”

“Not yet,” I replied.

“Not yet? If you told me in advance, I could have prepared something.” She cared for me.

Using open questions and rephrasing, I was eventually able to learn about where Mrs. Hara used to live and about her children and grandchildren. Invariably she would return to the beginning of our conversation by asking, “Have you already eaten? You should have come a little earlier.” The conversation would then go in circles and fail to progress any further. Our session would end with Mrs. Hara saying to me, “Please come again. I will be waiting for you.” Although our conversations were based in reality, I had not yet been able to delve deeper to uncover what she was feeling.

The staff shared with me that the evening following my fourth session with Mrs. Hara, contrary to her routine of waking up many times in the middle of the night and saying that her eyes and her legs hurt, she slept all night without waking even once. It was during our fifth session that Mrs. Hara expressed to me for the first time that her legs hurt and began to reveal the meaning behind her expressions of pain. She wanted to feel more useful to her third son. During the night of our sixth session, Mrs. Hara was sitting in a chair of the living room expressing pain:

Fumie:

Hello, I came again.

Mrs. Hara:

My leg hurts. I cannot move.

Fumie:

Your leg hurts. Does it always hurt?

Mrs. Hara:

It does not always hurt. It hurts in the morning.

Fumie:

When does it hurt the most?

Mrs. Hara:

Ouch. It hurts the most in the evening.

Fumie:

Where does it hurt?

Mrs. Hara:

Here, here (stroking her thigh). Here it hurts.

Fumie:

Is this where you had a fracture? (stroking together) Did you apply a compress?

Mrs. Hara:

Yes, I did. Ouch. It hurts. It hurts when I am resting.

Fumie:

It hurts when you are resting. Is it better if you are awake?

Mrs. Hara:

There is nothing good. Everything is full of pain.

Fumie:

Everything is so painful that it feels hard to live. How can this pain be relieved?

Mrs. Hara:

Well, it is painful no matter what medicine I take.

Fumie:

Will it help if you see a doctor? Do you want someone to keep you company?

Mrs. Hara:

It would be a little better if my son was here. Being here is meaningless. As I am not useful, I want to go home. (speaking much faster because of her irritation and anger)

Fumie:

Mrs. Hara, do you want to be useful to your son? What do you want to do when you go home?

Mrs. Hara:

My pain does not get better even if I stay here. I want to go home to help them work in the field. I want to look after my grandchildren. I want to be useful to my son. (Her breathing became faster, and she looked mortified and cried. She told me how hard her life was after her husband died and how she supported herself by working.)

Mrs. Hara’s physical pain was a manifestation of her emotional pain, which originated from the irritation and anger she felt about not being useful. As I continued the Validation sessions with her, I came to recognize her losses and sorrow and was able to find empathy and accompany her. Although Mrs. Hara said that her leg hurt so much that she could not move and she appeared to have difficulty breathing, she was able to stand up firmly and say, “It’s late. I will walk you out.” She then walked me to the entrance. From then on, the staff accompanied and listened to Mrs. Hara whenever she could not sleep. Three years later, Mrs. Hara passed away at the age of 91. She was in good spirits at the nursing home up until the day prior to her passing.

CHAPTER 4

Using Validation with People Who Are in Phase Two

The Case of Martha, the Birther

Here is a portrait of a woman who is still verbal, but who has returned to the past. She is not concerned with present-day reality. She has entered the second phase of Resolution. Old-old people rarely stay in one phase within a 24-hour day. Each person is unique, and there is no formula for human beings. The woman you will meet is living in her personal reality most of the time.

Eighty-six-year-old Martha Johnson grabbed her daughter’s wrist.

“Stop it, Mother,” Gloria gasped.

Martha’s sharp nails dug into her daughter’s flesh. Her long, bony fingers tightened as she pleaded, “You’ve got to get me to a doctor. It’s coming out, for God’s sake. I have to push. There’s no time. Hurry!” Martha clamped her thighs. Her breath came in short, hard spurts.

Gloria pulled herself free of her mother’s iron grip. “Mother, you’re hyperventilating again. You are not having a baby. You’ll make yourself sick. Then you’ll really need a doctor.”

Larry, Gloria’s husband, yelled, “Your mother needs a psychiatrist!” as he shuffled to the bathroom, his haven from his mother-in-law’s tirades.

“Take me to Puerto Rico,” cried Martha, her fingers clutching the arms of her chair, her teeth clenched. “I can have the abortion there. Get me to the airport!”

Gloria lost control and shouted at her mother. “You’re not going to Puerto Rico. Now quit it!”

Martha shook a bony fist at her daughter, her voice frantic, urgent, hissing. “You ungrateful slut! I have to get to Puerto Rico. I can’t wait any longer for the abortion. I’m 4 months pregnant!”

Larry emerged from the bathroom in a fit of anger. “Don’t you ever talk to your daughter that way. Do you hear me?” He grabbed her shoulders for emphasis.

Martha’s eyes were glued on Larry’s zipper. Her face was screwed up with pain, her lower lip caught in her teeth. Her voice was bitter. “You don’t care about me. You pretended. Well, I don’t care about you. You didn’t even pay for the abortion. You son of a bitch!”

“Gloria,” cried Larry, “This can’t go on any longer!”

Using Validation with Martha Johnson

One month later, Larry and Gloria showed up at my office, where they spilled their frustration. “We can’t live with her anymore,” said Gloria. “She rarely knows where she is. She keeps reliving some awful memory, something that happened before I was born.”

Larry and Gloria told me that Martha had been acting this way for over a year. Gloria had taken her to a psychiatrist and a neurologist. She had had blood tests, CT scans, all of the latest tests performed on her mother. The doctors had told her that Martha had neurocognitive disorder due to Alzheimer’s disease. I promised Larry and Gloria that I would meet with Martha.

Martha arrived at my office the next morning. Her hazel eyes darted quickly, searching for something. “Where is it?” she demanded.

I mirrored the look in her eyes. Martha pursed her lips, irritated at my not understanding what she meant. “The operating table,” she said. “I can’t have the abortion standing up, can I?” She looked at me sharply, sizing me up. “Are you going to do the abortion?” she asked. “I don’t want a woman doctor!”

“You don’t want a woman doctor,” I repeated. “Do you think we don’t know as much as men?”

Martha tightened her lip, giving me a quick glance. “I know men,” she said. “I learned the hard way.” Her voice was bitter.

“Did men hurt you?” I asked quietly.

“Why do you think I’m here?” she answered.

I nodded in empathy. “What happened?” I asked, touching her ever so gently on her sleeve. I wanted to know if Martha was more in Phase Two than Phase One. Old-old people in Phase One generally resent being touched by strangers. People in Phase Two, whose controls are weaker and who incorporate strangers into their world, readily respond to touch. Martha did not flinch from my touch, nor did she avoid the look of empathy in my eyes. If she were in Phase One, she would skirt questions that invaded her privacy. She would not expose her feelings. She would change the subject or tell me to stop asking her so many questions to protect herself from intimacy. Instead, she opened up completely, her eyes blurring with tears when they met mine. She held my hand tightly and cried.

“He came to fix our radiator. My parents were away on vacation. I have to go to Puerto Rico. You know why. I can never tell my parents. They would be so ashamed,” she said. “I’m so ashamed of myself. And I’m so scared.”

I nodded as Martha tightened her hold on my hand. She looked at me as one would look at a close friend. Martha was moving back and forth in time. She had lost cognitive ability. I tried to mirror her feelings of shame by remembering a time in my life when I, too, had been ashamed. I recalled my shame at being the only wallflower at a dance in high school. My tone of voice reflected the feelings I had then. “Were you too ashamed to tell anyone?”

Martha lowered her head and mumbled, “Yes.”

“You carried that shame your whole life?” I asked her.

Martha looked up at me, nodding. Her voice cracked. “I didn’t tell anyone,” she said. “Not my husband, not my children.” We looked at each other for a moment in silence. Gently, I stroked Martha’s cheeks with the palm of my hand. Martha smiled at me sadly and proceeded to tell me about her abortion.

Martha’s shoulders shook with fear, and she tightened her hold on my hands as she spoke. “I can hear them scraping inside,” she said. “The pain is so bad. It’s twisting around. Help me!”

I stroked her cheeks and held her as she sobbed. “Where does it hurt the worst?” I asked, focusing on the extreme. As she began to scream in pain, I used feeling words to focus on her preferred sense.

“Is the pain sharp or dull?” I asked.

“It’s a sharp pain, like a knife cutting me.”

After a few minutes, she pulled back and looked up at me squarely, her face calm and free of pain. “Do you think I should tell Gloria?” she asked. For a moment, she had entered present time. I rephrased her question to help her find her own solution.

“Do you think Gloria can handle it?” I asked.

Martha bit her upper lip and looked at me for a long time. Finally, she said, “When the time comes, I’ll tell her.”

I nodded.

After our meeting, Martha’s panicked, angry outbursts improved. Gloria and Larry immediately noticed the change. Martha recognized her daughter, albeit briefly. “She feels a little better,” I explained. “But she’ll get worse again. It’s going to take time. She wants to come to terms with her past, and she needs you to listen. Her mind can’t travel back to Puerto Rico all alone. Can you travel with her?”

Larry’s voice was incredulous. “You mean she’s going to keep calling Gloria a slut?”

I explained to Larry that Martha had probably felt this way about herself because of the trauma of her pregnancy and abortion 60 years earlier. “She is so ashamed of what happened to her long ago,” I said. “She felt like a slut then and projects her feelings onto Gloria now.”

Gloria listened carefully, eager to know how she could help her mother give birth to the anger, pain, and guilt she had suppressed for 60 years. I helped Larry and Gloria empathize with Martha. I showed them how to validate her by Centering, by using Martha’s kinesthetic sense, by rephrasing Martha’s statements, by asking specific factual questions, by using polarity.

I explained Martha’s need to be heard before she could stop screaming. I told Larry how to Center when Martha accused him of raping her, to rephrase her words, and to let her rant and rave. Deep down she knew that Larry was not responsible for her problems, and I knew that her screaming would abate with Validation. I taught Larry and Gloria how to travel with Martha by sharing her emotions, by feeling her anger, fear, and misery. Most importantly, I assured them that Martha would feel a sense of relief once she had shared these feelings and that her pain would subside.

Larry and Gloria validated Martha for 6 weeks, sharing their experiences in a family support group. Within weeks, the Validation techniques I taught them became second nature.

Martha’s pains continued but occurred less and less often. She no longer accused Larry. She recognized her daughter more often. She never completely stopped ranting and raving, but she was no longer abusive to her daughter.

Martha died in her own bed, at age 92. She died peacefully because she had given birth to her feelings 6 years before her death.

How to Read the Vital Signs of People in Phase Two

People in Phase Two are usually in their 80s or older; experience increasing cognitive decline; have varying degrees of difficulty in walking, hearing, and seeing; and have lost the ability to keep track of chronological time. With Validation, they need not withdraw or experience a decreased quality of life. Without Validation, they retreat inward for the following reasons:

- To survive isolation and feelings of abandonment

- To overcome boredom

- To restore feelings of usefulness

- To work through unfinished issues from the past

Because their weakened eyesight has diminished their ability to see, old-old adults often use the temporal lobes of the brain to restore images from the past. The temporal lobes of the brain also store memories of sounds and smells from long ago, and people in Phase Two often hear familiar voices from the past. Since memories that were imprinted earliest are generally retained the longest, older people often recall incidents from the very distant past.

Damage to the brain caused by strokes or Alzheimer’s plaques and neurofibrillary tangles affects the person’s ability to think logically and to distinguish the present from the past. Old-old people in Phase Two no longer keep track of chronological time. They have lost the ability to think in terms of minutes, hours, days, weeks, and months. Instead of keeping track of time, they keep track of memories. A 90-year-old woman forgets that she just ate. She remembers only that she must feed her children.

People in this phase lose the ability to categorize. People with unimpaired brains can identify chairs, tables, and desks as pieces of furniture; they recognize oranges, apples, and pears as types of fruit. People in Phase Two can no longer put pears or apples into the category of fruit. Similarly, they fail to distinguish between real objects and those that are merely symbolic. A hand that feels as soft as a baby becomes a baby for a woman who needs to be a mother. A daughter becomes a wife to a man who misses his deceased wife.

This woman is using a doll as a symbol for her own children. Maybe she misses being a mother and is trying to regain a feeling of identity. Perhaps she has a basic human need to give love, or she might be trying to resolve an old trauma from her past.

Physical Characteristics of People in Phase Two

People in Phase Two often share certain physical characteristics:

- Their muscles are loose.

- Their movements are slow and graceful, and they often wander aimlessly.

- Their eyes are clear but unfocused. They often seem to be gazing into space, although signs of cognition appear when they gaze directly at the caregiver.

- Their breathing and speech are slow.

- Their voices are low.

- They often use their hands to signal their emotions.

- Their shoulders often slump forward, causing them to shuffle.

- They are usually incontinent.

Psychological Characteristics of People in Phase Two

People in this phase share certain psychological characteristics:

- They cannot identify staff and often fail to recognize their families.

- They forget names.

- They mix up people in the present with people from the past.

- They have poor recent memories but vividly recall the distant past.

- They retreat from reality to escape from boredom and an often bleak present-day reality and to relive familiar scenes from the past, which they often struggle to resolve.

- They use objects as substitutes for people.

- They are unable to categorize or classify objects.

- They often retain the ability to read but forget how to write.

- They have short attention spans.

- They remember familiar songs but often sing off key.

- They are unable to play games with rules, such as Bingo.

- They are unable to control their emotions.

- They freely express their need for love and other emotions.

- They have no motivation to conform to the wishes of their caregivers and often disobey rules.

- They retain intuitive wisdom.

- They recognize genuine caring.

- They do not trust caregivers who argue or who pretend to agree with them.

“Helping” Techniques that Make Matters Worse

People in Phase Two do not know where they are and usually do not recall how old they are. They are not helped—and may, in fact, be hurt—by constant reminders of their lack of orientation. They are not helped by caregivers who insist that they know present-day reality by asking them how old they are or by asking them what day it is. They are not helped by behavior modification, insight-oriented therapies, or overmedication.

Validation Techniques for Communicating with People in Phase Two

Validation is crucial for people in this phase of Resolution. When they are validated, they continue to communicate and do not deteriorate. Old-old people in Phase Two respond well to both verbal and nonverbal Validation techniques because they are verbally expressing their needs and feelings with few filters. They often move from one phase to another throughout the day. They can travel from momentary orientation to living in their personal reality, sometimes within 5 minutes. However, they are in their own world most of the time.

The following are 13 basic Validation techniques to communicate with people in Phase Two:

1.Centering: People in this phase can be demanding, irritating, and frustrating. They often vent anger, sexual feelings, and grief. Validating caregivers must Center themselves before they can accept the emotions of the other person. Breathing deeply helps caregivers release their own negative emotions.

2.Using nonthreatening, factual words to build trust: Use words such as who, what, where, when, and how—but never why—to get at the facts of a situation.

3.Rephrasing: Repeat what the person says using his or her key words.

4.Using polarity: Some people in this phase of Resolution who struggle with finding words will respond to questions that ask them to relate to the worst or the best. Their attention span often increases when they talk about the extreme.

5.Using direct, prolonged eye contact: Old-old people with little energy respond immediately to empathetic, focused eye contact. Caring is communicated through the eyes. People in Phase Two can feel nurtured and safe. They often begin to talk after a moment of genuine eye contact. For people in wheelchairs, the caregiver should bend or sit down.

6.Using ambiguity to respond to a person who fails to make sense: People in Phase Two often create their own words. If a person uses an invented word, use a vague pronoun (e.g., he, she, it, someone) to respond. For example, a response to a person who says “These tips don’t felangle” might be “They don’t work? Did something go wrong?”

7.Using a clear, low, warm, loving tone of voice: When the person is emotionally neutral, use your diaphragm to project a clear, nurturing voice tone. Adjust your tone of voice to correspond to the person’s emotions. Some old-old people search for a loving parent. When the validator’s voice reflects concern and love, they will open their eyes, and communication can begin.

8.Observing and matching the person’s emotions: Observe the person’s eyes, lower lip, breathing, hands, and feet. People in Phase Two will resist the caregiver who asks them to conform to rules or to behave in a certain way. When the caregiver observes the facial expressions of the old-old person and matches the person’s emotions, the older adult will feel safe and will then move with the caregiver.

9.Linking the behavior to the need: People in Phase Two express basic needs (see Chapter 1). Very often the need to be loved, the need to be useful, and the need to express feelings are expressed through “disoriented” behavior. A former salesperson who is now 90 years old and lives in his personal reality packs his suitcase every day. The validating caregiver relates this behavior to his need and asks, “Do you want to get on the road, Mr. Jones? What do you sell?”

10.Identifying the person’s preferred sense and emphasizing that sense: To validate a person who frequently complains about the food, the caregiver should use words that evoke taste. “What does the food taste like, Mrs. Martin? Is it bitter? Is it too bland? When you were younger, did you like sweets? Did you do much baking?”

11.Using anchored touch: Unlike people in Phase One, old-old people in Phase Two are not afraid to be touched. They have lost their defenses and respond to a caregiver only if the caregiver is physically close to them. By touching a person in Phase Two in the same way that he or she was touched by loved ones as a child, the validating caregiver rekindles memories of a happier time.

12.Using voice, touch, and eye contact to stimulate a response: The combination of touch, genuine eye contact, and a nurturing voice tone often sparks dormant speech. Nouns, adjectives, and verbs will often increase (Feil, 1978, 1985; Fritz, 1986). Caregivers have found that touching older adults in Phase Two often kindles memories from long ago. These early, emotionally tinged memories are permanently stored in people’s brains and are sometimes stimulated by gentle touching (Feil, 1992b). When touched, the very old person’s eyes begin to light; gait and speech improve. People who are disoriented may begin to talk when the validating caregiver’s touch reminds them of their mother’s touch, their father’s hug, a child’s soft hand, or a loved one’s caress. When the validating caregiver gently touches the person’s cheek and asks in a soft, nurturing voice, “Is it your mother? Do you miss her?”, the old-old person will often respond with words.

In the 1978 documentary “Looking for Yesterday” (Feil, 1978), a caregiver touches an 86-year-old woman, Mrs. Kessler. For the first time in months, Mrs. Kessler opens her eyes, looks directly at the caregiver, and says, “I love my mother. She is the prettiest in the city.” Within 5 minutes, Mrs. Kessler progresses from Phase Three to Phase Two to awareness of present-day reality as the caregiver’s touch stimulates feelings of safety.

13.Using music: Songs learned in early childhood become permanently imprinted on the brain. Old-old adults who no longer recognize people and who are losing the ability to speak often remember songs.

This man is seeing something that is not there. The validator doesn’t correct nor agree but simply explores what he is experiencing.

A nonverbal, trusting relationship can be established with a person in Phase Two in as little as 1–5 minutes—much faster than with a person in Phase One. These sessions should occur several times per day. Whereas Validation sessions with people who are more oriented are best conducted in a private room, Validation can occur in any setting for people who are disoriented, as they will relate to validating caregivers anywhere. A housekeeper can validate the person in the day room; a nurse can validate while giving medications; family members can validate when they visit.

With Validation, older adults in Phase Two will not need tranquilizing medication, will become less angry, will cry less, and will maintain more direct eye contact. They will use more dictionary words. Their gait will improve. They will smile or sing, expressing heightened feelings of well-being. To prevent feelings of abandonment when a Validation session ends, the validating caregiver should leave the person with others whenever possible—with a nurturing old-old person, with another validating caregiver, or in a group where the person can engage in an activity.

VALIDATION AROUND THE WORLD

The Case of Hannah, the Talker

Nancy Thomas Brown

Validation Teacher

Melabev Memory Day Center, Jerusalem

HANNAH IS STILL VERBAL, but most of the time she returns to the past. She experiences significant hearing and visual losses which adds to her confusion. She was recently widowed and also lost a son during his army service more than 70 years ago. Hannah is bilingual and frequently reverts back to her first language. After a number of previous negative experiences in adult day center environments, she arrives at another center for the first time.

Hannah grabbed staff member Jody and cried out, “I don’t want to be here. I must go home.” Jody answered, “You can’t go home right now. Everyone goes home after lunch.” When Jody started to leave, Hannah grabbed her hand again and said, “You don’t understand. My husband will be worried. He doesn’t know where I am.” Hannah cries out, “Where’s Kenneth? Where’s Kenneth? I must find him to take me home.” Sherri, another staff member, sat down by Hannah and started talking to her in her first language. Hannah engaged more freely, and Sherri gathered some background information. Then Hannah blurted out in both languages: “I feel very sick. I feel so sick, I know I’m going to die. I must get out of here.” Sherri continued the conversation in Hannah’s first language, and then Hannah said, “You talk too much; you’re giving me a headache. Stop, go away!”

Using Validation with Hannah

Sherri shares with me her conversation with Hannah, but was totally frustrated. “Maybe you can get her to settle down.” I sat close to Hannah, placed my hand on her arm, and introduced myself. “You look very upset, Hannah.” “Yes, I must get home or I will die,” she said in a quiet but firm way. Even though she refused to make eye contact with me, I slowly and softly matched her energy and body language and asked her what was the worst thing about being here at the center. “It’s not home,” she replied. I paused and then asked her, “What will you do at home?” She replies, “Nothing, but I won’t feel sick if I’m at home.” She began telling me about a chair at home, her husband’s chair, and how he’ll be waiting. She talked about the handbag she carries has the money her husband gave her to pay the workers, and that he’ll be anxious to hear about her day. Then she quickly told me that he’s dead; “We were married for 74 years. When I look at the chair, I remember him.” I continued holding her hand as she gradually made glances in my direction. I responded, “That’s a long time … then he was your best friend. You were like one person.” She turned and made eye contact with me for the first time. “Yes, we were one person, and now he is no more.” “So, you feel that a large part of you is lost.”

She reached for my hand with both her hands, made eye contact with me, and, with tears in her eyes, she replied, “Yes, at home I feel safe.” We explored her feelings of “home” and what it meant to her, and how it satisfied her basic human need to feel safe and secure; it held the memories of her beloved husband and her son whom she lost many years ago. The mourning process is still very real for Hannah, and I am there to listen. By the end of the day, she gave me a hug, “Now, you are my friend.”

CHAPTER 5

Using Validation with People in Phase Three

In this chapter, you will meet an 88-year-old man who has retreated into the third phase of Resolution. People in Phase Three are still communicating, but because their cognitive impairment has progressed or they have withdrawn inward for safety, they communicate their needs and feelings using movements and sounds. They have lost their speech and use movements and rhythms to express their basic human needs. For people in Phase Three, Validation can help to prevent further withdrawal and improve their quality of life.

The Case of Marvin, the Pounder

The weary night nurse’s laconic smile masked her frustration. Eager to get home, she muttered to her replacement, “I called Dr. Morgan about Marvin Tubin. He says not to give him more medication, but I don’t think he’ll ever calm down without it. It’ll take all day to get his pounding out of my head. Goodbye!” She slammed the door on her way out. The abrupt thump jived with Marvin Tubin’s eternal tapping, ratatat … ratatatatatat … rattatat!

The LPN smiled. “The orchestra is warming up,” she said, humming an old pop song that harmonized with Marvin’s monotonous, thumping beat. “Do the Loco Motion with Me!” Her strident voice blended with Marvin’s pounding.

“Come on baby, do the Loco Motion with Me” Eighty-eight-year-old Helen Watsall cackled, chiming in with her shrill laugh. She urged her geri-chair closer to the nurses’ station, pummeling her heels on the floor to gain speed. “C’mon, Baby. Hey, girlie,” Helen hissed to the humming LPN, “The old crocker is peeing on the floor. That’s not the Loco Motion! Eh? Eh? Bubble, bubble, there’s the puddle!” Helen, a former English teacher, pointed to the urine seeping innocently under Marvin’s chair. She convulsed with giggles.

“Oh, dear,” moaned the LPN, following Helen’s finger, “they never changed Marvin. He’s too heavy to lift alone. I’ll wait for the orderly.” The LPN sighed. She glanced briefly at Marvin, his eyes closed, his face scrunched tight, his fist pounding the flat metallic tray of his geri-chair. He was oblivious to his runaway fluids. The acid urine smell filtered through the day room, bothering no one except, later, an occasional visitor. Staff and residents were used to it.

Whack! Whack! Marvin Tubin, age 88, slammed his fist hard on the tray. His peppery hair flopped to the rhythm of his smashing fist. Marvin’s lips were pursed; occasionally his tongue would sneak between his teeth, helping him to concentrate. Day and night, Marvin Tubin beat his tray. Without the tray, Marvin beat the palm of his hand, sometimes lacerating his skin and biting his tongue. His fist now lay limp, bruised from his relentless pounding.

Once Helen Watsall had propelled her chair in front of the LPN, she clucked, “Crack. Crack. He broke his back. Better check, honey,” she warned, “or there’ll be trouble, trouble on the double.”

“Oh my God!” The LPN found Marvin’s hand black and blue, the skin broken. “Marvin, what did you do? You hurt yourself again. What are we going to do with you? I’d hate for you to need even more diazepam.” The nurse’s voice was soft, caring. She gently touched Marvin on the back of his head, moving her fingertips in a circular motion, bending down for close eye contact. Marvin’s eyelids flickered, then slowly pulled wide open, like an old curtain, stiff with disuse. Tears fell slowly, settling in the crevices that ruled his face. His words formed slowly, each letter sounding itself out. “Dad, I got it in straight. Dad, it’s only a little crooked. Dad.” His voice shook, pleading for approval. Marvin held out his bruised hand to the nurse.

She gasped. She had never heard Marvin speak. His voice was low, rich with timbre. “Marvin,” the nurse said softly, bending down even closer to meet his deep brown eyes, clouded with cataracts and tears. Her voice held wonder, admiration, and respect. “You did a fine job. It’s in there, straight.” The nurse did not know what Marvin was pounding. She used the ambiguous pronoun it, rephrasing Marvin’s words, mirroring his pitch. She responded to this old man’s longing for approval from his father.

Marvin smiled, his eyes lit with love. “I did a good job, Dad.”

For the first time in 9 months, Marvin Tubin responded to another human being. For the first time in 9 months, he formed dictionary words. In Phase Three of Resolution, Marvin Tubin no longer knew where he was. His brain no longer informed him of his body’s whereabouts. Looking at the nurse, his eyes painted a picture of his father’s face. Marvin used his mind’s eye to transform the nurse. She had entered his world. Together, they walked through Marvin’s past.

This nurse validated Marvin for 3 minutes, four times a day. She used touch; vague pronouns when she could not make out Marvin’s meaning; and close, genuine, eye contact. She taught the Validation techniques to the night shift, who were relieved when Marvin’s pounding lessened. His dose of sedatives was lowered. The day nurse sang as Marvin Tubin occasionally pounded a straight nail for his Dad.

How to Read the Vital Signs of People in Phase Three

Old-old people who are not validated when they are in the second phase of Resolution, who receive no stimulation from the outside world, and who continue to deteriorate physically and mentally often retreat to primary, prelinguistic movements and sounds. They withdraw from the world to nurture themselves and to meet their basic human need to express their emotions. These people have lost their social controls and are no longer motivated to hide their feelings. In this next-to-last phase of Resolution, they heal themselves by releasing repressed emotions.

People in Phase Three use parts of their bodies, other people, and objects to represent significant people or events from their pasts. A fist becomes a hammer for a former carpenter. A suitcase becomes a briefcase for a former insurance agent. Body movements replace speech as a form of communication.

Old-old people in Phase Three lose their self-awareness. There is a blurring of the self, to the point that older adults in this phase no longer recognize themselves in the mirror. Their feelings spill without reflection. Their emotions pour out in ways that other people find inappropriate.

Early learned movements replace speech. Damage to rational thinking frees nonverbal expressions. Motion stimulates emotion. Speech becomes unintelligible. The lips, tongue, jaw, and teeth move freely to create new words. There is meaning to the behaviors of older adults in Phase Three. Although the brain no longer informs these people of their bodies’ whereabouts, their memories remain vivid. Memories of early, well-established movements are relived to help people survive the bleak reality of the present. These movements are not meaningless, but are ways for people in this phase of Resolution to deal with their losses and to restore some measure of dignity.

This woman is using the validator’s hand as a symbol for something or someone she loves. The hand feels soft perhaps like a baby. She can freely express her emotions and needs.

People in Phase Three tend to ignore caregivers who disapprove of their behavior. To validate someone in this phase of Resolution, the caregiver needs to link the person’s behavior to an underlying human need and then respond to that need. As shown in Part II, caregivers who link the behavior to the need are able to validate older adults who express themselves through movements and sounds. Validation helps to improve their cognition, gait, and social controls and prevents deterioration into the next phase of Resolution. A validating caregiver creates an atmosphere in which the older adult feels safe. The caregiver enters the person’s emotional world.

Physical Characteristics of People in Phase Three

People in Phase Three share some common physical characteristics and forms of self-expression:

- They are often unable to speak in intelligible sentences.

- They repeat sounds they learned in earliest childhood, including clucking, moaning, and chanting.

- They use repetitive movements to express emotions.

- They respond only when stimulated through touch, eye contact, or voice tone.

- Their voices are low and melodic or high pitched and shrill.

- They cry, pound, pace, and rock.

- Their eyes are half-closed or unfocused.

- They move gracefully.

- They are incontinent of urine.

- They lose the ability to read and write.

- They retain the ability to sing.

- They are unaware of the condition of their bodies.

Psychological Characteristics of People in Phase Three

People in Phase Three share certain psychological characteristics:

- They recall their earliest experiences but have no capacity to retain recent memory.

- They do not remember names or faces.

- They have short attention spans.

- They remember the validating caregiver’s touch and voice.

- Their emotions are completely uncontrolled.

- They withdraw from interactions with the outside world.

- They have lost reflective self-awareness.

“Helping” Techniques that Make Matters Worse

People in Phase Three are unable to stop their movements when asked to do so. They do not understand why they move the way they do and are thus unable to explain their behavior. Asking them to explain their behavior will be unproductive at best and may be counterproductive.

Validation Techniques for Communicating with People in Phase Three

Since these older adults have lost speech, verbal Validation techniques rarely apply. Nonverbal Validation techniques—touch; establishing genuine eye contact; matching emotion; using short, primary words to describe their emotion; linking their behavior to universal human needs (e.g., love, identity, the need to express emotions)—can restore communication. The validating caregiver becomes a trusted, significant person to the older adult, who incorporates the validator into his or her world. People in Phase Three never learn the validator’s name, nor do they recognize their relationship to the validator. Nevertheless, they take pleasure in this genuine communication.

For the caregiver, frustration and burnout often diminish after just 30 seconds of Validation with an old-old person in this phase. The caregiver feels satisfaction when people respond to the validating techniques of mirroring, using music, and matching rhythms. The validating caregiver experiences joy when the use of ambiguity wakes dormant speech in the older adult. Mirroring the movements of someone in Phase Three can spark immediate, direct, genuine eye contact. Seven basic techniques can prevent people in this phase of Resolution from deteriorating further:

1. Centering: Working with people in this phase requires a lot of openness and focused energy. The validating caregiver has to enter the emotional world of the older adult. Validating caregivers must free themselves of their own emotions so that they can be open to the emotions of the old-old person. An angry, tired, frustrated caregiver cannot experience the feelings of another person. Breathing deeply to Center (described fully in Chapter 2) frees caregivers of their own emotions so that they can validate.

2. Using ambiguity to respond to a person who fails to make sense: People in this phase often create their own words. If a person uses an invented word, use a vague pronoun to respond. For example, a response to a person who says, “These wratches aren’t rubbable!” might be “Is there a problem with them? Can we fix it?” Old-old people who are disoriented freely move their tongues, teeth, lips, and jaws, blending similar sounds and images to create new word combinations. For example, a woman in Phase Two in a Validation group at the Montefiore Home for the Aged in Cleveland, Ohio, combined the words “similar” and “file” to create the word “simofile.” P. K. Saha, a noted linguistic expert who has studied the speech patterns of very old, disoriented people, concluded that “nouns, adjectives, and verbs remain in their proper place…syntax remains intact. The old-old disoriented form unique word combinations that are not found in the dictionary because of deterioration to logical thinking capacities” (Feil, 1985). The retention of proper grammar and the creation of unique word combinations by very old disoriented people were first recorded in the documentary film “The Tuesday Group” (Feil, 1972). Later, Francois Blanchard, Director of Gerontological Medicine at the University of Reims, filmed this phenomenon in four hospitals and nursing homes in France.

3. Linking the behavior to the need: As with people in Phase Two, people in Phase Three express basic human needs. These most often include the need to be loved, the need to be useful, and the need to express feelings.

4. Using touch: People in this phase need touch to relate to others. The touching techniques (described in Chapter 2) should be used with people in this phase of Resolution.

5. Mirroring: Copy the person’s body movements, breathing, hand and feet movements, and facial expressions. Follow the person’s lead and dance to his or her rhythms.

6. Using voice, touch, and eye contact to stimulate a response

7. Using music: Songs learned in early childhood become permanently imprinted on the brain. Older adults in Phase Three may no longer recognize people and are losing the ability to speak, but they often remember songs. Speech often returns after singing a familiar song.

Validation sessions with people in Phase Three can take as little as 30 seconds and as long as 5 minutes. These short sessions can be held several times throughout the day to decrease repetitive movements and stimulate feelings of well-being. The sessions can end when the pounding, pacing, yelling, crying, or other repetitive behavior lessens and finds outlets through music, movement, or some other activity that meets the need of the individual.

VALIDATION AROUND THE WORLD

All Behavior Is Communication

Rita Altman

Validation Master

Sunrise Senior Living

United States

MRS. REYNOLDS, A FRAIL WOMAN with wispy gray hair and bright blue eyes, was known to residents and staff alike by her low, melodic voice, which was heard long before she was seen. She continuously repeated the phrase “beta, beta, beta” as her self-propelled wheelchair veered along the long, busy corridors of the skilled nursing center. The fast-paced, firmly planted, stepping movement of her feet seemed to be synchronized with the grasping motion of her hands as she attempted to reach out and grasp at every resident, staff member, or visitor she saw. The other residents moved out of her way whenever they saw her approaching.

Mrs. Reynolds fits the profile of a person in Validation’s third phase of Resolution. People in this phase have lost the ability to speak in sentences and often use repetitive, rhythmic movements to express their basic human needs. When individuals lose their ability to communicate verbally, caregivers and others have a tendency to interact with them less often, which can cause them to withdraw further into their own world.

As a novice and student in the practice of Validation, I wanted to spend time with Mrs. Reynolds, with the goal of discovering the reasons behind her behavior. First, I Centered myself, taking several deep, cleansing breaths to allow myself to be more open and better prepared to enter her world. Next, I observed Mrs. Reynolds from a distance in an effort to calibrate her motions and emotions. Then, I used the Validation techniques of mirroring and matching to establish a better connection with her. Before I could even properly introduce myself, I found myself practically running next to her wheelchair, all the while bending forward at the waist to remain at her height and eye level. To communicate with her, I needed to make eye contact while mirroring her movements and repeating her words.

After several minutes, Mrs. Reynolds slowed down, and I was able to connect briefly with her, repeating her words in the same tone and rhythmic tempo in which she spoke. “Beta, beta, beta,” I said, and then asked, “Mrs. Reynolds, do you want things to be better?”

I was surprised when she responded in a deep, protracted, and resolute manner, “Na na no.” It seemed as though she could communicate more than I thought she could.

Within seconds, we were off and moving again in a zigzag manner, up and down the crowded hallways. Mrs. Reynolds would often stop suddenly to gaze intently into doorways of residents’ rooms, as if looking for someone or something. In an effort to figure out just what she might be looking for, I asked, “Are you looking for a bed?”

“Na no,” she replied.

Mrs. Reynolds had a limited vocabulary, so I asked questions that required only a yes or no response. I asked, “Are you looking for someone named Betty?”

There was a tone of frustration as she replied, “No.”

Knowing that individuals in this phase of memory loss try to restore balance in their lives by returning to the past, often to look for those who bring them a sense of love and security, I asked one final question: “Are you looking for a baby?”

Mrs. Reynolds firmly replied, “No.”

Realizing that my barrage of questions was getting me nowhere, I invited Mrs. Reynolds to sit with me in the dining room. At first, she appeared very distracted as her eyes darted around the room. Then I noticed that her eyes appeared to focus on the seat of a wheelchair as she pointed at the tag that hung from it. I asked, “Would you like to have one of these tags?”

Mrs. Reynolds responded with a nod. As I reached over to tear the tag off, I explained in a lighthearted manner, “This tag contains a warning that it may not be removed under penalty of law, but for you I will gladly take the risk.” She seemed even more confident and in command as she pointed to another chair. Obediently, I removed that tag as well.

She reached out to take the tags from my hand, and with a deliberate look on her face, she carefully folded them several times until they resembled a narrow tube. Gradually, she reached toward me as if she wanted to touch my face with the object she had fashioned. Instinctively, I moved closer to her and sat very silent and still as she gently but intentionally moved it across my face. Several moments passed as she used the object to pat my hair, then my forehead, eyes, the contour of my nose, my cheeks, chin, neck, and shoulders. When she was finished, and with a look of satisfaction, she slowly and very steadily handed the folded-up tags to me. As I took them, I said, “Thank you, Mrs. Reynolds.”

Her intense, bright blue eyes locked with mine, and in a very protracted speech pattern, she replied, “Nn na na nooooo, Th th th th thaaaank youuuuuuuuu.”

Deeply moved by this unexpected, lucid, and sincere response, I felt tears begin to form in my eyes. “Oh, Mrs. Reynolds, you still know so much!” With a look of wisdom in her eyes, she seemed to acknowledge my response with a smile. I repeated, “You really do know so much!”

Later, as I was writing the course’s required journal entry about my Validation experience, I thought about the Validation principle that there is a reason behind the behavior of disoriented old-old people. According to Naomi Feil, “although we cannot always know why the person behaves in a certain way, we can help him or her express emotions to resolve unfinished business.” Feil also teaches us that very old people with dementia are often quite poetic and creative and can use symbols to re-create or relive events from their past.

Could I possibly figure out what, if anything, Mrs. Reynolds had creatively transformed those wheelchair tags into? As I reviewed her life story, her previous occupation suddenly came to light. She had been an artist! Was it possible that she had fashioned a makeshift paintbrush from those tags? Was she expressing the basic human need to have meaning and purpose again? It appeared as though she was reliving her days as an artist, and I was a symbol of the canvas on which she created her artwork as she dabbed at my face and profile. Her heartfelt “thank you” still echoes in my mind when I recall this experience. The purposeful look of satisfaction in her eyes certainly made it seem as though she was not only grateful, but also fulfilled.

My hypothesis was further reinforced by the nursing assistants, who told me that at mealtimes, Mrs. Reynolds often mixed the pureed foods on her plate to create different colors and textures. What appeared to some to be a mindless activity may actually have been her creative way of returning to her days as an artist mixing paints on her palette. When studying Validation, we learn that “all people are valuable, no matter how disoriented they are,” and when we use empathy and treat them with respect, we give them honor. My poignant encounter with Mrs. Reynolds taught me never to underestimate what people in the later stages of memory loss are capable of knowing or doing.

After I discussed this newly learned information about Mrs. Reynolds with the activities director, she began to engage with Mrs. Reynolds in some art activities that were adapted to her abilities, including painting with a brush and at times even some finger painting using pudding as the medium. Mrs. Reynolds’s basic human need for purpose and self-expression had been met and her dignity had been restored through the practice of Validation.

CHAPTER 6

Using Validation with People Who Are in Phase Four

In this chapter, you will meet a very old person in the final phase of Resolution. When no one listens during a crisis, when old-old people struggle alone and internalize their needs and feelings without Validation, they finally give up. They no longer move. They barely communicate with the outside world. Isolated from caregivers but still connected to internal memories and feelings, they also struggle to die in peace.

The Case of Nora, the Nonmover

For 6 months she lay inert; curled in a fetal position; her bony, rounded spine poking through the sheets like a pale armadillo. The woman’s chin was tucked tight against her chest, and her threadlike fingers clamped her scrawny shoulders like a vise. A few stringy strands of white hair revealed a meager lump of humanity, almost invisible in the hospital bed. Nora Miles took up little space. Automatically, nurses changed her sheets, toileted her, and turned her to prevent bed sores. Nora never moved, hardly breathed. Dried liquid crusts glued her eyes shut.

Her two daughters had given up 3 months earlier. Until then, they had visited faithfully, once a week. Nora never recognized them. She never spoke. Her lips had disappeared, sucked into her mouth. She had no teeth. Only Millie, a volunteer and childhood friend, tried to spark life from Nora. Millie asked me to help.

“Less than a year ago, Nora’s speech was perfect,” she told me. Her voice was saddened by memory. “Nora was the happiest of all of us. We were four couples. We grew up together. We were friends since kindergarten. ‘Nora ‘n Horace’ … they were close. You never said one name without the other. They eloped, both of them only 18 years old. I was their witness, so I went with them to the preacher’s house. They loved each other with a passion for 50 years. Nora knew Horace inside out. But Nora never knew about his first heart attack. He made the doctor swear not to tell. Horace died in the bathtub when he was only 68. He never gave Nora notice. I don’t think she ever forgave him.” Millie’s tone was solemn.

“At the funeral, everyone admired Nora. She never shed a tear. Her daughters made all the funeral arrangements. Nora stood straight and tall when they laid the casket. She wouldn’t look at him to say goodbye. For 10 more years, she strangled her grief. She volunteered with me at the hospital. She kept herself busy, babysitting her grandchildren, sewing for her church. Then she had two small strokes. Her recent memory began to go. The neighbors watched Nora slip outside in her nightgown in the middle of a wintery night. So her daughters placed her in this nursing home. She did not want to go. She fought like a tiger. She kept screaming that she had to find Horace. They had to medicate her to get her here. It breaks my heart to see her like this.”

Millie was a special volunteer. She had given me tremendous insight into Nora’s past. Now I had some understanding of why Nora turned inward. She was unprepared for nursing home placement. No one helped her grieve. No one listened so that she could vent her helpless rage. No one validated her feelings. Medication had only made her worse. Eight months earlier, on a wet September evening, Nora slipped past the receptionist, left the nursing home, and scurried down the street. She fell, broke her hip, and landed in surgery.

When she was immobilized after surgery, Nora seemed to die inside. She closed down. She no longer called for Horace. She no longer needed medication. She curled up and withdrew from our world.

Gently, I touched Nora’s neck with my fingertips in a circular motion … no response. With feather-like strokes, I moved my fingers from her ear lobes to her shoulder bone. I bent down to meet her closed eyes. Using all my energy, I focused on Nora to spark a flicker of a response. Softly, I sang the love songs that she and Horace must have known so well: “Love is Here to Stay,” “Love Me Tender,” “I Only Have Eyes For You,” “Put Your Head On My Shoulder.” Nora’s eyes stayed glued. Nothing in her stirred. She barely breathed.

I taught Millie the Validation techniques for a person in Phase Four. With genuine love, Millie validated Nora for 3 minutes, three times each day. One month later, Nora opened her eyes, smiled, and said softly but clearly, “Horace.” She died 2 days later.

How to Read the Vital Signs of People in Phase Four

In the final phase of Resolution, old-old people shut out the outside world, giving up the struggle to remain in contact with people or their environment. They shut down, move very little, and almost never speak. All their needs and feelings are internalized. Are they still resolving old issues? We don’t know because it is very difficult to communicate with them, even nonverbally through touch or song. Because of this, one of the main goals of Validation is to try to connect and prevent withdrawal to this phase.

Withdrawal occurs when a person receives too little stimulation, too much medication, or too little Validation. Although things are getting better in many care settings, Nora is typical of thousands of people wasting away in nursing homes and hospitals throughout the world: limp eyelids drooping over closed eyes, hands dangling like drifting oars without a rower, sputum dribbling, shoulders sagging, barely existing. Only the chest moves. No one is paying attention to what goes on inside.

People like Nora were not always silent. Their stillness developed gradually, growing day by day as their cries and moans, their repetitive pacing and pounding and other difficult-to-handle behaviors, were ignored too long by people who were too busy or did not know how to pay attention to them. In this final phase of Resolution, old-old people completely withdraw from a painful present-day reality. They give up the struggle to express their needs through sounds and movements.

Had these people been validated earlier, withdrawal could have been prevented. But when people are ignored and go without Validation from a trusted caregiver, with no one to share their inner world, they withdraw. Without stimulation, they begin to isolate. Once they reach this phase, it is difficult to reach them.

Old-old people in Phase Four live for variable amounts of time after withdrawing. Curled in a fetal position, toileted, turned to prevent pressure sores, tube fed, some people hang onto life for years. Others die soon after they enter this phase.

Physical Characteristics of People in Phase Four

People in Phase Four share certain physical characteristics:

- Their eyes remain closed.

- Their muscles are loose.

- Their bodies are slumped or immobile.

- They often lie in the fetal position.

- Their breathing is soft.

- They are unable to speak.

- They barely move.

Psychological Characteristics of People in Phase Four

People in this phase have withdrawn so completely that caregivers cannot identify psychological characteristics. They rarely express emotion and are unable to initiate activity. They barely respond to Validation.

This woman has withdrawn inward, eyes half closed, arms contracted toward her body, not speaking anymore and barely moving. These characteristics are typical of people who have entered Phase Four.

Validation Techniques for Communicating with People in Phase Four

Using Validation with people in this phase is more difficult, and the results are less dramatic, than when Validation is used with people in earlier phases of Resolution. Knowing the social history of the person is crucial because a person in this phase is unable to provide any clues.

The goal of Validation with people in Phase Four is to elicit some eye contact or facial movement—such as smiling, crying, or singing—and maybe some physical movement of the hands and feet. The following techniques sometimes stimulate nonverbal communication:

1.Centering: Validating caregivers must focus all of their energy on the older person. The Centering technique (see Chapter 2) will relax caregivers, enabling them to focus fully on making contact.

2.Using touch: Caregivers have found that touching very old people who are disoriented often kindles memories from long ago. These early, emotionally tinged memories are permanently stored in their brains and are sometimes stimulated by gentle touching (Feil, 1992b). In response to touch, the very old person’s eyes begin to light; gait and speech improve. People in Phases Two and Three may begin to talk when the validating caregiver’s touch reminds them of their mother’s touch, their father’s hug, a child’s soft hand, or a loved one’s caress. When the validating caregiver gently touches the person’s cheek and asks in a soft, nurturing voice, “Is it your mother? Do you miss her?”, the person will often respond with words.

If validators know the history of the person in Phase Four, they will know where to touch. If the person had a good relationship with a spouse, touching the person on the side of the jaw with the inside of the palm can stimulate pleasant memories. The person may open his or her eyes and look, for a moment, at the caregiver. Touching the check with an open palm in a slow, circular motion can trigger memories of being touched by a loving mother. Touching the shoulders in a gentle, circular motion can stimulate memories of a sibling or a dear friend. The validating caregiver can touch different parts of the face and shoulders to elicit memories of significant relationships.

3.Using music: Music can sometimes stimulate people in Phase Four. People most often respond to familiar songs learned early in life as well as songs associated with loving relationships and strong emotions.

Contact time with people who are so withdrawn is seldom more than 3 minutes. A Validation team can structure six very short Validation sessions each day. Even if there is no response, people in Phase Four will know someone is there and that they are not alone, and the physical contact will make them feel good.

VALIDATION AROUND THE WORLD

Combining Validation with Sensitive Massage and Focused Touch

Ann Catlin

Occupational Therapist and Licensed Massage Therapist Center for Compassionate Touch

United States

PEOPLE WITH LATE-ONSET Alzheimer’s disease have taught me they have not lost the capacity for human emotion or recognition of a caring touch. I have seen that even a person in a very withdrawn state of being retains these primal abilities. Validation has taught me to look beyond the obvious and focus in on the needs and feelings of the other person, even when that person cannot communicate with me using words. I need to see through the eyes of my client. I need to step into his or her reality, not force my needs or my reality onto the person. In addition to Validation, I am also trained in therapeutic touch and combine these two methods in my daily work with people who live in a nursing home.

A case in point is a woman who was very withdrawn inward. Her muscles were contracted, and she could barely move. She could no longer feed herself or tell someone if her nose itched or she was in pain. Her days were spent either in bed or in a reclining chair, with very little interaction with others except during her physical care. I saw her weekly for 30-minute therapeutic touch sessions. Focusing on this client with compassion, observing her reactions, and using Validation techniques alongside massage techniques provided a deeper level of care. Sometimes I would see very little obvious response to the hand, shoulder, or foot massages I gave her. I had a sense, however, that there was more happening than I could see. She seemed to relax into her bed a little, and her face also seemed relaxed. Sometimes, she would look into my eyes with a little smile. One day as I massaged her hand, she held mine, turned to me, and said in a weak voice, “You are very kind. I love you.” She was not only capable of receiving love, but also of giving it—a basic human need.

Validation and forms of sensory stimulation, such as sensitive massage and focused touch, share the following goals:

- Enhance the sense of self

- Improve alertness

- Diffuse confusion, fear, or anxiety by creating trust

- Ease the effects of isolation, loneliness, and boredom

- Acknowledge and affirm the individual as a person

- Reduce pain, leading to improved physical comfort and sleep quality

When combined with a validating attitude, giving a hand or back massage or simply holding a person has the power to elicit positive, life-affirming feelings and responses. For the person who is withdrawn, touch becomes a language of the human heart and a remembrance of his or her place in the world.

CHAPTER 7

Using Validation with Young-Old People Living with Alzheimer’s Disease

In this chapter, you will meet a 62-year-old man whose disorientation was not caused by loss of family, loss of a social role, sensory deprivation, or a loss of mobility. Damage to brain cells produces the cognitive decline of people between 40 and 70 years of age who are diagnosed with Alzheimer’s disease. This relatively young man deteriorated despite Validation.

The Case of Richard, the Mumbler

“Grandpa! It’s me, Johnnie! Stop walking away. Don’t you remember me? I’m Johnnie!?” the 7-year-old boy’s voice pleaded.

“Mayyyyy bee it’s the mutterrmublesumble mutter bies,” the grandfather mumbled.

“Grandpa, you don’t make sense! Why don’t you talk right?”

“Mutterbats mum mummfff,” said Richard Kraft, age 62, as he stumbled past his grandson. His eyes vacant, he stared without cognition. He shuffled toward an unknown destination. His shoulders hunched, he bobbed ahead like a ship with sagging sails, drifting with the wind.

“Johnnie! You come right here. Leave Grandpa alone. Do you hear me? NOW! ON THE DOUBLE!” his mother Nancy called sharply, her voice shrill. “Johnnie, I want you away from Grandpa.” Nancy gritted her teeth, stomping to the living room.

“Mom, look! Grandpa’s talking to himself in the mirror again!” cried Johnnie.

Richard Kraft peered at his reflection in the hallway mirror, his eyes blank, his mouth making angry sounds. “Meffle away you mutterstinks!” He shook his fist at the stooped, white-haired, handsome reflection. The blotchy, ruddy cheeks were unmarred by wrinkles. “Muddyi maaa musses musss. MUSSSSSTTT!” Richard Kraft roared like a lion and smashed the glass, his fist like a hammer.

“Oh! My God! Why didn’t I listen to the doctor about him needing a nursing home?” wailed Nancy. “Johnnie, call 911. Tell them we need an ambulance right away. Hurry!” Nancy ran to help her father as her son called for help.

Blood dripped from Richard’s torn tendon, splattering the rug. Dazed, eyes blank, he reeled toward his daughter. Nancy stopped the bleeding. She held her father and her son in her arms and wept, waiting for the rescue squad. “Oh, Dad, I love you so much. Why do you hurt yourself and all of us?”

After placing her father in the memory care community of the nursing home, Nancy talked to me freely. “Dad began to act strange when he was only 54,” she said. “He’d worked himself up from stockperson to president of the company. And now look at him.” Nancy’s tone shifted from pride to despair as she pointed to her father’s lifeless form in a leaning chair. “That man is not my father. There’s no spark. He scares me. His eyes aren’t human. He walks like a robot. He used to be curious about everything. He loved living, and he took us on trips all over the country. Then, about 10 years ago, his mind started to go. He got worse every day. But Mom would never put him in a nursing home. When the doctor said that Dad had Alzheimer’s, Mom couldn’t believe that he would lose all of his mental capacity.”

“He kept going downhill. He would put on his coat and start out somewhere, then forget where he was going. He lost his sense of direction. He couldn’t tie his shoelaces. Mom would call me, often at 2 or 3 o’clock in the morning, frantic because Dad took the car in the middle of the night. He drove her out of her mind. When Dad wandered or drove the car away, Mom got my uncle to find him. He always found Dad at work. Usually, Dad would be sitting in front of his old building, staring out the window of the car or staring at the wheel, not remembering how to get home. It got to where he never said a word. He wouldn’t talk to Mother or me. Johnnie was the only one he related to. They played checkers and read Johnnie’s school books. Then Dad began to lose every checkers game. He stopped reading. He didn’t recognize my mother. She died last year, and he couldn’t remember her name.” Nancy’s voice quivered.

“When Mother died, Dad moved in with us. Dad and Johnnie were buddies until last week, when Dad completely lost touch with reality. Dad’s deterioration had nothing to do with loneliness or boredom. Something happened to his brain to cause him to lose his sense of reality and his social controls. He was a kind, sensitive, social man. He loved people. I don’t want him to die all alone. Can you help me reach him, even if only for a few minutes?”

Nancy watched me mirror her father’s body movements. I matched his stride, imitated his gait, and moved to his rhythms. I mirrored his breathing, the downward pull of his lower lip, and the pitch of his voice. Together, he and I shuffled through the long corridors, he mumbling and I singing “These Boots Were Made For Walking.”

Richard Kraft had served as a Marine in the Vietnam War. He tottered a moment, then clapped his heels together, facing me with a sharp salute. “Mumster mafle here.” His husky voice was strong, his eyes no longer vacant.

I asked, “Sergeant Kraft?”

“Yes, sir. Present and mimbled, sir.” Richard Kraft talked for the first time in weeks.

“Where are you now, Sergeant Kraft?” I wanted to enter his world.

“Can’t fuster mums.” Richard Kraft’s eyes lost luster. He focused somewhere else. He grew blank.

Facing him, I struggled to hold his eyes even though he stared beyond me. “You can’t feel them?” I used the ambiguous pronoun them to keep communication going.

Richard Kraft turned, ignored my focused energy, shut me out, and shuffled past.

Nancy found three songs that stirred her father. She needed to reach him, to be with him, to love him. Together they would march down the halls, father and daughter, singing, stopping, saying a word or two. But 3 months later, Richard Kraft stopped walking. Within 1 year, he was dead.

How to Read the Vital Signs of Young-Old People Living with Alzheimer’s Disease

Alzheimer’s disease that begins in a person’s 40s, 50s, or 60s is fundamentally different from Alzheimer’s-type dementia in old-old people because the disorientation is usually not exacerbated by psychological and social losses. With old-old people, disorientation is often the result of a combination of physical, psychological, and social losses and not having the coping mechanisms to handle all those losses. Disorientation becomes a coping method that reflects the person’s struggle to survive.

Unlike very old people, younger people with Alzheimer’s disease usually are not trying to cope by retreating from present-day reality. Their sensory systems are intact; they see, hear, and (at least in the early stages of this disease) move comfortably. They have had a social framework. They do not want to lose contact with present-day reality. They want to keep their social controls and their role in life but cannot because of severe damage to brain structures and brain functions.

Diagram showing cross sections of healthy human brain and brain of someone with Alzheimer’s disease.

Most people with this diagnosis progress through distinct stages: mild, moderate, and severe Alzheimer’s disease. There is a progressive loss of cognition, and speech is lost early in the process.

Regrettably, there is no cure for Alzheimer’s disease. In older people who are disoriented, behavior often has meaning and represents a struggle to resolve unfinished business. In my work with young-old people with Alzheimer’s disease, I was unable to discover the meaning behind their apparently random behaviors. Although Validation can offer temporary satisfaction for young-old people with Alzheimer’s disease, it has not been effective in preventing or slowing a decline. By creating moments of connection and communication, however, Validation techniques can help.

Physical Characteristics of Young-Old People Living with Alzheimer’s Disease

Young-old people living with Alzheimer’s disease differ in their emotional lability, the rapidity of their regression, and the length of their lives. Young-old people with moderate to severe Alzheimer’s disease often share these physical characteristics:

- At moments, their eyes are vacant and show little signs of cognition.

- Their movements can appear robotic.

- They have a tendency to wander.

- They rapidly lose speech.

- They have trouble controlling their bladder.

- They deteriorate progressively.

Psychological and Behavioral Characteristics of Young-Old People Living with Alzheimer’s Disease

The psychological characteristics of younger people living with Alzhei mer’s disease are so varied because every person is unique. In the beginning of the disease, the person often experiences fear, denial, and despair. Each person’s temperament shapes how the individual handles those feelings and the knowledge of having a progressive disease. As the disease progresses, it can become difficult for a caregiver to know what is going on inside the person. Behavioral characteristics of young-old people with Alzheimer’s disease may include the following:

- They lose their way.

- They forget how to care for themselves.

- They lose words and forget how to use familiar objects, such as a comb or toothbrush.

- Their behavior becomes unpredictable.

- They can hit without provocation.

- They often pace when in a group situation.

- They seldom initiate contact with peers during or after Validation.

- They often do not respond to touch or eye contact.

- Slowly, they stop moving.

“Helping” Techniques that Make Matters Worse

In general, young-old people living with Alzheimer’s disease respond poorly to excessive stimulation, overmedication, and lying. Although reality orientation may be helpful in mild Alzheimer’s disease, this method can cause frustration and anger for people with moderate or severe Alzheimer’s disease. The same is true for behavior management. Lying to a person living with Alzheimer’s disease also is never a good idea.

Validation Techniques for Communicating with Young-Old People Living with Alzheimer’s Disease

The validating attitude is always useful and effective, and Validation techniques can sometimes create meaningful connection with young-old people living with Alzheimer’s disease. Validation will not improve speech, social interaction, gait, or eye contact, nor will it prevent further deterioration. Here are some steps for beginning a Validation session with young-old people living with Alzheimer’s disease:

- Always begin with Centering.

- Always approach from the front and find a distance that is comfortable for the other person.

- Always use a warm, loving voice tone. Try to pitch your voice lower if you usually speak in a higher voice tone.

- Be careful with eye contact. Some people want direct eye contact, whereas others are upset by it. Notice the other person’s reactions and respond accordingly.

- Carefully observe the person. Is the person zoned out or having a clear moment? Is there an emotion reflected in the person’s facial expression?

After observing and connecting with the person, the validating caregiver can use certain Validation techniques that may result in short moments of connection and communication:

1. Ambiguity: This Validation technique helps communication when the caregiver doesn’t understand what the young-old person is saying. Sometimes the person’s speech is monosyllabic, or the person uses a made-up word. Using nonspecific pronouns can help.

2. Mirroring: Young-old adults with Alzheimer’s disease will often respond when the caregiver mirrors their movements. Momentary eye contact may occur. A young-old person with Alzheimer’s disease may then imitate the movements of the caregiver, establishing a nonverbal relationship.

3. Using touch: Be careful when interacting with a young-old person living with Alzheimer’s disease, as some people may strike out at the caregiver without warning or provocation. At other moments or stages of the illness, the caregiver could try touching the person gently on the cheek, back of the neck, shoulders, or upper arm to make a physical connection that is linked with loved ones.

4. Using music: Early learned melodies with emotional overtones remain in the memory long after speech is lost. Singing a well-remembered song often sparks a connection. If the person lashes out, the caregiver can sometimes deflect the outburst by singing a marching song.

Young-old people living with Alzheimer’s disease require no more than 3 minutes of Validation, several times each day. Because younger people usually have more energy, anxiety, and mobility than old-old people who are disoriented, young-old people need more frequent Validation to restore feelings of well-being. They need regularly scheduled Validation in a room free of noise or distractions.

VALIDATION AROUND THE WORLD

Luigia, a Wife: My First Experience with Validation

Luigia Crippa

Italy

My first experience with Validation was at the beginning of my husband’s diagnosis at age 73 with early-onset Alzheimer’s—a disease unknown to me and difficult to manage. A friend of mine told me about a short course on Validation taught by Cinzia Siviero at Fondazione Castellini (Italy). I had already read some books that cover the subject of caring for someone with Alzheimer’s disease, written by authoritative doctors, but what I took away from the course was a real revelation for me. I learned to better care for my husband. I learned that you should not insist that a person understand things that he or she is no longer able to understand, and that we, the caregivers, must “get in the person’s world” and not the other way around.

The person lives in the past and often is confused, needing certainties, tenderness, and understanding. Sometimes I am not able to give my husband what he needs, and sometimes I am. Nearly every evening, my husband asks me if his mother (who died years ago) will come to see him. At the beginning, I used to remind him that she was already dead, but now I tell him, “Mother is always in our hearts.” I ask him if he misses her very much. Other times, he asks me where his wife is. At first, I felt despair and cried. It was not easy for me to understand his inability to recognize me. I have shared my experience with other relatives, and above all I have learned that there can still exist in him an “emotional memory”—that I am still there, in his heart.

My husband might also continually ask “to go home,” and this generally happens in the evening. Whereas before I would try to make him understand that he was in his house or I would tell him a lot of lies, I now know from taking the Validation course that authenticity is important, because at some level he could be aware. I ask him what house he is asking about, where it is, what it looks like, and he relates his memories and feelings and shares his anxieties. Other times, he may be looking for his car (although he doesn’t recognize it even if I show it to him parked in the courtyard). But I talk with him about the car anyway because I think that this topic could be important to him. Sometimes, he tells me that I told him to do something even though I haven’t, and I tell him that perhaps I am losing a bit of my own memory. More than once he has answered angrily, “Then have someone take care of you!”

My first experience with Validation has been very beneficial. Above all, I have learned that if I speak with a warm voice to my husband, and with an open heart, things go much better, and I am more convincing. It doesn’t always work out, but for the most part, it helps.

CHAPTER 8

Who Benefits from Validation?

Validation helps old-old people who are disoriented as well as the professional caregivers, friends, and families who care for them. Since 1963, tens of thousands of old-old people and their caregivers have benefited from Validation, which has been used in care settings in the United States, Canada, Europe, Australia, China, and Japan.

The Benefits of Validation for Disoriented Old-Old People

Validation is most effective with people who have begun to physically and mentally deteriorate in their late 70s or later. Some shared characteristics of old-old people who may benefit from Validation include the following:

- Loss of some recent memory
- Difficulty walking or sensory impairment
- Loss of social position or life roles

- Often diagnosed with NCD due to Alzheimer’s disease

Validation is ideal for older people who failed to face important developmental life tasks and never learned to trust that they could survive hard times. These older adults are often unable to cope with the loss of their families, friends, jobs, homes, and health. These are people who have locked up painful feelings inside rather than express them. Now, in their old age, when losses mount, they are overwhelmed. For such people, Validation can have the following benefits:

- Restores self-worth

- Reduces the need for chemical and physical restraints

- Minimizes withdrawal from the outside world

- Increases verbal and nonverbal communication and interaction with other people

- Reduces stress, anxiety, and anger
- Stimulates dormant potential
- Helps resolve unfinished life tasks

- Facilitates independent living for as long as possible

- Often restores sense of humor

- Slows down physical and mental deterioration

- Addresses basic human needs

People who are validated undergo less regression inward. Their speech improves; they cry, pace, pound, and wander less; their gait improves; they interact more with other people; they smile more and establish eye contact more often; they communicate more effectively with their families; and they do not need to be restrained by physical restraints or psychotropic medications (Alprin, 1980; Dietch, Hewett, & Jones, 1989; Feil, 1982, 1992a; Fritz, 1986; Jones & Miesen, 1992; Kim, 1991; Morton & Bleathman, 1988; Peoples, 1982; Sharp & Johns, 1991).

Validation may not be appropriate for all older people who are disoriented, and caregivers should be aware of its limitations. Although some caregivers have used Validation effectively with the following groups, Validation was not developed for these individuals:

- Very old people with a history of mental illness

- People with cognitive disabilities, such as intellectual disabilities or severe learning disabilities

- People with alcohol use disorder

Documented evidence of the effectiveness of Validation began to accumulate in 1971, when 30 disoriented old-old people at the Montefiore Home for the Aged in Cleveland, Ohio were studied after participating in a Validation group. These people became more aware of external reality, communicated more outside group meetings, and required less psychotropic medication and fewer restraints following participation in Validation groups (Feil, 1967, 1972).

In another study, the effects of Validation and reality orientation (the basic tenets of which are described in Chapter 9) were compared (Peoples, 1982). This study concluded that “Validation produced significant improvement in behavior … whereas Reality Orientation produced no significant difference” (Peoples, 1982, p. 90).

In 1986, a study of the effect of Validation on speech patterns in very old nursing home residents with cognitive impairment was conducted at the University of Toledo. This study found that “Validation made a significant improvement in the elders’ speech patterns” (Fritz, 1986, p. 14).

Researchers at the Irvine Medical Center in Irvine, California found that “Validation was … more effective than application of Reality Orientation… Greater staff awareness of the individual psychological and emotional needs of dementia patients will result in improved therapeutic care” (Dietch, Hewett, & Jones, 1989, p. 975).

Doctors in Australia found that both staff and residents benefited from Validation, with a reduction in withdrawal on the part of residents and more socialization among residents (Sharp & Johns, 1991). Similar results were found in a study conducted at Maudsley Hospital in London (Morton & Bleathman, 1988). In France, Validation was found to promote “an increased resolving of their conflicts and reduced anxiety, less suspicion, and increased trust between patients and nursing staff” (Prentczynski, 1991, p. 7).

In Italy, Validation was shown to reduce the severity and frequency of agitation, apathy, irritability, and other challenging behaviors (Tondi et al., 2007). In Chennai, India, Validation improved the level of cognition in a controlled study (Sindhumathi, 2012). In Sweden, Validation training was found to help nurses develop better communication skills and be better attuned to older adults living with forms of dementia (Söderlund et al., 2013). These results were duplicated in Austria (Pichler, 2014) and Japan (Tsumura, 2015). In Korea, a study found that Validation reduced symptoms of depression and behavioral problems in older adults living with dementia (Sung, 2016). In a recent literature review, Validation is reported to be “an effective tool that facilitates communication and interaction in care, reducing levels of stress and job dissatisfaction among care professionals” (Sánchez-Martínez et al., 2021).

Around the world, researchers have been able to document the effectiveness of Validation and the value of Validation training. The experiences of thousands of caregivers trained in Validation confirm this scientific evidence. A full listing of research that has been done on the efficacy of Validation can be found at https://vfvalidation.org/resources/types/research/.

The Benefits of Validation for Professional Caregivers

Professional caregivers—including nursing home staff, hospital staff, and community healthcare workers who help older adults live independently—often experience tremendous stress and frustration as a result of their daily work with people who are disoriented. Validation can help relieve the physical and emotional stress associated with caring for old-old adults who are disoriented. For caregivers, Validation can have the following benefits:

- Reduces frustration
- Prevents burnout
- Promotes joy in communicating
- Increases job satisfaction

The practitioner is at eye level, coming from the front. She makes physical contact, and there is clearly good communication between her and the man.

As noted, several studies of the effects of Validation training on nursing home staff found that staff began to view residents differently, seeing them as human beings with intuitive wisdom rather than just focusing on their disorientation and impairments. Staff began to understand the meaning behind the disoriented behaviors they witnessed in the care setting. As residents responded to Validation, several positive changes were noted. Fewer residents cried for help. Whining diminished, and more residents began to speak in more modulated tones of voice. The chain reaction that is often set off when one resident’s agitation causes other residents to become agitated was eliminated. The community was quieter and became a happier place to work, and nursing staff began to enjoy their relationships with the residents. Fewer restraints and tranquilizers were used to control resident behaviors.

As a result of these improved workplace conditions, staff turnover decreased 6 months after Validation was introduced. Nursing assistants were more willing to work on weekends and holidays, and activity therapists, recreational therapists, occupational therapists, and physical therapists reported increased job satisfaction. Nursing staff experienced less burnout and provided higher-quality nursing care.

Nursing home administrators and directors of nursing noted significant changes in staff behavior as a result of Validation. Following training in Validation, nursing assistants in these care communities were more likely to do the following (Alprin, 1980; Feil, Schove, & Davenport, 1972; Prentczynski, 1991):

- Call residents by name

- Use lower tones of voice when communicating with residents

- Bend down to face residents in wheelchairs to establish eye contact with them

- Spontaneously greet residents
- Touch disoriented residents
- Toilet and groom disoriented residents

- Communicate frequently with residents’ families to share Validation techniques

- Help residents find lost articles
- Listen to disoriented residents
- Refrain from scolding disoriented residents

- Respond to cries for help from disoriented residents by validating them

- Report improved relationships with their own parents and grandparents

The Benefits of Validation for Families

It is not unusual for families to experience even greater frustration than professional caregivers, who are often able to distance themselves emotionally from the people in their care. Family members are often angry at their relative for behaving in ways that they cannot understand. Validation has proved enormously successful in helping families communicate more effectively with their relatives. Families who learn to use Validation with their relatives who are disoriented often enjoy the following changes (Alprin, 1980; Ronaldson & McLaren, 1991):

- They experience less frustration with their relatives.

- They are able to communicate more effectively with their relatives.

- They experience relief when their relatives show improvements in speech and social functioning.

- They visit their relatives living in memory care settings more often.

- They begin to understand their own children better.

- They gain self-awareness as they begin to examine their own responses to aging.

Many of the vignettes in Part II show how family members have learned to use Validation to cope with the stress of caregiving and to improve the quality of their interactions with the people they love.

VALIDATION AROUND THE WORLD

Validation: Seeing Is Believing

Rita D’Alfonso

Psychologist and Validation Practitioner

Casa Famiglia San Giuseppe

Italy

I HAD BEEN HEARING AND READING about Validation for many years and was interested in learning more about what the method entailed and how it could help me better understand the world of the very old, disoriented person—a world in which many aspects are still unknown. I have worked in a nursing home for about 20 years and have seen how other approaches have been helpful. It has always proven very hard, however, to enhance communication with people who have the diagnosis of late-onset Alzheimer’s disease.

My experience with Validation has finally allowed me to learn some essential tools for understanding and relating to the people with whom I work—those who have some form of dementia. Knowing the old person’s biography, being a good listener, and using Validation techniques for the four phases of Resolution make it possible to connect and communicate with very old people who are in the final life stage, what Naomi Feil calls Resolution.

I’ve been struck by the importance of being honest when using Validation with an old person in Phase One. Relatives and nursing home staff, acting with only the best intentions, often consider it better to distract and deceive the person to reduce anxiety and distress. This approach actually produces only short-term effects, however, and can contribute to strengthening the old person’s confusion and distrust. As Naomi Feil states, very old people, no matter how disoriented, still know to a certain extent what the truth is.

I think that the core benefit of Validation for an old person is the opportunity to express emotions. Only by giving voice to emotions is it possible to reduce the so-called negative feelings and form interpersonal relationships with residents. Very old people who are disoriented have experienced physical, psychological, and social losses, but they still continue to express basic human needs, such as being listened to and recognized and having their reality given meaning. Let’s not forget that there is always a reason behind their behavior.

For example, I was recently assessing a new resident to the nursing home, Ms. N. While I tried to conduct the cognitive assessment, Ms. N. was intently handling the gauze bandages she had been given by the chief nurse. She was folding them, unfolding them, and rolling them while muttering meaninglessly, producing a lot of words that were a complete and long-winded confabulation.

At one point, I stopped asking standard assessment questions and started using Validation techniques. “What a lot of work! You must have worked a lot in your life!” At that point, Ms. N. stopped her flow of words and looked at me. In a completely intelligible way, she started telling me that she had lost her mother at an early age and had always been involved in doing the housekeeping, cleaning, washing, and ironing, just as she was doing at that moment. She added that she was also a bit tired. Such are the small yet great daily miracles of Validation.

CHAPTER 9

How Validation Differs from Other Methods Used with Old-Old People

The techniques of Validation are based on the beliefs and principles that underlie it. These techniques are tailored to the four different phases of Resolution and differ markedly from many other methods used with very old people:

- The validating caregiver never argues with or confronts the old-old person.

- The validating caregiver does not try to give the old-old person insight into his or her behavior.

- The validating caregiver does not try to orient the old-old person to time or place if the person does not wish to be oriented.

- The validating caregiver does not use positive or negative reinforcement to affect the old-old person’s behavior.

- The validating caregiver does not use individual or group therapies that require precise rules or orientation to present time.

- The validating caregiver is not an authoritative teacher, but a nurturing facilitator.

Validation is both similar to and different from other methods used with old-old people who are disoriented. To clarify how Validation compares with other approaches, this chapter describes the methods of reminiscence, life review, reality orientation, remotivation, behavior modification, diversion and redirection, therapeutic lying, and psychotherapy.

Reminiscence

The use of reminiscence as a therapy for older adults was first proposed by Mc Mahon, Rhudick, and Butler in 1963. Since that time, it has become an important therapeutic tool for working with older adults. Like Validation, reminiscence is based on the principle that human development follows specific stages. According to both methods, people manage their lives based on how they face the challenges of each developmental stage and how they adjust to transitions between the various stages. As in Validation, reminiscence can be used by individuals or groups of older adults and can be facilitated by trained paraprofessionals. Both reminiscence and Validation also promote socialization and mental stimulation and help older adults to wrap up loose ends and restore their sense of self-esteem.

Unlike Validation, reminiscence is rarely useful with old-old people who are nonverbal or in the later phases of Resolution. These people have lost track of present time altogether and live in the past. They are not consciously able to reminisce.

Life Review

Life review is a structured form of reminiscence developed by Pincus and Ebersole in 1970. During life review, participants take stock of their lives. As they review their lives, older adults recognize unproductive methods of coping and strive to redirect their lives using more effective coping mechanisms.

To undertake a life review, participants must possess verbal skills and retain an attention span that allows them to follow a train of thought. They must be able to put their memories into words and phrases. Some people in the first phase of Resolution may benefit from the reminiscing that is done in life review. However, they may feel threatened when the facilitator of a life review session attempts to give them insight or asks them to change the way they cope.

People in the later phases of Resolution lack the basic skills to benefit from life review. They will withdraw or become anxious when asked to distinguish between past and present time or to follow one train of thought.

Reality Orientation

Reality orientation was developed in 1964 by James Folsom, a psychiatrist working with veterans diagnosed with schizophrenia and intellectual disabilities. His goal was to rehabilitate his patients in the hope that they might return to the community. His results were promising. Reality orientation is based on the idea that (1) confusion can be prevented, (2) therapy should begin as early as possible, and (3) people feel better when they are oriented to present time and place.

In 24-hour reality orientation, all staff in the care setting are involved in the patient’s or resident’s therapy. All staff members who come into contact with the resident use every opportunity to orient the person with current information. For example, a caregiver greeting a resident might say, “Good morning, Mr. Johnson. It’s Tuesday, January 5th, and you are in Fairview Senior Living.”

If it is not feasible to involve the entire staff, a team is designated to orient the patient or resident. Classes, which can be led by nursing assistants, orderlies, or other paraprofessionals not specially trained to deal with psychiatric disorders, are held daily. Chalkboards, reality information boards, clocks, menus, calendars, and other teaching aids are used in these daily sessions, the aim of which is to orient the participants to present time and place. Participants are gently corrected when their responses do not correspond to present time and place. For example, a 90-year-old woman who remarks that she needs to visit her mother might be told, “You are 90 years old. Your mother is no longer alive.”

Both reality orientation and Validation attempt to provide a means for families, friends, and caregivers to communicate with old-old people. The two therapies differ in significant ways, however. Awareness of present time and place is not a goal of Validation, although it is often a result of this method, as people who are disoriented become more aware of present-day reality when they feel emotionally safe in their relationship with the validating caregiver. Validation respects the reality of the old-old person, which may or may not be in the present. In contrast, reality orientation insists upon orientation to present-day reality.

Validating caregivers accept old-old people’s beliefs and do not disagree with them. Validating caregivers are not teachers, but facilitators. Validation also tries to restore well-being through nonverbal stimuli, including music, movements, and the sharing of feelings.

If reality orientation is nonpatronizing, some people in Phase One who want to remain aware of present time may benefit from it. Other people in Phase One will not benefit from reality orientation when their belief systems are challenged. Reality orientation is unsuitable for people in Phase One who intentionally distort present-day reality to restore situations that were unsatisfactorily resolved in the past or as a coping method to survive the losses of aging.

People who are in Phase Two or Phase Three struggle in reality-orientation classes, which can make them hostile, anxious, or withdrawn.

Remotivation

Remotivation was developed in 1957 by Dorothy Hoskins Smith at the Philadelphia State Hospital. The goals of this therapy were to “remotivate the patient’s interest, to get him involved in the world around him” (Jones, 1964, p. 7). Even today, remotivation is sometimes used with older adults living with forms of dementia.

In remotivation, residents or patients meet in a series of meetings held once or twice each week under the leadership of a nursing assistant or other paraprofessional. Noncontroversial topics, such as birthdays, vacations, pets, and hobbies, are discussed. Feelings are not explored, and the emphasis is on factual observations about the present-day world.

Both remotivation and Validation seek to develop the healthy aspects of one’s personality and to promote the individual’s sense of self-respect and self-worth. The two methods differ in several important ways, however. Whereas remotivation encourages the group to stay on track rather than ramble from one topic to another, Validation encourages older adults to talk about whatever they please. Remotivation relies entirely on verbal communication, with the ultimate goal of relating individuals to present-day reality. Validation uses music, movement, and nonverbal media (e.g., balls, rhythm instruments) to stimulate interactions.

Old-old people in Phase One may benefit from a remotivation group that sticks to objective topics and avoids dealing with emotions. However, old-old people who are more disoriented will withdraw or become agitated by a remotivation group because of their shorter attention spans, garbled speech, and inability to interact verbally or focus on one topic.

Behavior Modification

Behavior modification is founded on learning principles and the concepts of John Watson. It is based on behaviorism, a branch of psychology that studies behavior and observable activities. According to the behaviorists, learning can be defined as the relatively permanent change in behavior brought about as a result of experience or practice. Behavior modification is a broad term encompassing many different types of therapies that are used with many different client groups. Assertiveness training, counter-conditioning (to deal with phobias), reinforcement, modeling, and behavior rehearsal are all aspects of this method of changing one’s behavior.

In modern psychogeriatric care, behavior modification is used in a variety of ways. Many of its common techniques are used by caregivers who want to change the “negative” behavior of older adults who are disoriented. Negative behavior is generally defined as behavior that deviates from society’s accepted norms. We naturally apply our own ideas of what is “good” or “bad.” Crying excessively, pounding, pacing, expressing anger in disruptive or aggressive ways, and wanting to leave the residence are usually described as “negative” behaviors that caregivers try to reduce. For instance, caregivers reward a resident when the person does not cry out for attention, interacting with the person and giving a positive word. Often, crying is ignored in the hope that “if no one gives her attention, she’ll stop.” Without realizing it, some caregivers use forms of negative reinforcement, such as chiding, scolding, or talking to an older adult in a parental manner, may be used to modify behavior. Negative reinforcement in the form of physical restraints or the use of sedatives is at times used; although it is rarely thought of as punishment, it is certainly a deterrent.

Behavior modification requires that the client have the cognitive ability to understand and to remember. As described previously, very old, disoriented people have lost a great deal of their cognitive ability. Short-term memory is limited. In addition, many old-old people who are disoriented are not motivated to change their behavior in the same way as younger people. The time for change is past. Thus, behavior modification techniques do not work with the population that is most appropriate for Validation. Sometimes, the opposite reaction is elicited with behavior modification; instead of reducing excessive crying, pounding, pacing, or expressions of anger, this method can cause an increase in these behaviors. Sadly, most often the insistence to change behavior causes many individuals to withdraw further into their own personal world and to stop communicating with an environment that offers no understanding or empathy.

For any form of reinforcement to be useful, the client must care about the rewards that are offered. An extra dessert, an excursion, or other such offering holds little value to a disoriented older adult who wants to be home with a spouse or working at a former job. Rather, older adults who are disoriented actively want respect, a feeling of being worthwhile, to be useful, to be loved, to be included, and to express feelings to an empathetic person who will listen. These are basic human needs that are not compatible with a reward system.

Diversion and Redirection

Diversion and redirection are two frequently used techniques that stem from behavior modification. Diversion is often used to modify negative behaviors. A caregiver trying to divert an old-old person from an undesirable behavior should provide pleasant distractions once the behavior begins. For example, a resident who is wandering may be distracted by the offer of a cup of tea. Once a person has been diverted or distracted from the behavior, he or she can be redirected to another activity that is more acceptable to the caregiver. In the previous example, after having the resident sit down for a cup of tea, the caregiver may present a newspaper for the person to read.

Diversion and redirection are temporary strategies, however, because the distraction does not respond to the need that caused the behavior in the first place. Reading the newspaper does not help the resident express feelings. If no one responds to the resident’s loneliness, the resident will continue to wander. A validating caregiver tries to establish a trusting relationship with the old-old person, who, once validated, no longer feels the need to engage in wandering behavior or feels the need to do so less often.

Patronizing with the Therapeutic Lie

The therapeutic lie is pretending to believe what a disoriented, very old person says is true even though one knows it is actually false. One lies to placate the client. The therapeutic lie arose from a distortion of Validation principles. Instead of exploring the depth of the older adult’s personal reality, the therapeutic lie maintains a superficial politeness. It does not consider the Validation principle—that there are many levels of consciousness. For this reason, Validation practitioners always are honest. We know that very old people, no matter how disoriented, know the truth, who is honest, and who is lying. If we want to develop a trusting relationship with our client, we must be honest and not lie. If we lie, the person may quiet down but will not trust us. Validating caregivers also do not confront reality, so they find the middle ground, usually associated with a need or emotion. An example from practice follows.

Mrs. Simon, an 87-year-old woman in a nursing home, says in a very worried tone, “Is my apartment all right? I’ve still got my apartment on Bond Street, don’t I?”

The nursing aide responds, “Of course you do. It’s still there like always.” Mrs. Simon quiets down.

Every day, sometimes several times each day, the resident brings up the question of her apartment. The actual fact is that her apartment is gone. The nursing aide lied. Mrs. Simon knew on some level that her apartment was gone, and so her worry was not alleviated. Her actual need to be an independent person (possibly the deep fear behind her worry about the apartment) was not met, and so the worry came back again and again.

Once we began validating the resident and the nursing aide learned not to lie but to explore the meaning behind the behavior, the scene changed.

Mrs. Simon:

Is my apartment all right? It’s still there, isn’t it?

Nursing aide:

Where was your apartment, Mrs. Simon?

Mrs. Simon:

On Bond Street. You know, right next to the bank.

Nursing aide:

Next to the bank. Was it a large apartment?

Mrs. Simon:

Oh, yes, lots of room for entertaining.

Nursing aide:

What do you miss the most?

Mrs. Simon:

Ah, the friends.

And so the nursing aide explores Mrs. Simon’s need for company and her feelings of loneliness instead of trying to placate her with lies.

You Can’t Fool Millie

Here is the story of an 86-year-old memory care resident who was verbal but living in her own reality—the second phase of Resolution. She needed Validation, not reassurance, therapeutic lying, or patronizing.

Millie Conrad raged incessantly. She swore. “Bitch! Let me out of this hellhole or I’ll piss on you.” Millie’s green-gray eyes blazed, gleaming with malevolent mischief. She stuck one arthritic finger under Katie’s nose.

The activity worker bit the inside of her cheek, adding to yesterday’s blisters. Millie was relentless. She would not calm down. Each day, Katie automatically used her techniques. First, she gently confronted Millie with reality: “It’s not nice to swear. You know that. You won’t have any friends if you go on swearing like that.”

Second technique: redirection. “Look at the clock. Goodness, it’s music time! You don’t want to miss music, do you? Let’s go. Mike is waiting for you. We can’t disappoint Mike, can we?” Katie’s voice rose, encouraging Millie, and she winked at the resident. Sexual innuendo flickered. “You like Mike. He makes you feel good.”

Millie stared into space, her eyes round, now gleaming. Her voice, dreamy: “Harold is waiting? He wants me?”

Relieved that Millie’s rage had vanished, Katie ignored the longing in her voice. She nodded furiously, using the therapeutic lie. “Oh, he really wants you. He misses you when you’re not there. C’mon, Millie, I’ll take you to the activity room.”

“Okey-dokey!” Millie’s high-pitched voice shattered the air. She shoved her hammertoes into faded pink slippers.

Katie took Millie’s arthritic hand. “Ouch!” Millie yelled and slapped the activity worker’s arm. “Bitch!” Millie whistled through false teeth. “That’s my bad hand. I told you not to grab. Can’t you people remember anything?” Millie muttered in disgust as the two approached the activity room.

Katie winked surreptitiously at Mike, the music director, and pointed to Millie. Twenty-four-year-old Mike fingered his guitar, waving to Millie. “Sweetheart, I’m so glad to see you.” Mike feigned delight. “You sit here right next to Sarah.”

Millie scowled at 92-year-old Sarah in her gigantic wheelchair, tubes taped to her nose. Mike’s voice hummed, “Now, ladies, take a deep breath before we start.”

“That old cow can’t even breathe.” Millie’s voice pierced the quiet as she pointed to Sarah. “Get rid of her. She stinks to high heaven.”

“We are all God’s children, Millie. We must learn to love each other.” Mike’s soft, patronizing voice quieted Millie. She ambled away from Sarah to get close to Mike, stroking his cheek. She peered into his blue eyes, crooning, “I love you, sweetie pie. When are we going to get married, lover boy?”

Embarrassed, Mike removed Millie’s hand and led her back to her chair close to Sarah, ignoring her question.

“All right, let’s start singing ‘What a Wonderful World.’” Mike strummed his guitar, his robust voice filling the room. A few weak croaks accompanied him. Six of the 10 residents slept. Millie got up and walked away, silent.

That night, Millie’s voice pierced the halls of the nursing home. “You son of a bitch! You liar! LIAR! LIAR! LIAR!”

The night nurse tried to shush her. “Millie! You’re waking everyone up. Nobody lied to you. Here, sweetie, have a nice, hot cup of tea. You’ll feel better. It’s rose tea.”

“You can take your tea and shove it. Rose tea, hah!” Millie splattered the hot tea on the floor with one furious sweep. “I know when I’m lied to—I’m not stupid. That bastard said he’d marry me. He tricked me.”

“Millie, nobody tricked you. Here, take this pill. It’ll calm you down.”

Millie needed stronger and stronger tranquilizers to calm her down. In 3 months, she stopped talking. In 8 months, she stopped walking. She lived for 3 more years, totally withdrawn and no longer talking to anyone.

If a validating worker had interacted with Millie, the worker may never have learned that Millie’s only love, Harold, abandoned her when she was 16. But the Validation worker would understand that there was a good reason behind Millie’s behavior. Millie’s past life experiences informed her actions in very old age. She was conscientious and worked hard her whole life. She never married and always cared for her parents. She reached old age friendless. Always controlled, Millie never complained.

At 86, with increasing memory loss, Millie was losing her social controls. Her brain no longer informed her of her whereabouts. She had lost clock time. Minutes, hours, and days lost their meaning. Logical thinking structures were damaged. She could no longer identify or classify people in present time. Mike, the music therapist, looked like her lover. Mike became her lover. People from the past often replace people in the present for very old adults who are disoriented. Millie’s pent-up rage finally splattered into the open. She could not control her feelings, and she didn’t want to control them.

Before she died, Millie needed to express her hurt and pain. In the final phase of Resolution, she wanted to heal herself. She needed someone to acknowledge her emotions, to validate her. But no one did.

A validating worker would have known that Millie’s behavior was not psychotic or mindless. Millie never had a mental illness. She always functioned well. Here is the scene replayed with Validation:

Millie:

BITCH! Get me the hell outta’ here.

Katie:

(catching the fury in Millie’s voice, reflecting her anger, using rephrasing) You hate this place!

Millie:

Damn right. And everybody in it.

Katie:

(using polarity) What do you hate the most?

Millie:

(curling her upper lip, leering, her voice high-pitched) You.

Katie:

(using open questions, exploring) What bothers you about me?

Millie:

Your baby blue eyes, all decked out, ready to snatch all the men. There’s a word for you. I’ll spell it: W-O-R—whore.

Wanting to laugh at Millie’s misspelling, Katie Centers. Laughing would have ruined their relationship. Katie is beginning to build trust. Millie’s eyes no longer squint. Her voice is less harsh. Her chin no longer sticks out, and her facial muscles are more relaxed. Her breathing is more even.

Katie:

(rephrasing) Are you saying that I put on too much eye makeup to attract men?

Millie:

And you’re a whore. I see you making eyes at Harold; don’t think I don’t know what you’re after.

Katie:

(using a vague pronoun, “he,” to replace “Harold” and “her” for someone in Millie’s past) Did he leave you for her?

Millie:

(spitting on the floor) The son of a bitch! He never wrote. He never called. I HATE HIM!

Katie:

He really led you on?

Millie:

(her eyes watering, lower lip quivering, hurt reflected deep in her eyes) What do you think?

Katie:

(softly) You never saw him again?

Millie:

(in a whisper) I saw him 25 years later with his wife and son across the street. He never saw me.

Katie:

(gently stroking Millie’s shoulder) You never could love anyone else?

Millie:

(sobbing, her arms around Katie) He was my whole life. I hate him.

Katie holds Millie until her sobs subside. The two share an intimate moment. Millie feels validated, her grief and hurt ventilated. Her self-respect has returned. Katie feels the joy of communicating humanely and effectively with another human being.

A Reminiscing Group or a Validation Group? What Is the Difference?

Reminiscing can be effective with a group of oriented or mostly oriented very old people, but it can be a disaster for those who are more disoriented. If the group is not a good fit for people who are disoriented, they cannot participate effectively and will not benefit from the group. In contrast, a Validation group is more suited to older adults who are disoriented and can better meet their needs, as shown in the next vignette.

Get Her Outta’ Here

Laura Thomas misplaced words. Often, but not always, she smeared similar sounds together, creating her unique vocabulary. She no longer knew where she was. She had lost clock time, wavering between Resolution Phases Two and Three.

Sally, an activity worker hoping to preserve Laura Thomas’s speech, invited Laura to join the newly formed reminiscing group. Here, residents shared pleasant past memories. Today’s topic was “How did you celebrate Thanksgiving?” Six women and two men, ranging from 86 to 94 years old, sat in a circle, not looking at one another. Sally wheeled in Mrs. Thomas and introduced her to the group.

“Her shoe squeaks.” Mrs. Arvey’s whiny voice pierced the silence. At 93 years old, she drooped, hunched in her wheelchair, her blurry blue eyes scanning the floor. The group ignored her. Mrs. Arvey was verbal, but she had lost her social controls. She swept the floor with her big toe in a grand gesture, waving a bony forefinger at Laura Thomas. “Get her outta’ here.”

Using a low voice, Sally gently admonished, “Mrs. Thomas is going to join our group. Why don’t we seat her right here?” Sally placed Laura Thomas’s wheelchair next to one of the men, whose eyes were closed and whose chin wavered precariously, drifting lower and lower.

“Today, we want to find out what you did on Thanksgiving.” Sally’s voice was cheery, full of energy. Silence sifted through the room. “Mr. Jones,” Sally addressed a good-looking man of 87, with bright brown eyes, “you were born in New York City. How did you spend Thanksgiving? Did your mother make a turkey?”

Harry Jones smiled at Sally, his dentures clacking in preparation for speech. “I can’t hear you, sweetheart. You’re sitting too far away. Why don’t you come over and sit on my lap?” He chuckled and leered.

Sally swallowed her embarrassment and turned to Tessie Lew, the most oriented group member. “Mrs. Lew, you were born in New York, too. Can you tell us, in a loud voice so that Mr. Jones can hear, how you celebrated Thanksgiving?”

Mrs. Lew, age 89, had jet-black hair that was streaked with grey patches and tied in a bun. Her wide forehead furrowed into hundreds of teeny, wavy lines.

“I’m afraid,” she started in a high, squeaky voice, “that I can’t talk loud, but I can tell you all that our Thanksgiving was the best ever. My mother made a turkey with all the trimmings. I have her recipe. I learned it by heart…”

“Shut up, slut. I don’t give a damn about your mother and her turkey.” Mr. Jones’s husky voice drowned out Mrs. Lew’s recipe. Undaunted, she continued.

Laura Thomas rose from her wheelchair, wobbling, crying, silencing the duet. “I have to go home. My mother is waiting. I must treeple the sinomats before Dad sees them.” She jerked her body forward, pulling at the arms of the chair that stifled her movements.

“But, Mrs. Thomas,” Sally cried, replacing the resident’s body in the chair, “you’ll fall if you walk. Please tell us about your Thanksgiving.”

“Let me out. I have to go home. Hellpen. Healpen,” Sally called out, yelling for help. The meeting was over.

Verbal, oriented residents who can remember the past, such as Mrs. Lew, flourish in a reminiscing group. Here, they can restore their identity and gain feelings of self-worth. However, most of the old-old adults in this group were disoriented and could not function in a verbal reminiscing group. Their attention span was too short, their logical and verbal skills too meager to respond to one topic. They could not separate past from present time, so they could not reminisce. They no longer had the words. They had lost social skills and interacted on an emotional level, not a verbal, logical one. In contrast, in a Validation group, where the topic is not thought-provoking but emotional, these same group members can better relate to one another. The validating worker helps group participants share common needs by expressing their emotions through words, movement, and music.

In a Validation group, people sit close together in a circle to create a “we” feeling. This photo shows group members playing rhythm instruments and singing along during the activity section of the meeting agenda.

Consider how the scene might have unfolded if the residents were attending a Validation group. When Mr. Jones asked the worker to sit on his lap, he would not be ignored. The worker might ask, “You miss your wife, don’t you, Mr. Jones? Did she sit on your lap?” The Validation worker tunes into Mr. Jones’s emotional needs. He always had good sex with his wife. His desire remains, even at age 87.

“You betcha.’ C’mon over, sweetheart.” Harry Jones winks broadly.

The Validation worker makes close, intimate eye contact with Mr. Jones, asking, “Did you love her a lot?”

“Damn right.” The old man’s eyes gleam.

“Should we sing ‘You Make Me Feel So Young’ in honor of Mr. Jones’s wife? Mrs. Lew, can you be our song leader and start us out? Can we hold hands to feel close to one another? Mr. Jones, can you hold Mrs. Thomas’s hand? I think she misses her husband, too.”

The Validation worker knows each group member well. Mrs. Lew was a kindergarten teacher and loves her role as song leader. The group sings with gusto. The theme is “Missing Your Loved One.” Group members look at one another. They express their longing. Music and movement bring them close.

Psychotherapy

Psychotherapy involves a verbal relationship between a client and a therapist. Through this special relationship, the client reveals important feelings and facts about his or her life. The goal of psychotherapy is insight, a combination of intellectual and emotional awareness that enables people to understand their unhealthy living patterns and defense mechanisms and then change their behaviors. Through psychotherapy, more positive coping methods are identified and more meaningful relationships with other people are established.

Validation and psychotherapy share certain basic beliefs. Both hold that people suffer when they suppress negative emotions and feel better when they express their emotions to a trusted listener. Both believe that early patterns of coping affect behavior throughout one’s life and that people can change their behavior only when they want to do so. Both seek to raise self-esteem to increase a person’s sense of well-being and ability to cope with stress. Because of the very nature of psychotherapy, however, it is not appropriate for people in Resolution.

People in Resolution have spent lifetimes denying their feelings and cannot find new ways of coping with these feelings in old age. Instead, they cling to well-established living patterns. Denial is their only way of coping with the stresses of daily life. Validation accepts the behavior of people in Resolution and does not try to change their ways of coping by providing them with insight. Instead, the validating caregiver listens empathetically to the emotions expressed by these people.

People in Phase One, who are mostly oriented, do not want insight. If they are confronted with their emotions, they can become hostile and anxious, and they may blame, complain, or withdraw. People in Phase Two, who are disoriented, are unable to benefit from psychotherapy because they have lost the ability to reflect. Those in Phases Three and Four are unable to communicate verbally. Validation accepts their intellectual and physical limitations and respects their nonlogical, intuitive wisdom. It uses verbal and nonverbal techniques to create an intimate relationship with an old-old person and to restore the feeling of well-being.

VALIDATION AROUND THE WORLD

My Meeting with Mrs. Buchmann

Christiane Grüenenwald

Validation Teacher

Landesverein für Innere Mission in der Pfalz

Germany

SITTING IN HER WHEELCHAIR, Mrs. Buchmann moves restlessly through the dining room, her face writhing in pain and tears running down her cheeks. I put aside my own thoughts and feelings and Center myself. I then watch Mrs. Buchmann and mirror her movements. Slowly, I get closer to her and address her by name. I move down to her level and face her, making honest and open eye contact. With an empathetic voice, I ask her, “What has happened?”

She answers directly, in a whiny and teary voice, “They don’t let me go home!”

I repeat her key words. “They don’t let you go home?”

She replies, “Yes, my daddy died, and I am not allowed to go to the funeral with them.”

I maintain eye contact while pulling a nearby chair toward me to sit down diagonally by her side, which allows me to continue the eye contact and place my hand gently on her head (a father-touch) to better establish a connection with her. She lets me touch her and goes on with a less whiny voice, “He died so suddenly.”

“What was the worst about it?” I ask her.

“He was only 40 years old, and they didn’t tell me anything,” she answers.

“Did that hurt you very much?”

“YES!” she says.

“Was he a good father?” I ask, and again her answer is yes.

Mrs. Buchmann tells me that she had four sisters and they all had to work a lot, even as children. She was the second-eldest daughter and had to assume the role of son for the father. Her oldest sister proved not to be as strong as she was.

“Then your father must have been very proud of you?” I ask, and she says yes while also smiling.

“Do you miss your father very much?”

Mrs. Buchmann answers, “Yes, sometimes I miss him. We always worked a lot together. Mother had to milk the cows and take care of the farm too.”

I start singing “Schaffe, schaffe, Häusle baue …” (an old Swabian folksong about being a hard worker and building a home), and Mrs. Buchmann joins me. We are singing together, at the same pitch and in the same rhythm.

Mrs. Buchmann is relaxed now and smiles at me. She tells me that there will be a fashion show at the retirement home later and that her dinner table neighbor is going to be there, but she herself isn’t too keen on watching the show. I say goodbye to Mrs. Buchmann with appreciation and respect and ask her if I am allowed to visit her again next week. She says, “I would be very pleased.”

Mrs. Buchmann grew up in a rural region of Germany. In her childhood, she had to work hard in the fields to help her parents. She herself has said, “I had to work like a man.” She probably wasn’t allowed to show any weakness and only allowed some feelings to show. Even now, in coming to terms with her past, she denies her feelings. There were also rules about tidiness at home and that one had to eat everything served. Cleanliness and tidiness are very important to Mrs. Buchmann. Her family’s belief in God was very strong, and her faith is also important to her. Despite the hard work and the stern discipline at home, there was solidarity in the family.

Currently widowed, Mrs. Buchmann lived with her husband until she moved into the retirement home. She has three children and has nice memories of their childhoods. Her daughter visits regularly and looks caringly after her. From time to time, Mrs. Buchmann is restless during the night, moving furniture around and wandering through the room. She goes through periods of sadness and is often conscious of her physical and mental losses.

Because of her physical and cognitive losses (decreasing ability to hear, lack of mobility, increasing loss of short-term memory), Mrs. Buchmann blocks out the present more and more and instead stays in her past. She lives on several levels of awareness, often at the same time. On some level, Mrs. Buchmann knows the truth. When Mrs. Buchmann is accompanied through Validation, her painful feelings are accepted and shared. When Mrs. Buchmann stays in the past, she accepts closeness and contact. The use of the singing technique has a positive effect, as she always joins in.

When the Validation session comes to an end, Mrs. Buchmann finds herself in the present again. Yet, she regularly returns to the past to relive positive or negative experiences and to escape the present when it feels bleak or painful. Through regular encounters with Validation, Mrs. Buchmann is able to re-establish her emotional balance as well as regain her sense of dignity and self-respect.

PART II

Communicating with People in Different Phases Using Validation

Part II presents very old people in different phases of Resolution and describes how Validation was used to help these individuals and their caregivers. These stories take place in settings that include long-term care communities, a hospital, senior housing, and in people’s own homes. Chapter 10 introduces five people in Phase One; Chapter 11 sketches four people in Phase Two; Chapter 12 describes two people in Phase Three. These chapters—based on vivid composites of real people with whom I have worked—show how the Validation techniques presented in Chapter 2 are used in real-life situations. These three chapters show how nurses, a doctor, community workers, nursing assistants, social workers, and family members learn to use Validation to ease their own frustration and help the very old person.

Chapter 13 follows the struggles of three very old disoriented people trying to live in the community. There are government and social pressures to keep people out of hospitals or senior living and in their own homes and communities, which means more and more of us will meet disoriented very old people and will need to learn how to communicate with them. How do we help an 82-year-old man who can no longer find his way to the drug store and blames his neighbor for changing the street signs? How do we deal with an 85-year-old woman who absentmindedly drops her Social Security checks into the garbage and accuses the mail carrier of losing her mail? The vivid, detailed vignettes in Chapter 13 illustrate how ordinary people—a mail carrier, a grocery clerk, a hairdresser, an emergency medical technician—use Validation to help their old-old neighbors maintain dignity and independence.

Chapter 14 discusses Validation for family members, and Chapter 15 discusses Validation in group settings.

CHAPTER 10

Communicating with People Who Are Mostly Oriented

Ellen, the Hoarder: “When You Listen, I Speak Clear”

Thick lashes lifted to reveal angry brown eyes. Ellen Haskins bolted toward me, bouncing her walker, meeting me head-on outside the doorway of Manor Home. It was 8:30 a.m. She was waiting to greet me with a sneer, curling her lips. “Hotsy totsy social worker with a master’s degree. Ha! You’re a master of dummies. You think you know everything, but you didn’t know that, did you?”

We walked inside to the dining room. In a grand gesture, her hand swept over the heads of 83 older people having breakfast. “Look at these dummies! They give me a pain in the neck!” Her chin, dotted with tiny white whiskers, jutted out, and her eyes narrowed in disgust. She reached for a wrought iron wastebasket. “Look at this!”

She dumped the contents, turning the wastebasket upside down, littering the tile floor. She picked up a gold band hidden inside a banana peel. Gently, she wiped away the debris, producing a shiny wedding ring, which she shook under my nose. “Now, that is a disgrace. The last thing my husband said before he died was, ‘Ellen, never take your wedding ring off your finger!’ Do you see it on my finger? No. Where was my ring? In the trash! How did it get there? Huh? How?”

I opened my mouth to answer. She shut it with, “I’ll tell you how! They stole it. In the middle of the night, while I was fast asleep, they snuck into the room and stole my wedding ring. I’m not a sound sleeper. They’re clever. They give out sleeping pills to knock people out so they can rob them at night.”

In 2 years, Ellen Haskins had burnt us all out with her “paranoid” behavior. We did not “buy into her delusion” or “feed her fantasy.” Day in and day out, Ellen would stash her gold band in the bottom of the wastebasket and then insist that someone had stolen it. We tried to change the subject when Ellen would begin to accuse.

A good example of an open, warm, and friendly interaction.

Finally, we avoided her altogether. Having spent too much energy on Ellen Haskins, we had given up trying to convince her. She herself had put her ring in the trash. The housekeeper saw Ellen carefully stashing her gold band in the bottom of a wastebasket.

Her daughter flinched, red-faced with embarrassment, when Ellen accused her of stealing the ring. Ellen’s voice would become mean, hateful, full of venom. “Don’t you tell me that I put my own wedding ring in the trash! You think I’m crazy?” Ellen hurt the people she loved. She had no friends. Residents called her “the bitch.”

A psychiatrist had diagnosed Ellen as having possible late-onset Alzheimer’s disease. Five years later, after a CT scan, the neurologist ruled out reversible conditions, such as subdural hematoma. His diagnosis was “neurocognitive disorder due to Alzheimer’s disease and some vascular damage.” Her test results showed failure in the areas of memory, judgment, and problem-solving as well as some difficulty with activities of daily living. Her personal care functions were found to be unimpaired. A physical examination found her to be a fairly healthy 86-year-old female, with some osteoarthritis and no reversible conditions that might account for her dementia.

Ellen’s speech was clear and her remote memory intact. She would forget names but kept careful track of present time and place. If I was 3 minutes late for our appointment, her foot would tap, impatiently marking the time, as she greeted me with “Do you know what time it is?” Occasionally, Ellen would forget the name of Manor Home, something that would cause her to panic. Terrified of falling apart, Ellen used filler words to cover. Her voice became shrill, and her words tumbled out. “Of course I know the name of this place. You think I’m crazy? Haven’t I lived here for years? Why do you keep asking me so many stupid questions? Don’t you have better things to do?”

Ellen Haskins was 85 years old when she began accusing people of dumping her wedding ring in the trash. She had led a productive life and had no history of mental illness. After her first husband died in the Vietnam War, Ellen struggled as a bookkeeper to raise her three children, succeeding in sending all of them to college. Her daughter told me that Ellen had been a strict parent, never expressing her love. “We were not a touchy-feely family,” she told me. Ellen Haskins held herself erect, often reporting with pride, “I taught my children how to be neat. Everything in its proper place. Socks have to be folded just so! My mother was a very clean person, God rest her soul. We didn’t dare mess up. I brought up my children the same way.” At age 46, Ellen fell in love and remarried. Two years later, her second husband died of a heart attack while they were hiking. Ellen went back to work.

At age 86, Ellen’s body was a summary of how she had led her life—bold, direct eye contact; neck muscles tight; chin jutted out; movements precise; speech crisp and clear. She often complained of a pain in her neck. Her favorite phrase was “Life is a pain in the neck!” She was a no-nonsense person. She held on. She did not want to be touched. She did not express emotions.

Ellen was afraid of losing control. To keep herself together, she hoarded. Newspapers she had saved for 20 years lined her drawers and covered every inch of floor under her bed. When the housekeepers wanted to sweep under her bed, Ellen stopped them. Arms folded, her voice level, she would order them to leave. “Get out of my room and leave my things alone. Those papers belong there.” Her purse, filled with faded newspaper clippings from the Vietnam War, was tucked under her arm and went with her everywhere.

Ellen was struggling to tie up loose ends in the Resolution Stage of Life. Unconsciously, she longed to put her life in order. She had never properly expressed fury or grief when she lost one husband and then another. When she lost the men she loved, she felt that life had dumped her, like her ring, into the trash can. She now used her wedding ring to express her deep sorrow and helpless resentment.

Ellen Haskins taught me an important principle of Validation—build trust by accepting feelings; don’t argue the facts. Ellen was using her wedding ring to symbolize her feelings of being dumped, feelings that she was afraid to express directly. For 60 years, she had accumulated unresolved emotions. To unleash her suppressed anger and grief at losing her husbands, she hid her wedding ring so that she could accuse the world of robbing her. The wedding ring symbolized her lost loves. The Validation worker would understand that this was her only way of expressing her deep loss. Her blaming and accusing helped heal her hurt. She needed someone to listen. Then her blaming would lessen. She had to hold on to familiar patterns. Arguing with her or reorienting her to the facts made her behavior worse. Blaming was a way of coping. Ignored like Isadore Rose, she would have withdrawn inward.

Older adults who blame others often act in mean and hurtful ways. Ellen Haskin’s daughter, Mary, learned to Center to wash away her hurt when her mother began to blame. To validate her mother, Mary had to acknowledge her hurt, put it in the closet, close the door, and listen with empathy. It is often harder for a family member to validate a relative than it is for professionals. Personal connections get in the way. The hurt is greater. Mary wanted her mother to be the same person she knew as a child. Now, the kinder Mary was, the more her mother blamed. “Why is Mother so mean?” Mary often cried.

The closer the relationship, the harder it is to listen without judging. Validation requires genuine, open, nonjudgmental listening—empathy. Sometimes, the older person will provoke feelings of anger, outrage, humor, or pain in the caregiver. The caregiver Centers. When Mary put her feelings in the closet, she was able to listen with an open mind. Her voice held respect despite Ellen’s outrageous behavior. Even if deaf, the older adult will “hear” the listener’s impatient sigh. An older adult who is blind will “see” the frustrated frown of the listener. Mary learned to listen exquisitely, becoming free to hear the undertones in her mother’s voice. For a son or daughter, this is not easy. Centering helps!

People in Phase One are afraid of feelings. When I tried to soothe Ellen by saying, “That must make you feel terrible,” she glared at me and responded in a biting voice, “I feel fine. There is nothing to talk about!” Instead of patronizing Ellen, I learned to walk beside her, respecting her space. I learned not to divert her or placate her, not to ask her to expose her feelings or to figure out why she behaved the way she did. Ellen did not want to understand her own behavior. When I gave up trying to change her, when I stopped trying to give her insight, she began to trust me.

“What was your first husband like? How old were you when he gave you the wedding ring?” I asked Ellen.

Her eyes softened as she recalled, “Harry gave me the ring when I was 16. We found it in an old jewelry store on 14th Street.”

I listened without interrupting. I never probed. Ellen was healing herself in her own way by talking about her husband. Her feelings of love and pain came out as she remembered his death. She had lost the angry look in her eyes, and her breathing became more even. Her facial muscles relaxed, her voice softening.

When Ellen accused the housekeeper of hiding her ring, I didn’t argue. I listened without judging, using nonthreatening, factual words to explore. “When was your ring stolen, Mrs. Haskins?” I asked.

Recognizing the sincerity in my voice, Ellen did a double take. “That awful housekeeper comes in the middle of the night when I’m sound asleep. They’re smart, those people. They take advantage of you when you’re not looking, when you least expect it. That’s when they rob you.”

In spitting out her anger at the staff, Ellen was getting rid of pent-up rage against the world. Her fury, expressed at last and acknowledged by someone she was beginning to trust, began to lessen. Her blaming decreased. Others noticed the change in Ellen’s behavior. I taught Laura, the wise housekeeper who cleaned Ellen’s room, the first two steps of Validation. Laura, her face crinkled with caring, listened closely. She understood. She quickly learned how to Center and to validate Ellen.

“Laura, I had 10 oranges in my sink. There are only three left. You know I keep them there to refrigerate them. You had no business removing my property. You stole my oranges. Put them right back!” said Ellen one morning.

Instead of angrily denying the charge of stealing Ellen’s fruit, Laura responded with a tone of respect. “How many oranges did you have, Mrs. Haskins?”

“You heard me. There were 10 oranges in that sink. My daughter mailed them to me from Florida.”

Laura continued to validate Ellen. “Your daughter thinks about you even when she’s on a vacation! What kind of oranges were they?”

“They were Sunkist,” answered Ellen, “and only grown for export. You can’t even buy them in Florida.”

“Your daughter knows how to shop,” said Laura. “How did you bring her up?”

“I had to teach her. You know, we lived through hard times when my husband died. We couldn’t afford oranges, and I loved them so. My mother always gave me oranges for my birthday. Big, juicy ones,” said Ellen, her anger already diminishing.

“What was it like during those hard times?” asked Laura.

“We didn’t even have a fridge that worked right,” whined Ellen.

“It must have been tough bringing up children then,” Laura responded.

“Would you have liked to live like that? I had to get by with food stamps, and sometimes we didn’t have enough at the end of the month. My poor babies were so hungry.”

Ellen and Laura continued to talk for another 5 minutes, sharing experiences, trusting each other. Laura understood that Ellen Haskins had grown up hoarding to keep herself together. Ellen felt safe when she had her possessions in one place. As a child, she had learned to put the right thing in the right place at the right time in order to be loved. In her old age, Ellen Haskins had lost her home, her husbands. The more she lost, the more she held on. After her first husband died in the war, she ran out of money. Now, she was running out of family and friends, out of her role in life. Her hoarding got worse.

Bottled-up feelings of loss had festered inside Ellen for a lifetime. She would never expose feelings directly. Her anger and fear were carefully disguised. She used oranges, her wedding ring, tiny bits of tissue carefully folded in triangles, to express her fear and maintain her control. As we listened to the facts, never arguing, Ellen’s fury lost its strength. Although disguised, her feelings were exposed to the light of day. We spent 5 minutes each day listening to Ellen. Within months, she stopped accusing staff or her daughter of stealing her wedding ring.

Lucy, the Spitter: “Bitch! Get Out of My Room!”

Lucy Kelly spat. She often spat at people she didn’t like, and Lucy did not like me. Her voice grumbled deep in her throat. “Goddamn son of a bitch, get the hell outta’ my room. Bitch!”

The last “bitch” was punctuated by spit, which hit the mark. I blinked.

“Well, aren’t you gone yet?” Lucy accentuated her words by jabbing me with the tip of her cane.

With some effort, I shut out the anger and kept my voice calm. Patiently, I reasoned with her. “Mrs. Kelly, my job is to help you feel better.”

She mimicked the tone of my voice to ridicule me. “I don’t want to feel better, so you better find another job. I don’t talk to idiots.”

“I like my job, and I like you,” I said feebly. “I want to help you.”

“LIAR!” she shrieked.

Lucy spoke the truth. I could not like her. Her beady brown eyes shot out hate. Her cheeks, swollen with medications, puffed in and out like an accordion. I stared at her for a moment, then softly said goodbye. In the hallway, I began to cry, without knowing why. As a professional social worker trained to understand and accept all human behaviors, I should not have reacted emotionally.

The next day, I tried to give Lucy insight. I wanted her to understand why she was so full of hate, to become aware of the reasons behind her fury, to want to change her behaviors. She was lying stiff as a board, her back rigid, her face turned to the wall. Tentatively, I approached her bed. “Mrs. Kelly, it’s me, Naomi. Are you still angry?” I waited, but there was no answer. In desperation, I continued exploring her feelings, trying to build a relationship. “I don’t blame you for feeling angry, Mrs. Kelly. You have lots of reasons. I know how you feel. You were an active woman. Now, you can’t even walk.”

Lucy Kelly remained silent. I gulped and went on in a shaky voice, “You’ve lost your wonderful job, your husband, and your friends. People looked up to you. You were the life of the party. No wonder you’re angry at the world. I would feel angry, too.”

“Oh, shut up, you fool! I don’t care how you feel. You can jump out the window as far as I care. AND DON’T TELL ME HOW I FEEL! I AM NOT ANGRY. NOW GET THE HELL OUT OF MY ROOM BEFORE I CALL SOMEONE TO DRAG YOU OUT! DON’T YOU KNOW WHEN YOU’RE NOT WANTED?” Her voice became cold and mean.

Clearly, Lucy did not want to get in touch with her feelings. Like Ellen Haskins, she did not want to know why she was so angry. She did not want to change. She could not trust herself or others. Since facing her fears might mean losing control, Lucy denied feelings. I was not about to change her at this stage in her life, when her world had fallen apart.

Lucy Kelly had been a successful businesswoman, the head buyer for a large department store. Her daughter, Norma, told me that she had always been bossy. “When Mother opened her mouth, everyone listened and did just what she said. She would tell Dad that I was naughty, and Dad would punish me without asking me what had happened. Mother was always right. When my mother calls me, my heart lurches. To this day, I jump. And I am 54 years old!”

Norma’s blue eyes blinked hard, filled with held-back tears. “When I was 10, I forgot to cross a ‘T’ on my homework essay. Mother made me write and rewrite the paragraph, smacking my hand when my letters weren’t perfectly even. My tears splashed onto the ink and blurred the words. I never did hand in that essay and got a detention. I’ll never forget hating my mother that night,” Lucy’s daughter concluded in a soft, apologetic voice, wanting to control the flood of memory.

Norma read the empathy in my eyes, and we both felt better. I suddenly experienced my own flashback. I had hated playing the piano, but my mother made me take piano lessons. My turn came at the big recital. I froze and sat there like a dumbbell. Mother got up; gave me an icy, unforgiving stare; and stalked out of the hall, with 85 people watching. I felt a brick of ice on my heart. A heavy, icy feeling struggled to come out. I had to face my anger at my mother or carry the burden of hate to my old age. Would I end up alone, like Lucy Kelly—self-centered, bitter, blaming, full of self-hate and hate for others? Would I alienate my children? If we stay frozen in the past, we might become stuck in anger at age 85.

Norma wondered at my sudden silence. I needed to teach her to face her hate so that she could move on. I spoke slowly, the words forming themselves with care. “Your mother hurt you terribly, and you hated her. Feel that hate!”

Norma stared for a minute. Her face lit with awareness. “My mother is a bitch!”

I nodded. “Can you forgive her?”

Norma smiled wryly, her feelings relieved. “Naomi, if you help me, I’ll give it my best shot. I don’t want to become like her when I get older.”

Once we had faced the hurt and the hate, Norma and I could Center, put aside our own feelings, and tune into Lucy’s world. From Lucy, I learned that we cannot help people who blame others unless we first acknowledge our own anger and lay it aside. I was learning the importance of insight into my own hang-ups. I was preparing for my own wise old age—a dividend I earned through struggling to empathize with Lucy. I tried different ways of building trust. I learned Validation the hard way. I made mistakes.

“Good morning, Mrs. Kelly,” my voice sang, bouncing with cheer.

“Oh, shut up. What’s good about it?” Lucy’s voice was dull and flat. She spoke to the wall.

I echoed her voice tone, rephrasing her words, “Are you saying that there is nothing good about the morning?”

“That’s right, you said it,” she answered. She was talking to me. Her face turned slightly in my direction.

I continued paraphrasing her words, reflecting her attitude with respect. “You wake up and nothing matters anymore. Is that it?” I asked.

“That’s it. That’s the way it is—no more, no less. So why don’t you leave me alone. Scat!” She shot out the words, only half meaning them. There was a pleading undertone to her words.

Encouraged, I continued rephrasing. “With nothing to do, there’s no use in talking?” I ended with a question in my voice to be sure that I had understood her meaning.

Lucy sat upright in her bed. “You said it!” She looked me straight in the eye for the first time. Our relationship had begun. Just rephrasing her words had worked.

Lucy Kelly taught me the Validation technique of rephrasing the person’s words and reflecting the person’s attitude without judgment or analysis—how simple! Matching Lucy’s voice tone was harder. Feelings would creep into my voice. With the sensitivity of a Geiger counter, Lucy could detect even the tiniest false note. Like a turtle, she would then retreat and withdraw inside her shell. To reflect her tone honestly, I had to keep myself Centered. I could only manage 5–10 respectful, genuine minutes with Lucy each day.

Once we began to communicate, I used the Validation technique of exploring with factual questions. “Mrs. Kelly,” I would ask, “what does a buyer in a big department store do?”

“Too much—I was busy from the minute I got up to the minute I went to bed.” Her voice held pride. For Lucy, work was everything. Out of a job, she was nothing. With nobody to manage, she felt helpless. She didn’t know how to act when the losses hit.

In the weeks to come, Lucy and I spent quality time every day remembering her busy life. She never learned to understand why she held on to worn-out roles, why her life stagnated in old age. But Lucy did not withdraw inward. She spoke to her daughter more civilly.

Lucy’s daughter, Norma, also learned to validate Lucy. It was not easy. Lucy had become a cruel person in her old age, and her cruelty extended even to her great-grandchildren. One day, Norma brought her granddaughter to visit Lucy. “Look, Mother, here’s Susy. Aren’t you going to open your eyes and say hello to your great-grandchild?”

Lucy remained silent. Norma pleaded, “Please, Mother, open your eyes.”

Lucy slowly lifted half a lid of one cataract-blurred eye. “Very nice. Now let me go back to sleep.” Her low, gruff voice cut like a knife. She closed both eyes and turned her back.

“Mother, you made me feel bad.” Norma was hurt by her mother’s selfishness. Lucy snorted, her voice muffled by the wall.

“Don’t you care about your great-granddaughter? About me?” Norma cried.

“I want to get out of here. I want to walk out. I want to get back to my job. If you do that for me, I’ll talk to your family.”

“Mother, they are your family, too. Don’t you love us?” cried Norma.

Lucy snorted again. Her back stayed stiff. “If you loved me, you’d help me get out of this place and back to work.”

“Mother, you need medications. I can’t lift you. You can’t bend your knees. How can you get up and go back to work?” asked Norma. No answer.

Norma tried again, stuffing down her irritation. Her voice edgy, she leaned over to look at her mother. “Mother, please, be reasonable. I can’t do what you want. I know you hate it here, but there’s nothing I can do.”

“If you cared, you’d do something. You don’t care.” Lucy began to spit.

Norma Centered herself. Facing her frustration helped her lay aside her simmering resentment. Then she spoke quietly, rephrasing her mother’s words with empathy. “Mother, you think that if I cared about you, I would take you out of here?”

Surprised at the quiet, caring tone, Lucy nodded. “That’s right. I’m a burden to you. You don’t want me around.”

Again, Norma rephrased. “You think that nobody wants to be with you because you can’t walk or work?”

“That’s exactly what I think. Without my legs and my job, I might as well be dead.” Lucy’s voice lost some of its bitterness and took on some longing. “Dad felt the same way when he couldn’t walk, Norma.” Lucy’s voice dropped. “Dad was miserable. He was so ashamed when he couldn’t even wipe himself. He was a proud man.” Lucy began to cry.

“Mother,” Norma said gently, “it’s hard for you, too, isn’t it?”

Lucy nodded bitterly. “I worked all my life, Norma. Now, I’m useless. I can’t stand it. I wish I were dead, like Dad. He suffered terribly. I heard him cry when he thought nobody was listening.” Lucy’s voice sobered at the painful memory.

“Did Dad ever get used to not being able to walk?” Norma and Lucy remembered together. Each day they built a relationship.

Norma no longer tried to calm her mother. She accepted her the way she was and validated her mother’s feelings without judging. This is not easy for an adult child who longs for a wise, dignified mother to love, a mother who deals with the losses of old age without hitting back at her children. This kind of mother is a rare gift. I hope that I will be giving that gift to my children when my strength fails and I need their help.

Sadie, the Martyr: “One Mother Has Ten Kids. Ten Kids Can’t Care For One Mother!”

“Ma, you used a bad word!” Eight-year-old Kenny’s eyes sparkled with mischievous glee. He didn’t notice his mother moving the phone she was holding away from her ear. He only heard the “bad” word and wondered how his mother was going to worm herself out of his trap.

“Honey, sometimes there is no other word. You only use that word when you are desperate—in an emergency. Do you understand?” Marge bent down to look straight into her son’s wide-open, brown eyes. A moment between them clicked. The little boy nodded and ran out to play, yelling to his mother over his shoulder, “Yeah, Mom! Bye!” The screen door slammed.

Marge smiled, a grin of gratitude for having a wise son. Then she stiffened, returning to her phone call. Her thin fingers shuffled through her prematurely greying hair. She pulled out one white hair and threw it in the garbage can, praying, “Dear God, please help me never, never to act like my mother when I get old. Please let me die first!”

Marge’s voice began pleading. “Mother, we’ve talked for 55 minutes. Thank God the baby’s still asleep. I can’t leave my family and take the next plane to Indianapolis. You’ve got two children who live 30 minutes from your house. Can’t you call Lillian or Joan? Mother … don’t cry … please, Mother … I love you. I don’t want you to be miserable all the time. Mother, what’s the matter? What happened?”

Marge heard her mother gasp for breath, then silence. Marge screamed into the phone. “Mother! What’s the matter? Should I call an ambulance?”

Her mother’s voice came through clear and strong. “Margaret, I have to call 911.”

Marge’s mother, Sadie, hung up. Marge stared at her phone. Without pity it rang again. Marge jumped, unprepared for the second shrill, relentless ring. Sighing, she replaced anger with resignation and answered the call. Her mother’s voice was frantic. “911 is busy. What should I do? Tell me! Quick, before it’s too late. I can’t breathe. My breath is gone. Hear it? Like a sheet of metal around my heart, squeezing my breath away. This is the end. Oh! It hurts so bad. It’s spreading to my back. It’s choking me.”

Marge heard raspy spurts of air quickening over the phone. “Mother, close your mouth. That’s right. Breathe slowly through your nose—in through your nose and out through your mouth. Take deep breaths. Rest your hands on your stomach. That’s right … good … that sounds much better. Keep breathing that way … don’t stop. Turn on the television. Watch and breathe for 5 minutes. I’ll call Lillian and Joan, and we’ll decide what to do.”

Marge had been through this scene a hundred times in the past 6 months. A Validation teacher had taught Marge how to Center and wash away her anger. When Marge’s father died 2 years ago, her mother had collapsed. After the funeral service, Sadie had moaned to her children, “Daddy is dead, and you should now bury me. After 44 years, I’m alone. Harry!” Sadie’s eyes lifted to heaven, imploring the clouds that drifted nonchalantly by, ignoring her. She raised both arms in prayer. “Take me! I’m 72 years old. I’ve lived a good life. I’ve raised my children. They have good jobs. They have families. They’re busy people. They can’t afford to spend time with an old woman who is all alone. I had time for them. Please, God. If you have a heart, take me.” Sadie rocked back and forth in anguish, a tear or two squeezing out from her tightly shut eyes.

“Mother, we’ll take you. You can live with us. We have room.” Sadie’s eldest daughter gladly made the offer. Her husband nodded.

Sadie slowly lowered her eyes from heaven and turned to her children. Her eyes were calm, subdued. In a dulcet tone, she demurred, “No. Thank you very much, but no. I have my own house, where I lived with my husband.” Her voice broke, and she swallowed to gain control, continuing,” I lived with him for over 44 years. The same house with the same man for over 44 years. How can I move? Even to a child’s house? It’s too late to make a change. I’ll scrape together what money I have left. I’ll manage. I’ll be fine.” Sadie’s children respected her strength and left her alone.

Sadie had been a devoted mother. Her children had been her life. She had sacrificed an acting career to have a family. If not for her four children, Sadie would have become a Broadway star, without a doubt. Six famous directors had told her so. Her adoring husband believed her story. Each one of Sadie’s children had been nursed on that story. They all believed it. Sadie believed it.

After her husband’s death, Sadie mourned for 1 year. Newspapers found their way to the trash, unread. Dishes piled up. Shades stayed down. Sadie shut out the traffic of the world. Her children ached for her. They took her shopping. They bought her groceries. They urged her to live with them. Staunchly, with pride, Sadie refused. One year and 6 months after her husband died, Sadie began her “organ recitals.” She started small, but with practice, she honed her skill.

Sadie’s organ recitals had a beginning, a middle, and a grand finale. She would usually begin with the top of her body and move down. “My head hurts. Oh! What a headache. Tylenol doesn’t help. If you could only feel the pounding—like a sledgehammer on my temples. There’s a pain in my heart, too. Don’t tell me it’s heartburn. I never had heartburn in my life. I know heartburn from heart failure—a dull pain that grips you, squeezing you, cutting your heart out. Your grandmother died from congestive heart failure. So did your Uncle Jake. Dropped dead on the front porch—right there, on the third step.

Sadie would then continue with the rest of her body, reciting every ache, pain, and problem. “Honey, rub my lower back. I can’t move. It’s a sharp pain. I’m paralyzed. Help me, honey. How can I get to the bathroom?” Sadie’s voice drops to a whisper. “And when I get there, nothing comes out. I was never constipated in my whole life. My bowels were perfect—regular as clockwork, once a day. Now, I’m lucky if I can go once a week. Maybe it’s cancer of the colon. That’s the worst cancer—the colon. The most painful. Oh! it hurts all over.” The finale was dialing 911.

Marge had listened to this recital for too long.

The slam of the screen door interrupted her thoughts. “Mom, I want a sandwich,” Kenny said, rummaging through the refrigerator, spilling a half-filled glass of milk.

“Kenny! Look at the mess you’ve made. Can’t you pay attention?” Marge shrieked, her voice cracking with strain.

“Mom, you’re getting hyper. Cool it.” Kenny wiped up the spilt milk, shrugging his shoulders.

Marge’s guilt struck her like a knife. I’m taking out my anger at my mother by yelling at my son, she thought. I’ve got to handle it better. Marge took Kenny’s hand and admitted softly, “Ken, I’m worried about Grandma. I’m sorry if I’ve been taking it out on you.”

“It’s okay, Mom. But you better fix it before you explode.” Kenny ran from the room.

Marge nodded and took some deep breaths to Center when the phone rang and her 18-month-old daughter started to cry at the same moment.

Marge scooped up her baby and answered the call.

“Margaret, I’m sure that I’m dying. You have to come out here right away. None of the other children understand what I’m going through. Margaret, do you hear me? I need you right now. You can’t wait. If you wait, it will be too late. I’ll be gone.” Sadie’s voice rose. She breathed hard into the telephone.

Marge felt rage blowing up inside her like a balloon. Sensing Marge’s fury, the baby cried louder. Marge shouted into the phone, her voice desperate and final. “Mother, I cannot leave my children and fly to Indianapolis. I just can’t. You’ve got three other children to call. Call them!”

Marge heard the call disconnect. Her mother had hung up.

Marge called her brother and sisters. Each one had suffered similar calls from Sadie. Each one had had it. Each one wanted to give up. Marge called me next. When she arrived in my office, she was jumpy, her eyes puffy with dried-up tears. She paced back and forth, stopping for a moment, pounding her knuckles to consider her next move.

“Should we place Mother in a nursing home? She’s only 74 years old. She would never leave her own home. She’s said that a million times: ‘I would rather die before going to a nursing home. Kill me first.’”

I tried to give Marge insight into her mother’s typical way of dealing with hard times. “Marge, did your mother complain of aches and pains when you were growing up?”

Marge stopped pacing to remember. She thought hard. “When Dad lost his job, she got pneumonia. We had to live with our aunt for 6 months while Mother was in the hospital. When our grandmother died, Mother lost her voice. Her bronchial tubes closed, and they had to stick a tube down her throat so that she could breathe. I guess when things go wrong, Mother gets sick.” Marge suddenly realized her mother’s inability to face hard times. She began to empathize with her mother—the martyr.

“Marge, I’ve seen hundreds of parents who act like martyrs. They damage their relationships with their children. They lose their friends,” I explained. “You love your mother. Maybe the Validation techniques will help. First, you need empathy. Find a time in your life when the bottom dropped out, when too much was going wrong at one time. That’s how your mother feels now.”

Marge bit her lower lip to remember. Her eyes lowered in pain. “When I had a miscarriage. The ache in the middle of my chest hurt most in the hospital just after I lost my baby. The nurse’s cheery greeting each morning afterwards was awful.” Marge’s eyes filled with tears.

I said softly, “Marge, can you think of that ache when you listen to your mother?” She nodded.

I taught Marge how to explore by asking who, what, where, when, and how questions. She learned to rephrase her mother’s complaints with empathy. Then, Marge learned the Validation technique of using the person’s preferred sense.

“Marge, when your mother called you yesterday, what word did she use the most? Can you remember?”

Marge opened her eyes wide in wonder. “I had never considered that. Her favorite word is ‘hurts’—this hurts, that hurts, it hurts all over. She could write a musical comedy, ‘Oh! How Much It Hurts Me.’”

I smiled. “Then you use similar words. Speak her language. Step right into her world. Your mother seems to be mainly a feeling person. She prefers her sense of touch, her sensations. Use feeling words with her. Ask her how bad, or how sharp, or how dull the pain is. Is it the worst at night? Or during the day?”

Marge asked, still unsure, “How long do these Validation sessions last? How do I end them? Do they go on forever?”

“Give her 5 exquisite minutes of listening. When her breathing slows down, and her voice calms, tell her you’re sorry, but you have to hang up. You are a mother responsible for young children. She’ll understand that. But be sure to reassure her that you’ll talk to her again soon. Don’t forget when you promised to call her. No matter what, remember to call her at that time. She’ll count on you. Your Validation sessions need to continue until your mother dies. Martyrdom is your mother’s safety survival kit. She’ll never go anywhere without it. She’ll need a trusted listener to travel with, forever.”

Six weeks later, telephone calls from Indianapolis sounded like this:

Sadie: (her breath rising and falling like waves in a thunderstorm) Come right away! I’m shaking all over.

Marge: Where are you shaking? In your hands?

Sadie: (taking a moment to find out) My hands? No. Not my hands? Yes.

My hands. They are shaking so badly I can’t even hold the phone. It’s dropping from my fingers.

Marge: Mother, try holding on for just one more minute. Take a deep breath. Where else in your body are you shaking?

Sadie: My heart. My heart is shaking … pounding … so hard. (Sadie’s voice trails.) My voice, too. Can’t you hear how my voice is shaking?

Marge: I hear it. It’s shaking so bad. Has it been shaking all day?

Sadie: Since this morning, when I got up. It started then. What shall I do?

Marge: Have you had breakfast yet?

Sadie: How can I eat when I can’t even talk? When my voice is stuck in my throat? I can’t find the words. I can’t even swallow. There’s a terrible lump in my throat.

Marge: (Centering quickly, to restore her loving voice tone) There’s a lump in your throat, Mother? What does the lump feel like? Does it hurt to swallow?

Sadie: It’s too horrible to describe. The pain gets so bad that I have to sit up in bed. I get up, and I walk around, but nothing helps. I can’t sleep a wink. (Sadie’s breathing quickens.) Is this living? If this is living, dying is a gift from God.

Marge: Is it hard at night? Is that when you miss Dad the most? Is that when the pain feels the worst?

Sadie: (now crying with relief) Oh yes, honey. At night I miss Dad so much. It makes me shake all over when I think of being alone without him. That’s when I get a lump in my throat. He was so good to me, Margaret. We lived together for such a long time. I can’t bear to go on without him. (Sadie’s voice softens with longing.)

Marge: Oh, Mother, it is so hard for you to stand so much pain. I wish I could be with you right now. Can you walk over to Joan’s house and tell her how you feel? She needs to know how much Dad meant to you. She also needs help with her kids. You know how much Joan’s kids love you.

Sadie went next door to Joan’s. Marge was able to explain the Validation techniques to her sisters and brother. Sadie never stopped complaining, but there were many times when her organ recitals stopped sooner. More and more often, the litany of health problems never even reached her stomach. She slept better at night. Sadie died at age 81 in her own kitchen.

Peg, the Victim: “There’s a Man Under My Bed”

“I wish he wouldn’t come tonight.” Peg Harvey clunked her dentures into the glass, enjoying the tinkling sound her teeth always made when she tucked them in for the night. She always brushed them the same way, quoting her mother: “Small, even, swift strokes to keep them white and pearly.”

“Did you say you’re getting up early?” Elsa, her roommate in the Hilltop Senior Housing Development, shouted from her bed.

“Pearly. I said pearly, not early. Why don’t you wear your hearing aid, Elsa? You never know what might happen during the night. At least you’ll hear what they say about you before you go.”

Elsa snapped, “I’m not going to die tonight. So shut up and let me go to sleep.”

Peg, hurt by Elsa’s cold tone, whispered, “Well, I might die. Did you see the moon?” Peg peered at the silvery moon bobbing behind the clouds. “A full moon—I can tell. It’s hiding its face in the clouds, but I know it’s full. Elsa, did you hear me? THE MOON IS FULL!” Peg shouted.

Elsa jumped up and lashed out, “If you don’t shut up and go to sleep, I’m going to call the Super, and they’ll put you on the third floor in the ‘D’ building with the people who aren’t in their right mind.”

Afraid of the threat, Peg muttered under her breath, “She thinks I’m crazy, but wait until that man shows his face to her. And God knows what else he’ll show. Then, it’ll be too late!”

Cautiously, tentatively, Peg poked her big toe under her bed. Relieved, she waved her whole foot, feeling the space, whispering, “He’s not there yet, but he’s coming. I can smell it. Something has got to be done. When it’s too late, they’ll all believe me. God knows what he’ll do to us. If only Peter would have waited one more year. Peter, why couldn’t you wait to die? We would have had our insurance money, and I wouldn’t have had to come to this place. It’s easy for you. You’re dead. I have to live with that Elsa, who’s almost deaf. Peter, listen to me. Tell me what to do. Should I tell the Super? He won’t believe me. They’ll put me in the other building on the third floor. That will be the end. The smell will kill me first, and then I’ll have to hear people yelling all day. No. But, I have to tell somebody. Shh, I think he’s coming.”

Peg froze. Her skin, now covered with bristling goosebumps, turned chalk white. She stopped breathing. She saw a form developing under her bed. First, the head, neck, and shoulders, and then the rest of his body. It was a man, and he was naked. Peg fled from her room, her white nightgown ballooning—a sail in the wind lifting her swiftly down the red-carpeted hallway, through the lobby, and out into the moonlit night.

I saw Peg the next day. Primly, she sat apart from the other women present, crocheting in the craft room. Her medical and social history told me that she had always been a relatively normal, albeit neurotic, woman. She had never been hospitalized for mental illness and was a physically healthy 82-year-old. Her two children lived far away but cared about her, visiting at least twice each year. Last night was her fifth nocturnal episode. The administrator of the apartment complex was worried. Should Peg be moved to the memory care floor? Her mental-status test results did not point to significant cognitive decline.

Peg smiled sweetly when I approached her, grateful for my attention. She looked sheepish when she saw me look around the room at the other women, who ignored us. Peg was obviously isolated. “They used to be my friends,” she explained, apologetically. “Now, they don’t want to sit near me because they know that I ran out of the building in the middle of the night. They all think I’m crazy.” Peg blinked away a tear. She was hurt by the rejection. Shoulders curved, head tucked against her chest, she would not look into my eyes.

Peg had the typical stance of someone who feels like a victim: shoulders rounded, eyes downcast, breathing slow, lips pursed, chin tucked in, movements indirect, body leaning forward. People who feel victimized walk slowly, bending low to protect themselves from the onslaught of humanity. They carry a heavy load. Adopting a victim mentality serves a similar function to blaming others—it is a way to avoid facing one’s own feelings. Older adults like Peg can easily move into Phase One, lugging their burden of suppressed emotions until the end of their life. During this phase of Resolution, they stay oriented to present time and place, but not happily so.

Peg hunched her shoulders, carrying the weight of the world on her back as we walked to my office. She sadly explained her slow gait. “I can’t walk very fast because of my back. Lower back pain is very painful, so you’ll have to bear with me. It’s going to take a while.”

I nodded. Peg wanted my time. She needed a friend. The tenants in her building walked away from her. They were afraid that they would have to witness her “hallucinations” and did not know how to handle them. They were busy dealing with their own losses and had no time left to listen to Peg’s fears. Her ignored feelings were festering. The fears were locked inside during the day and gained strength at night.

Trying to change Peg’s behavior by ignoring it made it worse. Peg Harvey needed Validation. She needed someone to listen with care. In a respectful voice tone, I applied the Validation technique of asking open questions.

“What happened last night, Mrs. Harvey?”

“Oh, it was terrible. He looked so evil.” Peg’s voice dropped in fear, and her eyes looked up at the ceiling in vivid recall. When people look up, they often visualize something. I investigated further. “Mrs. Harvey, are you picturing him right now in your mind’s eye?”

“Oh, yes. I see him clear as day, only he comes at night.”

“What makes him come to you?”

Peg bit her lower lip in concentration. Her eyes stopped blinking, and her forehead wrinkled in thought. She shook her head. “I don’t know, but he only comes when there is a full moon. Last night, did you see it?” Peg didn’t wait for me to answer, but rushed on. “A brilliant moon. Big and round. I wish I could enjoy it, but I can’t. The clouds tried to brush it away, but that moon wouldn’t let anyone push it around. It popped right out. And that’s when I saw the man so clearly under my bed.”

Peg Harvey used visual words. She drew vivid, poetic pictures of the sky. I explored, matching her preferred sense. “Mrs. Harvey, when you see this man under your bed so clearly, what does he look like?”

“He has black hair, sticking straight up, like a broom turned upside down. He has bushy, black eyebrows bristling up and down when he looks at me.” Peg stopped a moment to shudder. “He even has long, thin, black hairs coming through his nostrils, and little stubby whisker-like hairs coming out of his ears. He doesn’t have a mustache, but he has a beard. The beard hairs are bushy, too, like his eyebrows. They stick straight out, from one ear to the other. He has the same thick stubby hairs on his chest.” Peg stopped. Her image frightened her. She came close, whispering in my ear even though we were alone, “He has hair ALL OVER.”

Peg’s teeth began to chatter. I could barely hear her frightened whisper. “He is naked, and his thing is this big!” Peg moved her two forefingers 5 inches apart to indicate the length of his penis, shaking her head at its enormity.

I Centered, breathing deeply and slowly to silence chuckles that threatened to pop out of my mouth. Peg Harvey would turn away from me if I laughed. She was dead serious. She would spot a phony who found her funny. I would lose her trust.

Peg took my silence for disbelief. “Believe me, I am not exaggerating. If anything, I’m underexaggerating.”

I could not trust my voice to match her feelings, so I kept quiet. I needed to find empathy for her—fast! I remembered when I was 6 years old, playing “doctor” with Tommy, my blond, curly-haired friend who lived across the street. We were very serious, playing a game we invented that we called “Who’s got what and where?” With toy stethoscopes snatched from our black, shiny doctor kits, we examined each other. We had to remove our clothes to complete the examination. We ignored Dad’s heavy footsteps. He opened the door to my bedroom.

“MIMI! WHAT ARE YOU DOING?” He bellowed. He roared. His voice shook the chandelier. I trembled. What did I do wrong? “DON’T YOU EVER DO THIS AGAIN. TOMMY, GET OUT OF THIS HOUSE AND NEVER COME BACK! SHAME ON YOU. I’M TELLING YOUR PARENTS!” My old-fashioned father, who never used the word sex, smacked me hard across the face. My lip started to bleed. I was very ashamed. I wished to disappear from this earth. In high school, when my friends were experimenting in the back seats of cars, I sat prim and proper, my blouse buttoned securely. It took me years to untangle the fear-shame-guilt-sex knot tied together and locked up inside.

With a spurt of empathy, I continued exploring to help Peg Harvey get rid of her sexual hang-up. “Mrs. Harvey, what do you do when it gets that big?”

“Nothing. I freeze and hope it goes down before something terrible happens.” Peg’s answer was matter-of-fact.

Without thinking, I asked, “Did something terrible happen to you that frightened you like this before?”

She snapped at me, “This has never happened to me before. You think I’m crazy. I am not in the habit of seeing naked men. Anybody who suddenly saw a man with that thing poking up would be afraid.”

I had made a mistake. I had tried to analyze her, to search her past to figure out why she was afraid of men. I wanted her to face her fear of sex emotionally and intellectually. I was trained to offer people insight. I had to learn, again and again, that many very old people can’t use that part of my training. I had to abandon the goal of helping Peg find insight. I returned to the tried-and-true Validation technique of rephrasing. “Is his thing that big?” I asked her with respect.

She nodded, her eyes widening. Her two forefingers moved apart another inch. I reflected her movement with my words. “Does he get even bigger?”

She answered eagerly, “That’s when he pokes at me through the mattress, and you know what he wants.”

I nodded. We looked at each other, sharing common feelings. The moment ended. Peg got up briskly, her voice bright, her shoulders lifted. “Well, let’s go back to the craft room. We’ve talked enough. I’ll show you the cap I’m knitting for my grandchild. My children live in Vienna, you know. They work for the State Department.” She changed the subject herself, relieved.

Peg and I met twice a week, and each time we met, I Validated her. After several meetings, she stopped talking about the naked man with her friends, saving him for her talks with me and with the craft teacher. Peg knew that we would never ridicule her or withdraw from her. She knew that we believed her feelings. She trusted us. We were the people who listened, who understood.

Her fears lessened. We charted the change in her behavior. Despite two full moons over the next 8 weeks, Peg Harvey saw no man. And we never asked, “Mrs. Harvey, how is that man under your bed?” We talked about other things for 5–10 minutes each day, knowing that it was important to continue our relationship.

One day, Peg confided in me. “Naomi, do you remember that man with the fuzzy black hair I told you about?” I nodded thoughtfully, careful not to smile. I had passed the test. She went on, “Well, he doesn’t come anymore. Last night, there was a full moon, and he didn’t come!”

“That’s wonderful!” I said joyfully. Peg peered at me through the top of her trifocals, changing her voice to a whisper. “Do you want to know what happened?”

I held my breath. “Yes!”

“Well,” Peg said, settling herself in her chair and leaning forward with relish. “Do you ever watch Channel 5 on TV?”

I nodded, itching to find out the connection. But Peg was a storyteller. I had to wait for the end. “Do you ever watch the Fresh Wave ad?” Peg didn’t wait for me to answer. “Well, they advertise this super bottle of Fresh Wave. It’s special. You can’t buy it at the supermarket. You have to call Channel 5. Do you know it cost me $23.99? And that does not include the shipping and handling, which cost an extra $3.95, but it was worth it.” Peg smiled, changing her position in the chair, pausing. Satisfied that I was waiting with bated breath, she ended in triumph, “I sprayed that whole bottle under my bed, and that man hated the smell. He doesn’t come anymore!” Peg was saving face. She had removed the man—but not forever. Peg lacked insight.

Later that year, she experienced a setback. Her daughter in Vienna had promised to visit her on Christmas. Peg had been counting on seeing her grandchildren before she died. She marked off each day on her calendar—only 5 days left. The day before Christmas, her daughter called to say the trip was off. The family had been transferred to Tunisia.

On Christmas Day, Peg saw one man after another under her bed. The loss of her daughter’s visit in present time had triggered the memory of an earlier loss, perhaps the loss of her sexuality. We had to Validate her all over again. But we did not have to go back to the beginning. We had built trust.

One week later, knowing that Peg felt safe with me, I used the Validation technique of imagining the opposite. This very effective technique works best after I have built trust. “Mrs. Harvey, is there ever a time when there is a full moon and no man under your bed?”

Peg stopped rocking. “I never considered that possibility. You know, come to think of it, remember when you forgot your papers Tuesday night? It was about 10:00 p.m., and you saw that my door was open. Did you know that there was a full moon that night?” I shook my head. She continued, “Well, there was, a big orange one, full of holes. You stayed with me for about 10 minutes. Did you know that the whole time you were with me, there was no man under my bed?”

I gasped. She nodded, sharing my wonder. “But” (and now came the punch line), “as soon as you left, he came back!”

I rephrased her words. “When I was with you, there was no man, but when you were alone, he came back?”

Peg stared at me. The clock ticked away the silence. “Do you think I’m lonely?”

Peg Harvey had made a connection. She had tied her feelings to her needs. She had figured out a reason for the man under her bed—loneliness. But Peg would never gain insight into the underlying reasons behind her fears. Imagining the opposite was helping her think things through without threatening her. Asking Peg to imagine the opposite strengthened our relationship. If I had tried to get Peg to imagine the opposite when we first met, she would have answered, “The man always comes whenever there is a full moon. It doesn’t matter who is with me.” Without trust, Peg would not have been able to admit to me that she was lonely. I had to wait 3 months to build enough trust so that Peg would feel free to imagine the opposite.

Together, Peg and I faced her loneliness. We began to reminisce. Peg fluffed a few strands of her curly, pure white hair over one ear, like a schoolgirl. “You know, Naomi, I wasn’t always lonely. I never had many friends in high school, just one, but that was enough. My husband was my only boyfriend. We met when he was 21 and I was 17. He came to me right out of the Army, tall, tanned, so handsome. He had lips that curved up when he smiled. Just before he died, he held my head in his hands and looked up at me from his hospital bed. So often, I see his eyes, clear and light brown, covering me like a blanket, warm and safe. There was no room for anything else, just his soft, brown eyes.” Peg ended with a deep sigh, full of longing, her eyes far away in romantic memory.

She was humming a catchy folk tune. “We sang together. Peter was on key and I was off key, but he didn’t care. He loved me. We walked home from the movies, running up the hill to our new house …” Peg’s voice broke. She shoved her memory away and stared at me, bleak and empty. Knowing that Peg could not handle too much intimacy, I never touched her cheek, but I gently touched her arm with empathy.

Peg had been strong enough to survive her terrible loss at age 63. Perhaps she could recover enough strength to survive loneliness at age 82. I wanted to help her remember her earlier way of coping. It was too late to add new coping skills, but I could stir up some old ones. “What did you do to go on living when your husband died, Mrs. Harvey?”

“I couldn’t live alone, Naomi. That’s when I began seeing that horrible man under my bed. The one—you know.” Peg’s voice had changed to her man-under-the-bed whisper. I nodded. She continued, “My best girlfriend from high school lost her husband about the same time, so she moved in with me. We cried together. We remembered kindergarten and how we sent valentines to each other, and how she met her husband, Tim. He was wearing a kilt at a party, and Patsy fell in love. We walked during the day and talked through the night, and that’s how I got over my husband.”

Peg Harvey looked at me with a new awareness. Her eyes did the asking, and I answered, “I would love to spend time talking with you during the day, but I’m only here 3 days a week. Do you think you could find a friend here who would enjoy looking at your photo album with Peter’s pictures?”

She nodded. “You know Sophie Hale, the pudgy one with the rosy cheeks who always pokes her needle at you when she knits? She’s really a nice person when she puts her needles down and you get to know her. Her husband died at about the same age as Peter. She misses him. She carries his picture under her dress, right near her heart.”

Peg and Sophie stayed friends until Sophie died 3 years later. Peg died peacefully, 1 week after Sophie, without ever seeing the man under her bed again.

Stewart, the Complainer: “You’re Killing Me Here!”

Stewart Charkoff, age 81, was deaf in one ear. On even days, he wore his hearing aid. On odd days, he tuned everyone out. He had become “sick and tired of living with these old people in this old folks’ home with nothing to do.” Arthritis gripped his knees, and he could no longer walk. He refused to be “hauled around on those iron thingamajigs,” his name for wheelchairs. He resented being “mauled by those prissy nincompoops” who came to wheel him from place to place. Painfully, Stewart pulled himself up, each bone in his body creaking. Painfully, he reached for his walker, which somehow always escaped his grasp. He never cried for help. Moving arthritic fingers with the skill of a juggler, he attached the top of his cane to the foot of the walker. To go to the bathroom, he pulled himself up and pushed himself off.

“Mr. Charkoff, please, you shouldn’t go to the toilet alone. You’ve been in the bathroom for 2 hours. Let me help you back to bed. It’s 3 o’clock in the morning.” The nursing assistant was worried. Stewart Charkoff had fallen from the toilet four times in the last 2 weeks.

He poked the nursing assistant away with his rubber-tipped cane. “Get outta’ here, you asshole. She put poison in my tea, and I have to flush it out. I don’t care if it takes 10 hours. I am not going to die in this hellhole. Now get away and let me be. I have to take care of my business.” Stewart slammed the door to the bathroom. The nursing assistant sighed and complained to the head nurse.

The next morning, in the dining room, Stewart roared, “This tea is too hot!” The well-meaning server put ice in his tea.

“What’s this?” Stewart glared at her. “What did you put in my tea?”

“Ice—that’s ice,” the server explained, walking away to serve someone else.

Stewart caught her elbow with his cane. “Oh! No! You’re not getting away with putting lice in my tea.”

Exasperated, the server shook herself free. “I said ICE, not LICE,” she shouted. “If you grab me like that, I’ll report you for abuse.”

Stewart was adamant and shouted, “Quit yelling at me. I heard what you said. I’m not deaf. You better take away those lice or I’ll report you.”

Everyone in the assisted living community dreaded interacting with Stewart Charkoff. They called him “the menace.” It was hard for many staff members to not feel relieved when he was whizzed to the hospital in an ambulance and they got a reprieve from his angry, aggressive outbursts. He had finally broken his hip reaching for his walker trying to get off the toilet. “Maybe he’ll never come back,” some of the aides whispered, giggling anxiously. They had been hurt too much and too often by his actions. They had lost compassion for Mr. Charkoff.

In the hospital, Stewart Charkoff’s behavior worsened. Totally dependent on the hospital staff, he became demanding. One nurse complained, “Your hand is never off the call button. We can’t be running in here all day. We have other people who are really sick who need us. If you want service, get a private duty nurse.” Stewart turned to the telephone. He called local news outlets. “They’re poisoning me in this hospital,” he cried. “The public ought to know what they’re paying for. I’ve put in Social Security for 63 years. I’ve paid for my rights to get a decent meal and decent service. You know what this lousy hospital room costs? The meals stink, and they poison my food. I haven’t had a decent bowel movement since I got here.”

Mr. Charkoff had no children and had never married, so he had no family support. The hospital social worker called me to help. Unlike the other patients’ doors, the door to Mr. Charkoff’s room was closed. The nurses wanted to shut him out. His insistent call button kept ringing. Often, out of exasperation, they ignored him. “Physically, he’s fine,” they told me. “Mentally, is another story. We are an acute care facility, not a psychiatric institution.” I entered Stewart’s hospital room with caution. He looked up with suspicion. Pushing himself up, he leaned on his elbow to stare at me. “Well, you finally got up off your fat ass to see if I was dying? You’re trying hard, but I’m not dead yet! One more meal like the last one, and you’ll have the body. You want to use my parts while they’re still warm? If you keep poisoning me, I won’t be good to anybody, dead or alive!”

He waited, expecting me to argue. Instead, I sat down near his good ear, took a deep breath to Center, and rephrased his own words. “Mr. Charkoff, you say they are poisoning your food?” I asked.

“Are you deaf? Can’t you understand plain English?” Stewart Charkoff peered at me with disgust, amazed at my stupidity. I swallowed, Centered, and acknowledged my hurt. My father had often used similar words when I was 16. I searched for Stewart’s preferred sense. Perhaps his taste buds were damaged, a big loss for a man who loves to eat.

“Mr. Charkoff, does everything taste awful here? Is it worse here than in the assisted living community?”

“The food over there is just as bad. I told the press what goes on.” His anger was subsiding as he talked it out.

I tried using the Validation technique of asking the person to think about the worst case. “When is the food the worst? Breakfast, lunch, or dinner?”

“That’s a good question. That cook is a genius with chemicals because each meal tastes worse than the other. I’ve had lousy cooking in my life, but this place tops ‘em all.”

He was beginning to reminisce. Moving gently, I explored his past. “Was your mother a good cook, Mr. Charkoff? Did she make goulash with paprika?” I had a Hungarian husband who loved this dish, and I thought Stewart Charkoff might also appreciate it.

“You must be Hungarian,” he said, chuckling to himself.

“You can spot a Hungarian. But my husband is Hungarian, not me. Were you born in Hungary, Mr. Charkoff?”

Surprised, he nodded vigorously. “Yeah! If anyone knows Hungarians, it’s me.”

I continued questioning him gently, carefully avoiding the word “why.” I did not want to threaten this suspicious man. My voice held respect for Mr. Charkoff’s wisdom, born from a lifetime of experiences. I always used his last name, aware that his generation used first names with children and peers only.

“Mr. Charkoff, were you a little boy when you came to Cleveland?”

“My father and mother brought me here when I was 10. They couldn’t speak a word of English, but I learned fast. I’m what you call a ‘landscape artist.’” He raised his eyebrows in appreciation of his craft.

I raised mine too, matching his movement, genuinely reflecting his feeling of accomplishment. My tone mirrored his pride. “Mr. Charkoff, who taught you how to become a landscape artist?”

“My father. And his father before him. My people were not vagabonds. We owned land in Hungary. We knew how to work! You should have heard my father yell at us. At 5 o’clock sharp, every morning when the cock crowed, he got us up.” Stewart Charkoff raised himself, frustrated by his broken hip.

“It’s a hard pill to swallow, to stay in bed when you’ve worked all your life. That makes you angry, doesn’t it?” I said, trying to acknowledge his feelings.

“That’s the way it is,” he said coldly. His voice became flat, bitter, and resigned, and he tuned me out. Like many other people, Stewart Charkoff did not want to face his feelings. He denied feelings. He did not want to change his behavior. Confronting him with the consequences of his acting out would destroy our budding relationship. If I had asked him, then, to stop swearing at the doctors and nurses, he would have told me where I could go and what I could do with myself when I got there. I was stuck. Ending our first interview badly could prevent the establishment of trust.

Again, I tried using the preferred sense. Perhaps hearing, not taste, was Stewart Charkoff’s preferred sense. In addition to denying his feelings, Stewart had also denied his hearing loss. He had asked me if I was deaf. He had used hearing words to describe his father. I tried to speak his language by also using hearing words. “Mr. Charkoff, did you always listen to your father when he spoke to you?”

Stewart’s voice lifted as he remembered. “Damn right, I did. I knew what he’d do if I didn’t—out came the razor strap. But he was a good man. He wanted to do right by us. To this day, I can hear him. He gave people holy hell when they didn’t listen to him!” Mr. Charkoff’s appreciative chuckles mounted to a rip-roaring clap of laughter. He was remembering something specific.

“What did you hear him say, Mr. Charkoff?”

“He told that son-of-a-bitch teacher to keep her goddamn hands off my hair.” He slapped his thigh with pleasure.

“What happened?” I wanted him to keep talking.

Stewart Charkoff gave me a sharp look, checking to see if I was really interested. I was. He went on reminiscing. “Once a week, she checked our hair. She was looking for lice. She found some on me. She told all the kids, ‘Stewart has lice. Don’t go near Stewart because lice crawl from one head to another.’” Suddenly, his voice was quiet. “You know, no kid went near me for months. I was isolated. That teacher finally called and told my parents I had lice. My mother scrubbed my hair with that stinky stuff. But my father told the teacher what she could do with her lice.”

There had been a good reason behind Stewart Charkoff’s hearing the word lice instead of ice in the dining room. Loss of his hearing had isolated him, just like the lice in his hair had when he was in the eighth grade. The feeling of being so cut off was the same. His mounting losses in present time had sparked the memory of the lice. Similar feelings attract. They float through time and attach. Stewart Charkoff, feeling alone and useless, overwhelmed by the loss of everything that mattered to him, felt victimized by life and expressed these feelings by yelling at others and complaining to everyone around him.

For the next 5 days, Mr. Charkoff and I talked. We spent 10 quality minutes interacting each day. Stewart’s hip mended. According to the nurses’ reports, he had calmed down, and tranquilizing medications were no longer indicated. We continued our talks when he returned to assisted living. To help him get rid of so much anger, I often used the Validation technique of polarity.

“Mr. Charkoff, what is the worst thing about living here?”

His answer was swift. “Having nothing to do. Sitting in this chair like a goddamn idiot.”

Stewart began to look for something to do. He wanted to work and was sad that he could not. To help him accept this loss, I used the Validation techniques of imagining the opposite and reminiscing.

“Was there ever a time in your life when you couldn’t work?” I asked.

Stewart thought carefully. “My father died fairly young. I was just 16 years old and couldn’t find a job.”

“What did you do?” I asked gently.

“I got hired by a construction company—off the books. They sent me with a gang to dig the foundation for a new hospital in Pennsylvania. I’m a landscape artist, not a ditch digger. My father would have tanned me good with his strap if he had seen me with a rusty shovel.” His voice was bitter.

I persisted, wanting him to compromise, to accept his losses with less rancor, to find dignity in his life despite his sores.

“Did you quit, Mr. Charkoff?”

“Hell no! I couldn’t quit. I would have starved.”

“Don’t quit now, Mr. Charkoff. Don’t starve yourself.” I stared at him, knowing that he would understand my meaning.

“I’m not starving myself; it’s that goddamned cook in the kitchen. I can’t eat that slop.”

Rephrasing, I moved toward finding a creative solution. “You can’t eat that slop, and you don’t want to be here, but you are here. Do you think you and I could go to the head of this place and ask for some work for you, like you did before?”

It took 6 more weeks to convince Stewart and come up with an arrangement. I introduced Stewart Charkoff to the gardener, who was not Hungarian, but who, like Stewart, loved the land. The gardener became a member of my Validation team. In the spring, he helped Stewart steer his walker to a little plot of land nearby. From my office, I could hear Stewart boss the gardener. “Hey, Charley, that’s too much topsoil. Petunias can’t stand that much.”

VALIDATION AROUND THE WORLD

Finding a Common Language

Kevin Carlin, Meridian Senior Living Seattle, Washington

In 1997, my grandmother was forgetting things at a rate that none of our family, including myself, really understood. I didn’t know anything about Validation at that time, but following my heart helped me connect with her. It wasn’t until I learned about Validation while working toward doing my master’s degree in Gerontology at The University of Utah that I realized I had been using a Validation technique. I vowed to continue that journey throughout my professional career.

Erna Schwarz, my grandmother, was one of my heroes. I respected and loved her with all my heart. Grandma came to the United States in the 1930s from Germany; she landed in Queens and then Brooklyn. By the 1970s, when I was fortunate to spend several summers with her and my Grandpa (and be spoiled by them), they lived in Union, New Jersey, in a house built by my grandfather. In the 1990s, when her cognitive decline progressed, she was still living at home and had reverted back to speaking only German, her native language. Fortunately, by then I had learned German as a way of reaching more deeply into my heritage. I had visited her hometown in Germany and seen where she had grown up.

During our last conversation, I started speaking German with her. Even though I felt she didn’t know who I was, I decided to talk to her about Stuttgart and the surrounding area, where she had grown up. As I started naming some familiar places, her demeanor changed; it was as if a light went on and she woke up. But she woke up in the past. She spoke in great detail of Feuerbach and the Black Forest. Because I had been there, knew that what she was describing was not a fictitious place but her hometown. I was able to “travel” with her and visualize the places she was describing. It was so powerful, and I still think of the conversation to this day as a happy moment during difficult times. It is not easy watching someone you respect so much be robbed of their memory.

Later, in graduate school, I read about Validation in my Gerontology textbook. As I read about the techniques, I realized that, in my last conversation with Grandma, I had been using reminiscence and probably mirroring, going with her movements as she spoke. By then, I had also entered into the senior living industry, and I wished I had known about Validation many years earlier. I vowed to learn more, and to someday hopefully meet Naomi Feil and help spread the word about how we can have positive interactions with someone with dementia using Validation. Since then, I have watched and used the Validation method and seen many touching interactions between caregivers and older adults both in the United States and China. It is truly amazing to watch communication between someone who knows how to use Validation and an older adult who, without Validation, could well be sitting alone without any connection to anyone.

CHAPTER 11

Communicating with People Who Are Living in a Personal Reality

David, the Toucher: “I Am Not Dr. Willard. He’s on an Extended Holiday!”

“I’m going to report him for sexual abuse!” Clara, the nursing assistant, tossed her head and pursed her lips. “He’s a dirty old man, pure and simple.”

“He’s not so pure, and it’s not that simple,” Linda, her friend, giggled in answer, cupping her hand over her mouth to hide her laughter from the Director of Nursing (DON). Linda ran toward a resident who was sitting on the toilet, hollering, “Help!”

The DON, hand on hips, locked eyes with Clara, who immediately blushed and looked down. “Well?” asked the DON, in her clipped voice.

Clara sucked in her breath, squared her shoulders, looked the DON in the eyes, and said defiantly, “I’m reporting Dr. Willard. He’s grabbed my breasts for the last time. He’s fast, I’ll say that for him. They must have taught him in medical school just where to pinch. That is abuse. I could take him to court.”

Clara went back to work in a huff, and the DON walked down to my office. Frowning, she sat on the edge of her chair. Together we reviewed Dr. Willard’s history.

December 5, 2015: Dr. and Mrs. Willard admitted to the nursing home. Mrs. Willard was oriented to time and place. Dr. David Willard was diagnosed with Alzheimer’s disease. They were placed in separate buildings. Mrs. Willard indicated that she did not want to be near her husband and was not interested in visiting him. She would not elaborate.

I looked up at Miss Jenkins, who had been the DON on the Alzheimer’s floor for 10 years and who knew the residents and their families. I wondered about Dr. Willard’s other family relationships. “Does their daughter visit?” I asked.

Miss Jenkins arched her eyebrows. “The daughter is Mrs. Elizabeth Whiting. Naomi, if you don’t know the daughter, you’ve missed out. I’ve never been bossed around more by anyone in my life. The Whitings. Very well-to-do, apparently a big name in real estate. Mrs. Whiting comes every day to see her mother and to tell me what to do for her father. But she never even says a word of hello to poor Dr. Willard. Naomi, you’ve got to do something. Dr. Willard is really upsetting that nursing assistant, Clara. I’m concerned that it’s beginning to affect her work.” Miss Jenkins patted me on the shoulder for good luck and bustled back to work.

Dr. Willard’s voice boomed at me from inside his room. “Come in, honey! I’ve got something you’ll like. I can stick it right in.” He was sitting on the edge of his bed, bare feet dangling, searching for something in his nightstand drawer. I had knocked loudly, knowing that he was deaf in his right ear and that he refused to wear a hearing aid. David Willard winked at me as I approached him. He did not know that he had never met me before. In an instant, he had incorporated me into his world.

“Don’t worry, honey, I’ll find it later. I’ve got plenty of time.” He smoothed the space next to him, patting it and jerking his head at me, indicating that I should sit down.

I smiled, sat down where he indicated, and shook his hand to introduce myself. “I’m Naomi Feil.”

“Sweetie, I can run a mile, too. We’ll do it together,” he snickered, rubbing my breast insistently with his elbow.

Stifling a smile, I repeated, “My name is Feil.” I stood up slowly, so as not to surprise him. My voice was gentle. “Dr. Willard, do you mind if I pull up a chair?” I sat facing him.

He chuckled, undaunted by my move. “Smile awhile with honey Feil.” His high-pitched, crackly voice reverberated. He looked like a leering, nonmenacing crow. His thin arms flapped at the elbows. He cocked his head from side to side, sharply examining me from top to toe.

David Willard was 93 years old, but his thick white hair was streaked with black clumps. His bulbous nose, nostrils flaring, dominated his thin, bony face. He hunched his shoulders, erasing his neck, and squinted at me with beady, twinkly brown eyes, daring me to take him seriously.

“Dr. Willard, were you looking for something important when I came in?” I began, my voice sober, respectful.

He ignored my question, reached close, and pinched my cheek with one hand while rubbing my neck with the other. “How do you like them bananas, huh, honey bunch?” he cackled.

Gently, I removed his hands and laid them on his knees. I bent down to meet his brown eyes. Dr. Willard weighed 103 pounds, and his eyes held humor, not malice. I began again. “Dr. Willard, do you know that you are making me feel uncomfortable?” My voice was soft. Did Dr. Willard know what he was doing, or had he lost his self-awareness?

“Am I making you feel uncomfortable, honey bunch?” Although partially deaf, Dr. Willard mimicked my voice tone with perfect pitch. Then, in his own cackling voice, he confided, leaning close, breathing hard into my ear, “I am not Dr. Willard. David Willard is in his office, practicing medicine.”

I did a double take and scratched the back of my neck to regain composure. Perplexed, my voice managed a concerned “Oh?” without breaking. In a respectful, matter-of-fact tone, I asked, “Well, who are you?”, feeling a little like Alice in Wonderland.

He ignored my question, cocked his head, pointed to his scrotum, and cackled, “I’ve got a lovely bunch of coconuts just for you!”

I nodded, acknowledging his offer. Suddenly, he became serious, bent his head close to mine, and whispered, “David Willard is a very busy man. His nurse has his operating schedule. You must make an appointment with her. But I’m afraid you’re too late. He’s gone.” Dr. Willard looked away, shutting me out to rummage in his drawer.

Suddenly, I felt sad, weighed down, depressed. Tentatively, I asked, “Do you think he’ll ever come back?”

David Willard remained silent. His brain was no longer informing him of his body’s whereabouts. He no longer knew where he was or who he was. He had put himself outside himself, picturing the well-known surgeon wearing his white coat in his office and practicing medicine as a separate person. His controls gone, his self-awareness gone, Dr. Willard was releasing his sexual urges by pinching women without restraint.

“Do you want to see your wife?” I asked. Dr. Willard stopped rummaging in the drawer. I looked straight into his eyes. He averted his gaze, slid off the edge of his bed, and pulled the drawer from the nightstand, dumping the contents on the floor. He peered under the bed and into a corner, and then he opened the closet—his movements quick, urgent, frantic. He ignored me. I softly said goodbye and left.

Soon after, I meet with Dr. Willard’s wife. Martha Willard, 84, sat straight up in her chair. Her sharp, blue eyes were cold. Her red-lacquered fingernails drummed lightly on the nightstand. Her newly styled hair was fashionable, pure white in an exquisite bun. Aristocratic portraits of Martha Willard’s family hung on the walls; her father, mother, sisters, brothers, and daughter, in silver frames, smiled graciously. Her husband was missing. “You have a very handsome family, Mrs. Willard,” I said, opening the conversation. “Your daughter is beautiful. She looks like you—the same even features.”

“You don’t have to compliment me. I know why you’re here. My husband is doing awful things. I have no control over him. He is not my responsibility. That man never paid any attention to me. Now, it’s too late.”

I was taken aback by her frankness. Sucking in my breath, I explored. “What do you mean, ‘it’s too late,’ Mrs. Willard?”

Her response was sharp and pointed. “I should have left him the first year we were married. In 65 years of marriage, he never showed a shred of emotion. Maybe it’s all coming out now. He was a bland, cold man. He didn’t want a wife; he just wanted to be married. He loved his work, not me. He wanted a child, not because he wanted to be a father, but because his mother wanted a grandchild. I’ve told you everything you need to know. I have no more to say.” She looked at me intently, raising her eyebrows. She then dismissed me by turning to her book. I left.

Next, I met with Dr. Willard’s daughter. Elizabeth Whiting was beautiful, but her luminous hazel eyes reflected embarrassment. Her hands fluttered. “Mrs. Feil,” she said, “I don’t want to hide anything from you. My mother is very happy at Sunshine Villa. She’s made friends here. She wants nothing to do with my father. I don’t want to rock the boat. I arrange everything for him. Ask Miss Jenkins. I see to it that his suits are always pressed and that he sees the barber every week. Just recently he got a costly new pair of dentures.”

“Do you see him often?” I asked gently.

She averted her eyes, quickly inspecting her fingernails. Finally, she looked up. Her voice quivered a little. “I can’t look him in the eye. My father was never around for me or my mother. He was a famous surgeon, but when I almost died of pneumonia, he was too busy taking care of his patients to see me. When Mother got appendicitis, she almost died. Father saw her in the hospital only after the operation. Even his doctor friends couldn’t understand why he didn’t rush away from patients who were strangers to take care of his own wife.

“Now, he acts like a dirty old man. That is the height of irony. He never showed Mother any kind of love. I never even saw them kiss. And I really don’t think he ever fooled around with other women. He was always at the hospital, working. It’s weird that at age 92, he’s letting it all out, making a fool of himself, embarrassing everyone. I feel sorry for the nurses. He’s taking it out on them. With us, he was an uptight, unfeeling human being. Mother stayed with him for my sake. I wish I had had the sense to help her leave him when she was still young enough to make a new life for herself. She was a wonderful mother. I love her very much. I know how deeply my father has hurt her. Now, she’s beyond being hurt. She doesn’t care what he does.”

Elizabeth Whiting’s voice broke for a moment. “He never came home for dinner unless it was a party for his doctor friends. We couldn’t even make an appointment with him in his office. I don’t think he wanted a family. He certainly didn’t want us.” Her voice turned cold. “I can’t stand him. I can’t look at him. I check up on him to make sure that his needs are met, for my sake, not for his. He is my father, and I owe him that.”

I sighed. Neither mother nor daughter could help David Willard. My next move was to talk to Clara, the nursing assistant. Clara was cute, with short black hair and chubby, red cheeks. She was 18 years old and had just finished high school. For the past year, she had worked as a nursing assistant. Her parents worked long hours, and money had always been a struggle for the family. When I asked her about Dr. Willard, she complained, “Naomi, you should have been there. You wouldn’t believe how hard he can pinch. That man has strong fingers and sharp nails. He may be skinny, but when he gets going, watch out!”

I nodded, knowing what she meant. “Does he frighten you, Clara?” I asked quietly.

“Would you like to be pawed and pinched every time you get near someone?” Clara’s voice rose, her cheeks flushing with fury. She eyed me sidewise, checking my reaction, afraid that she might have gone too far by yelling. Her anger seemed to be out of proportion to David Willard’s feeble attempts at seduction.

I asked her in a quiet, matter-of-fact tone, “Clara, do you think that Dr. Willard knows what he’s doing? Do you think he can control himself?”

“You better believe it!” Her voice was emphatic. “He knows exactly what he’s doing. They all do. I know a wolf a mile away. I’ve known them since I was a little girl.” Clara’s voice held smug conviction.

“You have? How awful! What happened to you?” My reaction was spontaneous.

“Well, when I was walking around town one night with some friends, these drunk men chased us. One of them caught up with me. I saw the look in his eyes.”

“Clara, does Dr. Willard look like those men?”

Clara looked up, visualizing Dr. Willard. She frowned, concentrating. “No. Actually, he looks just like my Uncle Stanley. Dr. Willard has the same hair color, white with lots of black streaks, and the same hands and fingernails. I always notice their nails. Uncle Stanley had his nails polished, too.”

“Did your Uncle Stanley disgust you, too?” I asked quietly.

Clara looked at me, her eyes full of surprise. Her mouth flew open in shock. She answered me slowly, each word loaded with awareness. “Yes. Uncle Stanley was just like Dr. Willard.” Clara spat out her words, her anger growing, unleashing. “My Uncle Stanley had that same slimy look—so does Dr. Willard. Whenever I bent down, Uncle Stanley would reach under my dress and feel around with his scratchy, lacquered nails. My mother didn’t believe me when I told her, because Uncle Stanley was my father’s oldest brother and loaned us the money for our house. I never had the nerve to tell my father. He would have called me a liar. I had to protect myself, all by myself. Naomi …” Clara began and then stopped talking. Her eyes clouded with sad memories and tears.

I sighed, remembering my own suppressed anger that suddenly found the light of day when a bitter, 80-year-old resident reminded me of my father. I paid the price of self-awareness, too.

Clara was stung by feelings. She began to speak slowly, forming each word with sudden insights. “I didn’t know it, but Dr. Willard brought out the anger I had to keep inside when Uncle Stanley pawed me. I felt so embarrassed, so awful, so mad. I guess it was not being able to do anything, knowing that no one would listen. Do you understand, Naomi?”

I nodded, my voice full of empathy. “Most of us who work with very old people experience what you’re going through. The residents remind us of people in our past, and we don’t even consciously know it. Sometimes we act toward older people the same way we wanted to act toward our parents, but couldn’t. With you, it was your Uncle Stanley. You couldn’t tell him to leave you alone, so now your anger is coming out at Dr. Willard. It’s very important to become aware so that we can change how we respond. We are all human and frail, but we struggle to become aware so we can change and grow.”

We shared a silent moment, looking at each other with understanding. Clara spoke first. “I understand myself a lot better now. I think I’ll get along better with my boyfriend after today. Naomi, I know that Dr. Willard has Alzheimer’s disease, and that he’s lost his control and can’t help what he’s doing. He’s not like Uncle Stanley; he doesn’t want to hurt me. I kind of feel sorry for Dr. Willard. His wife is so bossy, and his daughter is so snooty. Poor Dr. Willard! Always bossed around.” Clara’s words poured out in a rush, one thought following another.

I gave Clara one more idea to take home. “Clara, sometimes families who can’t communicate directly with their relatives dump their frustrations on staff. Mrs. Whiting seems snooty, but maybe she’s afraid that she’s not doing what a daughter should do, so she wants to make sure that the staff are doing everything possible. By doing this, families are reassured.”

Clara got the point. “So that’s why Mrs. Whiting keeps pushing me to buff Dr. Willard’s nails and brush his hair and shine his shoes, even though I’ve told her a million times that he pinches me every time I bend down?” I didn’t have to respond. Clara smiled, sprung lightly from her chair, and waved, reassuring me over her shoulder. “Don’t worry, Naomi, I can handle ‘Wiggly Willard’ from now on.”

“Clara, just one more question. Does Dr. Willard have a girlfriend here?”

Her hand over her mouth, she stifled a giggle. “He sure does. He follows Melba Holiday all around. Where she goes, he goes. They’re kind of cute. Anything else? My boyfriend’s waiting for me.”

“No,” I smiled at Clara. “Have fun!” She shot out of my office.

I included Melba Holiday in my Validation group, where residents sat close, held hands, danced, and swayed together. We sang love songs in the group and talked about needing love and affection. These wise residents helped one another solve the universal problem of loneliness. The group met their need to unleash strong emotions. All through the day, the staff made sure that Melba Holiday sat next to David Willard. They held hands; she served him juice and cookies; they danced together and touched in a socially acceptable way.

Within 6 weeks, David Willard was no longer pinching the staff as often. One week before he died, I visited him in his room. He was sitting in his usual position on the edge of his bed, legs dangling, rummaging in his nightstand drawer.

“Dr. Willard, can you not find what you are looking for?” I asked.

David Willard leaned over to stare at me, locking my eyes. He said simply, with deep conviction, “David Willard is not here. The drawer is empty. I’ll never find him.”

David Willard’s search for his identity came too late.

The Validation worker sits close, at eye level and at a distance that is comfortable for the other person. She is making eye contact in a respectful way and exploring what the man is saying. He is sitting in a relaxed position and making good eye contact, comfortably engaged in the conversation.

Margaret, the Mother: “I’m Living In My Own Home; These People Don’t Belong Here!”

“Bethy, come home, honey!” wailed Margaret, loudly. She mumbled to herself, “Margaret, don’t yell so loud! You’ll disturb the neighbors.” A moment later, she forgot herself once again. “Bethy was here just a minute ago. I hope nothing’s happened to her. Maybe she’s playing with her friend. I have to get out of this chair, but there’s a knot around my waist. I need a pair of sharp shears. Where did I put my sewing box? Wait! Thank God the knot’s not too tight. I can slip right under. I better hurry, before it gets dark and Bethy loses her way. I should have asked Mother to take her. But Mother is always so busy; she doesn’t have time for me or my children. Bethy! If I yell loud enough, maybe she’ll hear me. She couldn’t have gone far on her little legs. Bethy! Come home right now! It’s getting dark!”

“SHADDUP!” “SHADDUP!” A chorus of voices chimed, one mimicking the other. “If that woman doesn’t stop, I’ll report her to headquarters,” a 90-year-old former executive bellowed as he shuffled to the nurses’ station, pounding on the glass partition, demanding action.

Susan, the LPN on duty, was overwhelmed. “Four o’clock,” she muttered, “and they all act up. Especially Margaret Dowling I wish they’d do something to calm her down. She’s wearing herself out yelling.” She turned to Hal, the 90-year-old man pounding on the window. “Hal, if you keep on pounding, you’ll break the glass and cut yourself,” she said.

Michael, a bearded, muscular nursing aide, wiped the sweat off his chin with the back of his hand and moved toward the LPN to complain. “It’s too hot on this floor. Why don’t they turn up the air conditioning? By the way, I can’t toilet three people at one time, and I am not bathing Hal. He weighs 210 pounds, and I can’t lift him by myself. I don’t want to get a hernia.”

Susan nodded. “Can you just put Margaret back in her chair before you go? I’ll toilet Hal. Poor Margaret! Her daughter took her doll away last week, and she’s been hysterical. What’s wrong with an 86-year-old woman holding a doll if it makes her happy?”

“She’s not my mother, so the doll hasn’t bothered me. But it bothers her daughter. I’ll tell you one thing, I’m not getting myself sick over this job,” said Michael. “Hey! Margaret! Come back. You can’t go out that door.” Michael grabbed Margaret’s sleeve as she tried to escape.

“Let her go, Michael, the door is locked,” said Susan, sighing as she took Hal by the hand and escorted him to the toilet.

“Oh, yeah? Watch.” Michael arched his eyebrows and folded his arms, releasing Margaret, who sashayed past. Unperturbed, she fiddled with the keypad and slipped out the door. Michael followed with weary eyes, grumbling, “I knew it! She’s figured out the combination. She’s out!” Margaret sped down the hallway, jabbering, “Bethy’s probably looking for her little friend Tommy across the street.” She bumped into a wooden post. Her hands pressed the smooth, hard wood. She used her mind’s eye to picture her old neighborhood. “These trees were just seedlings when we moved here. Goodness, birch trees grow fast. Well, Margaret, you’ve lived in this neighborhood for 30 years. Everything grows older. Now, which way did Bethy go?”

Margaret followed a railing that led to the elevator. She scooted inside the elevator just as the door closed. “They’ve changed the street all around. They put in this alley. No wonder Bethy gets lost all the time. You never know what they’ll put in next. I better look on Chalfant—that’s Tommy’s street.” Margaret slipped through the open elevator door toward the main exit as Michael grabbed her from behind. His hands tightened on Margaret’s arms. Margaret shrieked, “LET ME GO! YOU TOOK MY BABY AWAY! LET ME GO! I HAVE TO FIND HER!”

“Now, Peggy, honey, I wouldn’t take your baby. She’s in her crib, safe and sound. Let’s go back, and you can sing her a lullaby.” Michael grasped Margaret’s hand, pulling her gently as he spoke.

Margaret pulled free, dusting his fingerprints from her sleeve. She peered up at him, straightening as much as her hunchback would allow.

Wagging a bony finger under his nose, Margaret hissed, “My name is not Peggy. It is Margaret. Mrs. Margaret Dowling. And my daughter is not in her crib. And I don’t need you to tell me what to do—impertinent young man. Your mother should teach you how to behave with your elders.” Her lips quivered. “No manners.” Margaret clucked her tongue in disapproval.

“C’mon, don’t give me any trouble. I should be home by now instead of wasting time with you.” Michael had lost his limited patience.

Margaret admonished herself. “I am not listening to this young puppy. Margaret, you march yourself right out that door and find Bethy. The sun’s down, and it’s dark. She’ll get lost. Get your hands off me!” she cried, as Michael grabbed her waist, pulled her into a wheelchair, strapped her down, and wheeled her swiftly into the elevator and back to her floor. He dumped her by the nurses’ station.

“I’m going home,” he told the LPN. “She’s all yours.”

Margaret’s breath came in small spurts. Blue veins splotched her neck. Furious, she shook her fist at the LPN. “I will have you arrested if you don’t get me out of this chair immediately.”

Susan turned her back on Margaret. By ignoring her, she hoped to stop Margaret’s tirade. Perhaps this negative reinforcement might change Margaret’s behavior.

“HELP! POLICE!” Margaret screamed at the top of her voice.

Susan called the doctor, who prescribed a tranquilizer. Two hours later, Susan called me, just as I was leaving for the day. “Naomi, come up to the floor right away. We had to quiet Margaret, so Dr. Finch prescribed Ativan. Now Margaret won’t wake up, and her daughter is furious.”

“Mother, wake up. It’s Molly.” Molly Dunne gently pushed her mother’s eyelids upward with stubby thumbs. Margaret’s eyes would not focus. Her head slumped on her chest. She drooled. “This woman is not my mother. What did you do to her?!” Molly’s voice cracked. She turned from her mother to look up at me, demanding an explanation.

“I wish I had an explanation,” I said, my voice full of regret. At age 86, Margaret’s system had reacted quickly to the medication. “Mrs. Dunne, can I meet you here at 4 o’clock tomorrow? Your mother always seems to panic around that time. Do you know why? Was 4 o’clock an important time in your mother’s life?”

Mrs. Dunne had calmed down and was willing to talk. “Well,” she said, “that’s when we came home from school. Mother was very strict. None of us dared to be even 5 minutes late, except my sister Beth. She was always late. Mom always worried. Poor Mom—look at her now. She looks dead.”

The next day at 4 o’clock, Margaret was very much alive. “Mother,” Molly pleaded, “Beth is a grown woman. She lives in Huntsville, Alabama. She has three children. You are a great-grandmother, for God’s sake. You are 86 years old!”

Looking into space, Margaret ignored her daughter. She muttered over Molly’s shoulder, “This woman acts as if she knows me. I won’t pay her any attention. But I’ve seen her somewhere. She has a familiar face—nice eyes. Don had those same blue eyes and blond hair.”

The resemblance to her husband reminded Margaret of Don, and her thoughts turned to him. “Oh, Donald, you died too soon. I knew you would die when you got so frail. Your heart was never so strong. And then, you got that double pneumonia. You left me all alone. Beth has my eyes—small and squinty. Bethy is just like me, Donald. Molly is like you. That woman with the squeaky voice is talking to me. She squawks like a hen laying an egg. I better find Bethy before she catches cold. It’s supposed to storm. Get out of my way, Miss. I have to find my daughter. Molly is safe and sound, but I have to find Bethy. She’s out there somewhere all alone in this storm. Get out of my way, please.” Margaret poked Molly, sticking her elbows in her daughter’s ribs.

“Mother, you’re hurting me. Sit down. Beth is fine.” Molly’s voice was angry.

I moved close to Margaret, touching her gently on the back of her neck, adopting her voice tone, picking up the rhythm of her breathing. “Are you worried about Bethy? What do you think will happen to her?”

“Oh, honey, she’s all alone out there, in a terrible storm. Her father and I worry so much. She’s just a little thing.” Margaret moved toward the door with urgent, frantic energy.

I moved with her, gently touching her, mirroring her emotion. To put myself into her frame of mind, I thought of the time when my daughter ran into the street and almost got run over. “Where do you think she went? How far has she gone?” My worried voice matched Margaret’s fear.

“Three long blocks … without a sweater in 30-degree weather,” Margaret cried.

Margaret was visualizing her daughter, using her mind’s eye, picturing little Bethy struggling in the snow. “What was she wearing, Mrs. Dowling?” I asked, using visual words to match what I perceived to be Margaret’s preferred sense. Glasses never corrected Margaret’s impaired vision. Her outside world blurred. She moved inside, restoring people from the past like a painter repairing a faded portrait.

Margaret moved in small, agitated steps. I fell in step with her rhythm. Her breath came in small spurts through her nose. I matched her breathing. Gently, I moved my fingertips on the back of her neck in a circular motion, a movement that often triggers memories of children. We moved toward the door together. I moved with Margaret, following her lead. I knew that the slightest pressure on her arm to turn her away from the door would spark a fight. She would resist, pushing me away, if I tried to lead. With my voice reflecting her fears and putting her feelings into words, we moved as one. “Do you think she fell in the snow? Did she have on her boots?”

“Of course she wore her boots!” Irritated at my stupid question, Margaret stopped to give me a scathing glance. “I would never let her go out without boots. What kind of a mother do you think I am?” Margaret’s voice broke. She choked on her words. Grabbing my arm, she stopped dead in her tracks, her tone somber, low, and still. “It was a boy. I carried him for 9 months. Full term. He was fine inside for 9 months. He jumped in my stomach. I could feel him play inside me. I know he was healthy. But when he was born, he came out half dead. My first baby boy—he only lived for 12 hours. The pain digs a hole in my chest, but I can’t cry. My baby died. Full term.”

Margaret looked through me, not seeing me at all. Cupping her fingers, she gently placed her right arm in her left arm, caressing it. She moved the right arm to her lips, kissing the back of her hand, crooning. “My baby—here he is. He has his father’s beautiful straight nose, but my eyes. Luckily he didn’t get my long nose. He does look just like his dad. And look at his dark hair. He has so much hair. The girls didn’t have all that hair. Shh. Don’t cry, my baby boy. I’ll sing you a lullaby.” Margaret held her hand-baby close, singing softly. Her eyes filled with love, she sat to rock her infant.

I sat opposite her, bending close, gently placing my palm over hers, mirroring her loving strokes. “You love your baby, Mrs. Dowling,” I whispered. “You worry so much about your children. You want Bethy to be safe. You don’t want her to get hurt like your other baby. Is that why you worry so much when it gets late and she’s not home?”

Margaret Dowling stopped stroking her arm to look me straight in the eyes. “Yes,” she said. Sudden cognition came over her. Fear and pain filled her body. She shuddered. “I’m afraid Bethy will get hurt like my baby boy.” A few tears came, then many, racking her body.

Molly took her mother in her arms, rocking her. For the first time, she understood her mother’s grief. Her eyes widened. “Oh, Mother, that doll was your newborn baby. I took your baby away for the second time last week. I didn’t know you missed him so much. You never cried when he died. I often wondered what happened. You never talked about it. Then Beth was born. I was always jealous because you worried so much about her. You never worried about me. But you always heard my tears. I love you, Mother. You were a wonderful mother to us.”

Margaret Dowling smiled at her daughter, tears forgotten. Her blue eyes lighting, Margaret took Molly’s head in her hands, stroked a few stray strands of her daughter’s hair, and whispered, “You are a wonderful daughter.” Margaret turned to me. “And you are a nice girl. This is my daughter.” Margaret patted my cheek. “And what’s your name, honey?” Margaret had forgotten her daughter’s name, but remembered her face. The 86-year-old woman had traveled 60 years in 60 seconds, moving through her lifetime.

With my help, Molly learned to travel through time with her mother. Margaret still looked for Bethy every day at 4 o’clock, but she had Molly to support her, and when she needed it, she had her doll.

Harry, the Hitter: “Come in, You Old Battle Ax!”

“GODDAMN SONOFABITCH! GET OUTTA’ MY ROOM!” Harry Tross narrowed his eyes, bared his teeth, and swung his cane at me. He leaned forward menacingly in his wheelchair.

Instinctively, I Centered. To mirror his anger, I pictured myself stuck in the middle lane in heavy traffic, frustrated, helpless, trapped with nowhere to go. “Do you hate being stuck here, Mr. Tross?” I asked, matching his staccato, frustrated gestures with my fist.

Harold Tross split the air with a tremendous belch. “None of your goddamn business! Get out!” he bellowed.

Harry had turned his former personality inside out. He had been a meek sales representative, selling a line of stationery products for 65 years. Supposedly, his wife had been domineering and harsh, and he had avoided his home and his responsibility as a father. His daughter felt sorry for him but rarely visited. His wife could not understand his sudden violence. She lived alone in her family home and wanted nothing to do with her formerly mild-mannered husband.

I wanted to build a trusting relationship with Harry Tross, to help him express his anger and relieve it so that he could make friends instead of isolating himself. I knew that without stimulation from the outside world, he would withdraw inward and become isolated. “You moved around all your life, Mr. Tross. In how many states did you sell stationery?” I asked.

Harry sneered at me, screwing up his lip, exposing his gums, a red valley among three yellow teeth. “You are the ugliest woman I have seen in a long time.”

Hurt, I Centered again. My voice quivered, but I continued, “Your territory included Ohio and Pennsylvania, didn’t it?”

Harry Tross pursed his lips and narrowed his eyes, leaning forward. He crooked his finger, motioning me close. I took a chance, hoping that I could catch his cane if he should strike. I moved in 2 feet, bent down to meet his eyes, and moved my hands slowly toward the arms of his chair. Whack!

Involuntary tears blurred my vision. I jumped away. Outrage swept through my body. My hand stung, pulsing with throbs of pain. I breathed slowly, in and out, continuing to Center until the pain subsided. My hand would soon turn black and blue. (Life is colorful in a nursing home, I thought.) My sense of humor restored balance.

I looked at Harry Tross. His eyes held torment. “Goddamn Harry. Hari-kari. Harold Tross, shut up!” His deep voice rumbled, catching in his throat. He stopped suddenly, caught his breath, and seemed to shrink, folding himself into his chair. His head slumped, shoulders curved together, feet tucked tight, he shrank, a mean scrap of humanity in a wheelchair.

“Do you feel bad when you hurt people?” I asked, wanting to put his feelings into words.

No answer. Harry Tross had become a lifeless lump of flesh, almost invisible. He turned his chair toward the wall.

Harry Tross dominated our staff meeting. We showed one another our “Harold Tross bruises.” A male nurse commented, “He never hits me. I think he only hits women because he hates his wife. And, I don’t blame him. She is a bitch!” At age 82, weighing 110 pounds, Harold Tross’s system would not tolerate high dosages of tranquilizing medications. My assignment: Talk to Mrs. Tross. Find out if she could help her husband.

Helen Tross had a mustache. She breathed hard, ruffling the fine hairs. She dyed her thinning hair orange to match her lipstick. “Mrs. Feil, I live 2 miles from here, and I don’t drive a car. I had to take a cab here. That is quite an imposition. I am not a young woman, you know. I won’t tell you how old I am because you won’t believe it—nobody does. Ask me!” Her smug smile revealed well-matched dentures. I opened my mouth to ask, but was interrupted before I could speak.

“I am almost 80 years old. Isn’t that something? My mother lived to be 98. She was some woman.” Mrs. Tross paused to remember her mother.

I seized the moment. “Mrs. Tross, your husband is giving us a lot of concerns. He is becoming more and more violent. We know that he reacts poorly to tranquilizing drugs, so we don’t want to medicate him. Can you help us?”

Mrs. Tross’s eyes widened, incredulous. “My husband? Violent? That man was afraid of our cat. I put him in here because he couldn’t find his way from the front lawn to the door of our house. He got lost putting out the garbage. He is so afraid of people he wouldn’t answer the door. How he ever worked as a sales rep is beyond me. Lucky my parents left me something. All he left me is a pile of headaches. You called me here to ask me to fix him?” Helen Tross laughed cruelly, tossed back her head, and put on her coat. “And I thought you got me here because he left me some more money. Will you call me a cab?”

Mrs. Tross had failed to help us. We were on our own. We tried behavior modification. Whenever Harry hit out, became abusive, or used obscene language, we isolated him. When he refrained from verbal or physical abuse, we rewarded him with special attention and extra desserts. Our efforts were in vain. Harold Tross continued to strike out.

My heartbeat quickened when I knocked on his door the next week.

“Come in, you old battle ax!” he cried.

His raspy voice reached the pit of my stomach. A little voice inside me whispered, “This is not the right time. Tell him you’ll come back later. You have to go to the bathroom.” I smiled, recognizing the voice of fear. I breathed in and out. Letting my stiff, hunched shoulders relax, I felt my arms swing free. Now, I was ready to greet Harold Tross.

He taunted, his tone sarcastic. “Why don’t you give up, lady? Can’t get enough of me, huh, bitch?”

“Mr. Tross, I will not take any more of your swearing,” I said calmly. My voice was even. I turned my back to walk out of his room. His shoe flew out the door, just missing my left ear.

Over the next 2 weeks, we tried different types of behavior modification. Harry’s aim improved. One day, a staff member met me on the unit floor. “Naomi,” she said, “we won’t need to medicate Harry Tross.” She pointed to his room. “Look inside.”

I gasped. Harry had squeezed his head through the narrow space that separated the back of his chair from the seat. His arms dangled, lifeless. He had put himself in a stockade. He looked nowhere, his eyes numb. Over and over, he chanted solemnly, “Hari-kari. Hari-kari. Harry Tross, shut up.”

I bent down close to him and echoed his chant. He focused, seeing me for the first time. His eyes filled with shame. A moment passed—he began to sing. “Up into the wild blue yonder,” his voice blasted. Imprisoned by his chair, his arms plunging up and down, he mimed the motion of an airplane, hollering, “We are the Army Air Corps.” He slashed the floor, hitting it hard.

“Mr. Tross,” I asked, “are you flying an airplane?” No longer aware of present time and place, his controls gone, Harold Tross was using his chair to replay his past.

“You’re goddamn right, I can fly this plane. But I can’t fly outside the plane. I’m dead, lady. I died last year … a thousand deaths,” he answered swiftly, making poetic sense. “Hari-kari. It’s the only way.” He twisted his head, jerking his body violently back and forth, pulling his chair downward, wanting to hit the floor.

I bent down with him, filled with his grief. “Mr. Tross, do you want to commit hari-kari? Are you so ashamed?”

“Yes,” he whispered.

I watched a tear find its way to his cheek. Gently, I wiped it. Harry closed his eyes and wept. In this moment, the seeds of trust were planted.

Harry became the drummer in our Validation group’s rhythm band. Slashing the drum with his fist, riding his rage, he got rid of some of his anger. He was never easy to deal with, but he stopped throwing shoes. He and I talked often about his wife, his work, his regrets. We smiled a lot. I loved talking to Harry Tross. He made my work lighter. He gave me joy. And he outlived his wife.

Validating at Home: Karl, the Flasher

Karl Madson adored his wife. She was the light of his life. They met when Karl was 25 and Hazel was 23. He was an accountant, and she was a bank teller. It was love at first sight. Karl was a virgin when he married Hazel. He had been tempted as a 19-year-old, but had never been with another woman. Hazel had flirted. She had an affair at age 17 with a young man who was drafted to serve in Vietnam and then never came back.

Without Hazel, Karl would have floundered. She supported him, encouraged him, and dominated his thoughts. He rose to chief accountant. Hazel lovingly, but with a firm hand, raised their two children. When their daughters married, the couple grew closer. Puttering with daily chores as the years flew by, they had few friends and never traveled. Karl and Hazel enjoyed their routines. Karl played bridge on Tuesday nights; Hazel studied yoga. Neighbors smiled, poking each other, peering through curtains, a bit envious as they watched 75-year-old Karl hold his wife’s hand while strolling home from church every Sunday.

At age 85, Karl began to lose track of days. He wandered to the bank at 1:00 a.m. to demand his job back. The police brought him home, warning Hazel that he was disturbing the peace. Hazel watched him night and day. One day, at the supermarket, Hazel heard a gasp. She turned to find Karl unzipping his fly and pulling out his penis. Stunned, flushed, and fuming, Hazel dropped her groceries and dragged Karl into the street.

Contrite, unaware that he was acting inappropriately, Karl took Hazel’s hand, tottered by her side, and was subdued and docile.

At her wit’s end, Hazel scolded, “Karl, aren’t you ashamed of yourself? How can you behave like that? What am I going to do with you?”

Karl blinked away a tear threatening to dribble down his cheek. “I love you, sweetheart. I don’t want to hurt you.”

“You are hurting me. You are killing me. If this keeps up, I’ll have to put you somewhere.”

Shortly after, the neurologist found severe arthritis, increasing brain atrophy, and a score of 19 on the Mini-Mental State Examination (MMSE). Karl was diagnosed with neurocognitive deterioration due to Alzheimer’s disease. The neurologist suggested long-term care. Hazel’s heart ached.

At 3:00 a.m., while Karl wandered aimlessly from room to room, Hazel cornered him. “Karl, we can’t go on this way. Either you behave or you’ll have to live in a nursing home.” Karl kissed her and promised to behave. But Karl couldn’t behave. He had lost his social controls. He had lost self-awareness and cognition. He was not aware that he was losing sexual inhibitions. He had moved into the final life struggle: Resolution.

In his Harold’s own personal reality, sexual feelings that he had repressed for a lifetime surfaced. He had worshipped Hazel. She was a goddess. He had always controlled himself in bed. He had never abandoned his strict moral code; he couldn’t give himself to her without restraint. In old age, however, unfulfilled desire demanded fulfillment. If Karl had released his sexual drives as a young man, he never would have acted out sexually as an old man in Kansas. He would have expressed his emotions throughout life. Sexual longing would not have built up inside for so many years, waiting to erupt.

Hazel loved Karl quietly, without passion. Her love was enduring. Sex was acceptable but not fun with Karl. Only once, when they were first married, did she have an orgasm. At age 83, Hazel had grown accustomed to a meager sex life. She felt no pangs of desire. She never spoke of sex to her husband, and she didn’t miss it. Now, she resented his loss of control; furious, she wanted to hit him at times. But she knew that he would deteriorate away from her in a nursing home. Hazel decided to keep Karl at home.

Embarrassed but desperate, Hazel confided in her minister. Her head bowed in shame, she could not look Reverend Johns in the eye. The minister’s mother had also been diagnosed with Alzheimer’s disease. He had researched the field and had just returned from a Validation workshop in Lansing, Kansas. He handed Hazel a copy of The Validation Breakthrough. Every Sunday, Hazel attended the family support group that Reverend Johns had created at the church. Here, family members learned to Center, to accept their loved ones “where they are,” and to stop judging.

One Sunday, Hazel gasped with a jolt of sudden insight. Karl’s mother, severe and forbidding, had taught him to respect women by not touching them. Early learning stays. Karl felt guilty when his sexual urge surfaced. He learned to mentally slap his hand at age 8. “No wonder he is suddenly touching me all over. Poor man. He could never be himself. He’s so full of love. Now, it’s all pouring out.” Hazel’s compassion and caring grew. “How can I expect him to act the way he did when I first met him? The man is 85 years old. He has Alzheimer’s disease. His normal, human urges are coming out, and he can’t control them. He doesn’t even know what he’s doing. I can’t expect him to behave. But I can help him. I can be with him. I can feel the way he feels inside; show him that he’s not alone.”

Hazel learned many of the verbal and nonverbal Validation techniques. When Karl unzipped his fly in the supermarket, Hazel moved close, helping him tuck himself back into his pants. Hazel used the Validation technique of anchored touch. Where one touches is important. Karl wanted sexual love. Facing him, she gently stroked the side of his neck, moving her middle finger from his earlobe to his chin. She validated his human need with words, whispering close to his ear, “You want sex now, is that right, Karl? You feel that urge?”

The gentle stroking motion soothed him. “I love you, sweetheart. I never want to hurt you. Never.” His voice cracked with love.

Quietly, hand-in-hand, the two moved home together as one. Hazel used the Validation techniques of rephrasing, polarity, and preferred sense (i.e., feeling words) to help Karl vent his sexual needs with words. He rarely needed to act them out.

At home, Hazel faced Karl on the couch, touching him once more on the side of his neck, asking softly, “Is your heart beating fast now, Karl? Do you feel warm?” (She used the kinesthetic sense.)

Karl smiled and gently stroked Hazel’s breast.

“That feels good, honey.” Hazel moved closer.

Karl suddenly lunged at Hazel, now on top of her, shouting, “So you’re the whore? You better be good, baby. I’ll show you how.”

Hazel’s inner voice came through loud and clear. Automatically, she Centered, breathing slowly until the shock subsided. Her inner voice continued, “Rephrasing always works when I don’t know what to say.”

Listening to Karl’s voice tone and the rhythm of his speech, Hazel picked up her husband’s intonation, asking, “Did that whore know how? Did you show her?”

“Damn right, I did.”

“What was the best thing you did, Karl? What made you the happiest?” (Using polarity.)

Karl’s eyebrows twitched. His eyes lit like a torch, twinkling in glee. His lips puckered. He curled his tongue. He whispered, cupping his hands over his mouth, telling a shameful secret, “I French-kissed her.” Then he roared, slapping Hazel soundly on the knee.

Karl started to sing with gusto, moving away from Hazel, swinging his arms to an internal rhythm. “I can’t get no satisfaction. I can’t get no satisfaction. ‘Cause I try, and I try, and I try, and I try, I can’t get no. I can’t get no….”

Hazel joined Karl, and the two sang old songs into the night, falling asleep in each other’s arms.

Isobel, the Poet: “I Untangle the Noodles in the Mirrors of My Mind”

She peeked into dresser drawers, wastebaskets, toilet bowls— … anything that might hold something. Her oversized housedress swished as she walked, pockets loaded with odds and ends. Her pale blue-green eyes glowed with anticipation, peering, poking. I watched her chubby form, enfolded in fabric, disappear behind the drapes. “What are you looking for, Mrs. Blue?”

“Honey,” she smiled, her dentures clicking, “I’m looking for yesterday. I have to untangle the noodles in the mirrors of my mind.”

I blinked, struggling to grasp her poetry. I rephrased,. “You’re untangling the noodles of your mind? Have you found them?”

“If I found them, I wouldn’t be looking, would I?” she whistled, patting me on the cheek. “Fay, you have the sweetest fiddlemaker, but you filled that forman with swadle fellows, and that’s why you can’t heddle him,” she confided in a rueful cadence, sighing a sad sigh.

“Does that make you sad?” I asked. I had no idea what Isobel was trying to say, but wanted to continue talking.

“Dear,” she confided, “you pull those strings too hard.”

“Oh! Am I pulling your strings too hard? I’m sorry.” I wondered if I had asked her too many questions.

“Honey, we all play different tunnels. You can’t fiddle all the time. That man will fleck your undertomes no matter how hard you pitzzle him.” Her voice, warning me, held fear. Isobel’s eyes narrowed into green-flecked slits. She pursed her lips and split the air with her hand, whacking an invisible something. “Ouch! That hurts!” she yelped.

From across the day room, Isobel’s equally disoriented roommate made circular motions with her forefinger, pointing to Isobel’s head, screeching, “She’s nutty as a fruitcake! She’s crazy!”

“It’s better to be crazy,” Isobel tittered, slapping her thighs, “because then it doesn’t matter what you do!” She tugged the drapes, convulsing with glee.

The nursing assistant wagged a finger at Isobel. “Leave those drapes alone! That’s naughty.”

“I’ll tell my mother on you!” Isobel shot back, flicking her wrist at the nursing assistant.

“Isobel, sweetie, you are 88 years old. Your mother would have to be at least 110. Honey, she couldn’t be alive.”

Isobel shrugged. “Well, I know that, and you know that, but my mother doesn’t know that, and she won’t like it one bit when I tweddle her! I just had a wonderful squackle with my mother and my aunt, and I didn’t have the heart to hittle them. It’ll hittle them too hard to know that they’re dead. And …” Isobel tossed her head, hands on hips, in a final gesture, “… a lot of old people live a lot longer than younger people. So waddle out! Today you say; tomorrow, you’re dead!”

The nursing assistant threw up her hands. I scurried off to find a pencil to preserve Isobel’s warning. Crooking her finger, Isobel motioned for me to join her in her makeshift office behind the curtains. I slipped in by her side. “Fay, you’ll get swaddled if you keep mixing with that one.” Isobel pointed to Harry Tross, sitting in his wheelchair nearby, tearing pieces of tissue. Isobel shivered.

“How do you mean, ‘swaddled,’ Mrs. Blue?” I mirrored her ominous tone.

Isobel whacked the air with her hand, her fingers stiff. Her sudden, forceful movement frightened her. She trembled, hiding her body behind the folds of the curtain.

“Are you seeing the man who swaddled you?” I put an arm around Isobel to ease her fear. She nodded, holding me close. “Did he smack you with his hand, like that?” I mirrored her hand motion, thwacking the air.

Isobel’s eyes widened. “With a switch and a paddle,” she whispered in my ear.

“Oh!” Isobel’s meaning dawned on me. She had combined the words “switch” and “paddle” to form the word “swaddle.” Blending words and images, Isobel freely moved her tongue, teeth, and lips, letting similar sounds create new words.

“Was it your husband who paddled you?”

Isobel shook her head, tears surfacing. “He makes me cry. He wants me to fiddle all by myself. Fay, I can’t.” Isobel’s voice broke. She tugged at my sleeve, imploring, “I want to fiddle, but I can’t. Tell him that.”

“He wanted you to fiddle, but you couldn’t?” I repeated. I bent down, studying her eyes. All my energy was focused on Isobel.

She hung her head. “I can’t play. I’m no good. He pulled my strings and broke it.”

“Your father wanted you to play the fiddle? And you couldn’t, so that broke it?” My voice caught. Gently, I touched Isobel’s cheek with the palm of my hand, nurturing her.

“Mother tried to heddle him, but she couldn’t. Fay, you can’t do it. It’s a florid invention.” Isobel looked into my eyes, somber.

“A ‘florid’ invention?” I asked.

“Fluid. Your eyes are watery. Fays don’t cry,” said Isobel, patting my cheek.

“Is Fay your mother?” I asked. Isobel called all the female staff “Fay.”

“No. Fay. Fay Wray. Fay is anyone who knows anything. Fay can fiddle like a falstra.” I remembered that Fay Wray was a silent movie star, a heroine who survived.

Isobel moved away from the curtain toward Harry Tross. Her body swayed, graceful and fluid. She stretched her hands, palms upward, toward Mr. Tross. “Daddy, don’t swaddle me. I’ll fiddle for you,” she begged.

“You will, will you?” Harry Tross boomed. “Well, fiddle away, whore.”

I rushed to get the rhythm band instruments, and we found a fiddle for Isobel. In the weeks to come, Isobel would sometimes hide her fiddle behind the curtain, but more often, in the Validation group, she played. I never found out what happened between Isobel and her father. In the Validation group, backed by the group members, Isobel was able to tell Harry to stop calling her names. Two weeks later, at her birthday party, she pulled me close to whisper, “I’m a Fay, too.”

VALIDATION AROUND THE WORLD

Relieving the Fear

Cinzia Siviero

Validation Teacher

Italy

SERGIO LOOKS AGITATED AND FLUSTERED. He has a faraway expression. His hands, shaking, hold tightly to the armrests of his wheelchair. His daughter and son-in-law are frightened. He has done this many times, and we are all afraid that this intense anxiety will give him a heart attack.

I attempt to relieve his anxiety through Validation. First, I Center myself. I then ask, “Sergio, what is happening?”

He doesn’t see me, although I am in front of him and at his same level. He breathes very quickly. Every muscle of his face expresses fear and anxiousness. I adapt my breath to his and ask again several times, “Sergio? What is happening?”

At a certain point he responds, “I am scared.”

Cinzia:

What about?

Sergio:

I don’t know.

Cinzia:

You don’t know? My God, what can it be that scares you so much?

Sergio:

I don’t know. (He seems on the verge of crying.) I don’t know, but I am scared!

Cinzia:

You don’t know why, but you are scared—what an awful thing to go through. How can I help you?

Sergio:

I am scared of dying!

Now, I decide to try to breathe with him. I put my hand on his chest, and together, in unison, we breathe in and out. Sergio calms down after 2 or 3 minutes. He looks at me and now he sees me. He even smiles.

I ask him, “Do you feel a little better?”

“Thank you, dear,” he replies. “I want to go home.” He looks at his daughter, who is standing nearby.

I understand his need to feel safe, knowing well that the house Sergio refers to is the one of “there and then,” a house from his youth. It is easy to empathize with this desire for home; as with many other needs, it is a feeling that we all share. When we are somewhere that feels unfamiliar, we often long for a familiar place filled with familiar things. Sergio talks about that house, and from the description, his daughter says she thinks he is talking about his grandparents’ house, where he grew up.

He tells me that he wants his mother. We talk about missing his mother. I ask Sergio some more questions to explore and allow him to express his feelings, and then I say, “Mother is always in our hearts. Can we ask our mother to help us in such a difficult moment? Maybe a prayer?” I begin the Hail Mary prayer, often recited by Catholics and associated with the iconic mother figure, the Blessed Virgin Mary, mother of Jesus Christ. “Hail Mary, full of grace …” Sergio joins in, and his face relaxes.

I say goodbye, thank Sergio, and suggest that he eat the lunch that has been ready for him for some time. He gives me a heartfelt “thank you” that I can’t describe. It’s my emotional reward, my recharge. Soon after, when I am talking with the daughter and sharing this moment, the son-in-law arrives and tells us joyfully and with disbelief that Sergio is eating, unworried, as if nothing had happened.

Knowing something about Sergio’s past helps us understand him today. He was sent to a boarding school as a child by a single mother who was unable to care for him. He never knew his father, and his mother rarely went to see him. He grew up among boarding school children and with his grandparents, who lived with some aunts. Later, he was sent to live with a family who welcomed him warmly, and where he found the mother he had always desired, a mother with a lot of love to give him. Sergio’s daughter remembers how he used to tell her that his new mother from his adoptive family was wonderful. Fate, however, treated the boy cruelly again. Sergio was moved away from this family, and it caused a trauma that he harbored throughout the rest of his life.

Sergio came to our facility with a diagnosis of dementia. He often cries when somebody says the word mother. His family and the staff now understand why and show him the love he needs.

CHAPTER 12

Communicating with People Who Express Themselves Mostly Through Movements and Sounds

Andy, the Walker

His pockets heavy with items collected along the way—paper, napkins, spoons, even bits of food—Andy trod heavily through the halls of the locked memory care unit every day for hours. His old sweater sagged with the burden of half-eaten sandwiches and used tissues. At 88 years old, Andy moved steadily on his tree-trunk legs despite his extra weight, not seeing much of the outside world, but having clear visions of his personal world using his inner eye. At times he would knock on a closed door, waiting a minute before moving on. None of the care staff had heard him say a word for the 2 years he lived at Three Haven. He walked every day, whenever he was not slumped in a chair sleeping.

Sarah, one of the day-shift staff members, tried every day to empty Andy’s pockets. He would push her away, sometimes very hard. She tried switching out sweaters, telling him that the other was in the wash. Andy would just fill up his pants pockets instead. It became a burden for Sarah because she felt responsible for keeping the residents clean and neat. Plus, the half-eaten food was a hygiene issue for the home.

Sarah came to me one day, totally exhausted and frustrated. “I tried everything. He won’t let me touch that old filthy sweater. I tried giving him another sweater that looks just the same. He refused. I tried cleaning out the pockets before he woke up. He filled them back up again within an hour. I explained the health department issue to him. He didn’t look at me or listen at all. I don’t know what else I can do!”

Together, we looked at Andy Weber’s biography. Three Haven always did a nice job on constructing biographies of each resident, adding stories from family members and friends whenever possible. It was a shame that no one on the staff read them or learned how helpful these stories could be in understanding the sometimes-strange behavior that residents repeat and repeat.

Andy had worked at a large tech firm and was proud to be one of the first in the computer industry. He helped develop some of the first home computers. He married Ann, another engineer at the company, and together they lived a simple, happy life. His daughter remembers everything being quietly happy at home when she was a child. But the computer business moves fast, and as quickly as Andy tried to keep up with the new developments, something else came along. Colleagues his own age were being replaced by 20-year-olds who knew more, moved faster, could fit their fingers on those little buttons. And then he was forced to retire at just 60 years old to make room for another young kid. Andy didn’t say anything; he just packed up his few private things and walked. In the ensuing years, Ann and Andy tinkered at home with old computers, watched the grandkids for their daughter, read the tech journals, and kept quietly busy.

Eight years ago, Ann died of cancer. Andy managed living alone but often complained to his daughter, who lived nearby, “Another one died this week!”—meaning one of his friends or former business associates. Every day, Andy walked around his neighborhood for hours, contemplative, occasionally saying hello as he passed someone on the street. Then came the day that he could not remember where he lived. Panic consumed him. “I’m losing my mind,” he thought, along with everything else. The police were called, and they brought him to his daughter’s home. For several more years, Andy managed alone, but with increasing forgetfulness and increasing isolation. He would read the paper, especially the obituaries, and then walk.

Five years ago, Andy finally moved in with his daughter and son-in-law. There, he continued the same pattern: After breakfast, he read the paper, saw who died, and then walked around the neighborhood. Then one day, he fell and broke his hip. After a short hospital stay, Andy went to the rehabilitation unit of a long-term care community. His walking habit became his physical therapy, and he progressed well after the hip replacement, but he continued to be confused about where he was and who was who. Andy rarely spoke. When he could not go outside, he walked the halls of the unit, touching the walls as if for guidance. The staff and his family decided he was not going to regain enough ability to care for himself, and he was moved to the memory care unit next door at Three Haven.

“There are a few things we can learn from this,” I said. “Walking seems to be his way of coping with life’s losses. Also, he has never been a very verbally expressive person. I keep seeing the word ‘quiet’ throughout this history.”

“Also,” Sarah exclaimed, “he must have felt terrible being replaced like that at his job.” She was suddenly filled with empathy for Andy. She too was getting older and had a harder time keeping up with the younger staff.

“Maybe you can start with something there. Try walking with him. Use his rhythm. Don’t worry about perfectly mirroring him. That’s not important.” I tried to explain how empathy was the way into Andy’s world and how it could provide a better understanding of why his collecting behavior was so important to him.

The next week, every morning after breakfast when she had a couple of minutes, Sarah walked next to Andy, trying to move at his pace. Looking at his face, she saw how drawn it was, concentrated inward. His mouth turned downward, not in anger or sadness but in deep thought. When Andy stopped to take a spoon, Sarah didn’t stop him; she just stopped with him. Guessing that Andy was searching for something, she asked, “Is that the right one?”

“Nah,” croaked Andy. The first word he had said in years! Sarah had started to make a connection.

The next day, while empathetically pacing with Andy, Sarah suddenly got an insight. “Are you looking for work, Mr. Weber?”

Andy stopped, made eye contact with Sarah, and with warmth said, “Can’t find the right parts.”

Totally dumbfounded, Sarah didn’t know how to respond. She simply took his hands gently and maintained the eye contact. Her silence was actually the best response for Andy, and he smiled. Together, they turned and continued walking down the hallway, now in sync and connected.

This Validation practitioner is at a comfortable distance for the woman in Phase Three and making warm eye contact. They clearly have a good connection.

By building trust with Andy Weber and walking in his shoes, so to speak, Sarah was eventually able to help him get rid of the “wrong parts” and continue to search for the right parts. She located an old computer and other leftover computer parts. In a corner of the hallway, she set up a workstation for Andy where he could tinker with the computer parts. From then on, after breakfast, Andy would head over to his station and work. No longer searching for parts, his pockets were empty, and his need to be useful was fulfilled.

Mary, the Pacer

Swish. Black slacks flew past rows of wheelchairs. Smack. Sneakers thumped the tile floor. Hss. Sharp spurts of breath warned innocent passersby. Fists tight, elbows jutting out, Mary Thomas paced back and forth endlessly. Eyes screwed tight, lips pursed, head down like a bull lowering its horns, she scared everyone. She never looked up. Her eyes hugged the floor even when she ate. Her lips wobbled, releasing high-pitched bleats: “Baa. Baa. Baa.”

“PIPE DOWN, BITCH!” Harry Tross bellowed, drowning her sheep sounds.

“Get me out of here!” wailed a 102-year-old woman.

“Tell her to shut up!” another resident chimed in.

“Lock her up,” ordered a former police officer.

Heedless, Mary Thomas bleated past them all. She came close to kicking the others in her size-11 sneakers, but she never touched anyone. Mary traveled alone. The other residents kept their distance. No matter how many times we bathed Mary Thomas, she smelled. A pungent, sweaty odor seeped from her clothes into the day room. She needed no other protection.

“Naomi,” wailed Darlene, my second-year graduate student, “I can’t work with Mary Thomas, and it’s not the way she smells.”

Darlene caught my surreptitious blink. “I’ve gotten over that. I spray the air with air freshener whenever I go up there.” Darlene, a 23-year-old redhead from Minnesota, wrinkled her freckled nose and grinned. “It’s …” Struggling to pinpoint her thoughts, she stopped talking, twisting her fingers. She looked up, thinking.

Finally, she ruefully admitted, “I just don’t like her. I know that I have to stay objective, but how can I do social work with someone who turns me off?”

“That’s a good question.” I nodded in sympathy. “Nobody, not even a professional social worker, can like everybody.” Darlene grinned, relieved.

“What turns you off the most, Darlene?” I asked.

Darlene thoughtfully lifted her chin, visualizing Mary Thomas pacing back and forth in the day room. “I think it’s that she never looks up. It’s as if her eyes are stuck in the underworld. How can I reach her if she doesn’t want to be reached? She always looks down, ignoring me!”

“Darlene, are you picturing Mary Thomas now? Can you actually see her feet?”

Darlene looked surprised. “Yes. She has holes in her sneakers and wears at least a size 11.”

“Darlene,” I said with a smile, “you are probably mainly a visual person. You prefer your visual sense. Do you dream in color?”

Darlene nodded emphatically. “I see my dreams like watching a colorful movie. I picture different scenes in my mind every night before I go to sleep.”

“That’s great!” I admired Darlene for her visual skills. “Most of us have a preferred sense. To picture something, most people look up and to the right. Before you answer a question, you almost always look up. Are you aware of that?”

Before answering, Darlene instinctively looked up. She smiled and nodded.

“Mary Thomas always looks down,” I said. “That may mean that she prefers her kinesthetic sense. Mary Thomas feels things. Her sense of touch is important. She thumps her feet, scraping the floor, hitting the road, probably enjoying the sensation. Mary is a person who feels before she sees or hears the outside world.”

I wanted Darlene to step into Mary Thomas’s shoes, so we reviewed her history. Raised on a farm, the oldest of eight children, Mary never finished high school. Diagnosed with Alzheimer’s disease at age 79, she had been living with her son for 5 years ever since her husband died. She was admitted to the memory care unit the previous year after she threatened her son with a broom handle. He claimed that she was becoming violent and placed her in the long-term care community.

When we met with Mary’s only son, Malcolm, now age 58, he said that he never understood his mother. She barely spoke to him. Mary’s husband had believed that she should perform certain duties as a woman—cooking, cleaning, laundry, sewing, shopping. Malcolm’s father, a factory worker, expected his lunch to be packed and ready on time, and Mary always did what she was told. Malcolm remembered one stormy Tuesday when his mother overslept. At 5:45 a.m., a sleepy Malcolm watched his father drag Mary out of her bed, shake an empty lunchbox in her face, and slap her. “She never forgot after that!” Malcolm assured us.

Darlene bristled. “Did your mother ever get to go on a vacation or leave the house to play bridge or spend time with friends?”

Malcolm shook his head. “She never had time,” he answered simply.

“What made her threaten you with the broom?” asked Darlene. A feminist, she was gaining empathy for Mary Thomas.

“She hung a greasy shirt in my closet. She never washed out the stains on the collar. So all I did was give it back to her and say, ‘Ma! You’re supposed to get out all the stains!’ She spat on my best shirt and started yelling, ‘Baa! Baa!’ She wouldn’t stop. It drove me crazy. All I said was, ‘Ma, quit it!’ She shook the broom handle in my face. Then she took her scissors and cut my best shirt into a hundred pieces. My best blue plaid shirt. Right after that she started her lousy pacing—night and day, back and forth, ‘Baa. Baa.’”

Darlene went upstairs to validate Mary Thomas. Mary was breathing hard. Her bleats were nasty blasts, hurtling anger. Darlene, the daughter of a domineering father, still furious at her dad, had no trouble empathizing with Mary. She mirrored Mary’s quick, fiery breaths. She paced with Mary, matching her sharp, staccato rhythms. Like two bulls, Darlene and Mary kept time.

“Now there’s two of ‘em,” a resident roared.

“Put ‘em both in the pen!” the former police sergeant bellowed.

The LPN on the floor was part of our Validation team. She had experienced the effectiveness of mirroring. She tossed a bean bag with the other residents to engage them in an activity, giving Darlene room to mirror Mary’s gait, to match her breathing, to duplicate the expression of her lower lip, and to reproduce the tonal quality of her bleating sounds.

Mary stopped short. She stared at Darlene. Darlene’s eyes held compassion born of shared pain. Mary cried, “I’m not a sheep.”

Using the palm of her hands, Darlene gently touched Mary’s cheeks. “No, Mary,” she said softly, “you’re not a sheep, and you don’t have to do what everybody tells you. You are a person, Mary Thomas.” Their eyes locked.

Slowly, Mary’s lips formed the words “a person, Mary Thomas.” These were the first words that Mary had spoken in over a year. They were not her last. Mary Thomas continued pacing, but she rarely walked alone. A Validation team marched to the beat of her drum.

VALIDATION AROUND THE WORLD

The Wisdom of Disorientation

Heidrun Tegeler

Validation Teacher

Bremen, Germany

MRS. PETSCHEL WAS 86 YEARS OLD when I got to know her. For about 4 months, I visited her three times a week in a nursing home and did individual Validation with her. When I arrived, she was often sunk in an armchair and slightly bent forward, with very slack face muscles. With her right hand, she would softly stroke each individual finger of her left hand, the motion almost a caress. She did not speak while doing so and did not notice what was happening around her. Her feelings of love for something were spilling out, unhampered by self-consciousness.

As she sat in her armchair in this way, I knelt before Mrs. Petschel and mirrored the soft movements of her fingers. I made eye contact with her. With one hand on her shoulder, and with love in my voice, I said, “Hello, Mrs. Petschel.”

She lifted her head and straightened her whole body. Her face showed a beaming smile, and she replied, “Aha, it’s you.” She stopped stroking her fingers. We were connected.

To deepen this connection, I faced Mrs. Petschel and gently placed my hands on the back of her neck, using child-touch. I began to sing an old folk song. “You, you matter to my heart …” She sang wholeheartedly along with me, and she beamed even further.

The Validation techniques I used with Mrs. Petschel created a strong emotional bond between us and gradually enhanced her ability to express her feelings. She developed so much renewed energy from our encounters that she began to speak again. Her feelings were focused especially on her children. She carried them with her in her heart. Mrs. Petschel could speak about her children, but she always had to be stimulated to do so.

During other visits, Mrs. Petschel often walked back and forth along the corridor of the nursing home in an insecure and withdrawn manner. She again seemed not to notice other people or her environment. When she had no more physical strength to go on, she would stop somewhere along the corridor, lean against the wall, and stroke her fingers very carefully. I came to understand that her own fingers had become symbols of her children. Whenever Mrs. Petschel had the urge to withdraw from the pain of feeling useless and lonely in the present, she would slip into her role as a mother looking after her children with complete attention (carefully, lovingly stroking her fingers). In this way, she regained her sense of identity, felt valued, and found inner peace.

Mrs. Petschel was born in the Czech Republic, married there, and had two sons and one daughter. Her husband died in when he was very young. Shortly thereafter, her eldest son also died. Her youngest son drowned while ice skating. She escaped the Russian occupation with her daughter to Germany.

Before Mrs. Petschel moved into a nursing home, she had lived alone in a house in Bremen. She ran her household independently until she was 84 years old. Her daughter lived about 30 kilometers away from her. Mrs. Petschel apparently became disoriented to time and place rather suddenly. She was frequently brought home by the police. Her daughter told me later that her mother began to run away after she learned from news stories about a catastrophic flood in the Czech Republic. I concluded that the flood reminded Mrs. Petschel of her youngest son’s fatal accident on the ice. She had not worked through the emotional pain his death had caused her. Seeing the images of the flooding on the television, in addition to experiencing the deterioration in her physical health, Mrs. Petschel could not keep her psychological balance. She became disoriented, was constantly on the move, and could not find her way back.

Validation teaches us that painful events, emotions, and images in the present can trigger similar emotions felt in the past. Mrs. Petschel had been unable to cope with the death of her son when it occurred. In her deepest being, she carried an impressive wisdom that made it possible for her to work through her unresolved pain on an emotional level. Naomi Feil calls this “intuitive wisdom in disorientation.” When Mrs. Petschel was disoriented and living in a nursing home, this wisdom enabled her to care lovingly for her children and to address what she could not do in the past (cope with the loss of her children). After 4 months of intensive individual Validation, Mrs. Petschel was finally able to die in peace.

CHAPTER 13

Communicating with Disoriented People Living in the Community

Validation can be used anywhere and by anyone. Once someone has mastered the initial steps that lead to approaching another person with empathy, respect, and no judgment, one can use simple Validation techniques to communicate better with older adults living with cognitive decline anywhere.

The Apartment House Manager, the Police Officer, the Emergency Medical Squad, and Thomas Konig

“Mr. Konig? Are you in there? Mr. Konig?” The mild-mannered apartment manager’s voice climbed a half note. Smelling trouble, he knocked with more force. In 9 months, there had been numerous battles with the tenant in 14-B.

“GET THE HELL AWAY FROM MY DOOR, YOU PIPSQUEAK!” thundered a voice from inside.

The apartment manager swallowed his fear. “Mr. Konig, you left the water on in the tub. We have to fix it. The ceiling is leaking in Mrs. Alderside’s room. Please open the door.”

“Screw Mrs. Aldertop! She could use a bath once in a while, the way she stinks up the toilet,” yelled back Mr. Konig.

“Mr. Konig,” the manager persisted, sweating, “I’ll have to call the police again. Remember last time? They broke your double locks, and your son had to pay?”

“It’s about time that son of a bitch paid me back for what I did for him. I’m not opening the door, for you or anybody else, so get out of here!” Thomas Konig jiggled the lock, shaking the door to assert his independence. To prove he meant what he said, he stripped and hopped into the overflowing bathtub. His 208 pounds whipped up a splendid deluge.

A retired sailor, 80-year-old Thomas Konig loved water. “Anchors Aweigh, my boys, Anchors Aweigh. Farewell to college joys, we sail at break of day …” Thomas Konig stopped singing to lean out of the tub and bang the floor with the handle of his scrub brush, yelling lustily, “Hear that, old lady watertop? The landlubbers lie down below. So shaddup!” He smiled, looking down toward his neighbor below.

The police arrived shortly thereafter. Thomas looked up into the eyes of the police officer. The officer, feeling resigned after 10 years of Thomas disturbing his neighbors, warned quietly, “You’ve disturbed the peace in this neighborhood long enough. You’re going to the hospital.” The police officer spoke to the two emergency medical technicians waiting to remove Thomas from his watery lair. “You can take him on the stretcher if he won’t walk.”

Thomas rose, water dripping from his naked body, his fists moving in circles like a boxer. “Get away from me. I’m only minding my own business. Why can’t you people leave me alone?”

Not wanting to use restraints on the older man, the police officer tried logic. “Every night, at 2:00 a.m., we get complaints about you.”

“Me?” Thomas gasped, astounded.

Patiently, the officer explained, “Last night at 2:12 a.m., you emptied three garbage cans on the sidewalk. You banged tin cans together and then you sang dirty Navy songs at the top of your voice. You howl worse than the alley cats.”

“Nosy people. They should be sleeping, not listening to me. Why don’t they mind their own business?” Thomas fumed, folding his arms in defiance. “I am not leaving this bathtub. And no one is going to make me!”

John Dawes, an emergency medical technician, was trained in Validation. He used Validation techniques for the old-old person who holds on to worn-out roles, who cannot face unpleasant emotions, who cannot tolerate old-age losses. John rephrased Mr. Konig’s words, stressing the key word. “No one’s going to make you do what you don’t want to do. Is that right, Mr. Konig?” John’s voice held genuine respect.

“Damn right,” Mr. Konig retorted, in grudging agreement.

“What do you want to do?” asked John.

“Finish my bath alone. Without you nosing in my business!” he snapped.

Thomas Konig stood in the tub with the typical stance of someone in Phase One: fists in front, ready to strike, defending himself from the outside world. Deep down, Thomas was afraid of losing control, of falling apart, of having nothing to do, of dying alone.

Suspecting that Thomas was afraid of intimacy and would probably recoil from any expression of emotion, John Dawes kept his voice level, matter-of-fact. “What do you hate the most when people butt into your affairs?” John asked, hoping to help Mr. Konig express himself so that his anxiety would lessen as he felt validated.

“Damn! When they tell me what to do, boss me around.”

His anger out, Tom’s voice was not quite so loud. He lowered his fists. His muscles began to relax.

“Did that ever bother you before?” John asked, encouraging Mr. Konig to reminisce, to think about a happier time, when he was in control.

“Hell, no! The captain knows how to steer a straight course. You have to take orders on a ship.”

John handed Thomas a towel. The old man accepted the towel as a gift and stepped from the tub, drying himself as he recalled the past.

John tried another Validation technique by asking Thomas to imagine the opposite. “Was there ever a time when things went wrong? When someone made a mistake?” he asked.

Tom chuckled, snapping the towel. “That was something. It was me. I got drunk and loaded the wrong cargo. We were stranded in the North Sea with a load of lettuce instead of fish. Lost my lieutenant stripes.”

John Dawes nodded with empathy. “Did you give up the ship? Did you tell the captain to go to hell?”

“Hell, no!” Thomas shot back.

John was trying to help Tom find a familiar coping strategy to overcome present-day losses. “What did you do that time, Mr. Konig?”

“I told the captain I was drunk and I made a mistake and that I’d take my punishment like a man, but I never apologized. I’m not going to take anything back. I’m not going to tell old lady Waters I’m sorry, if that’s what you want me to do.”

Respecting Thomas’s defensive shield, the veteran police officer reassured him, helping the old man hold on to his dignity. “You don’t have to apologize to anybody, but do you think that you could swim at the Y instead of in the bathtub? They have a bus that picks you up right outside.” The officer knew that the nearby YMCA served older adults well. The next day, the officer would stop by the Y to enlist their help. Thomas might even join the YMCA band instead of banging trash cans in the middle of the night.

“I might do that,” said Thomas Konig. He shook hands with the police officer, the emergency medical technicians, and the apartment manager, dismissing them with a wave. He closed the door behind them, forgetting to bolt the double lock.

Thomas Konig remained angry over his losses, but his nocturnal noises stopped. Neighbors complained less, and the police were rarely summoned. He lived in his own apartment until he died.

The Mail Carrier, the Grocery Clerk, the Hairdresser, and Millie Stonewall

“Poor thing, no mail on her birthday. And she’s probably waiting for me in this cold weather at the mailbox.” Rudy, the mail carrier, rubbed his aching knee, picturing Millie Stonewall. The thought of her always made his heart ache. Rudy shook his head in wonder. Did Millie remind him of his mother, who also lived alone and was now 85? “Maybe,” Rudy reflected, “I worry too much. But then, I can’t help it. Poor old thing. Eighty-five years old and living alone on top of that hill, in that big house.”

Rudy imagined Millie, her white hair blowing over her eyes, her food-stained apron flapping with the wind, winding her way down the steep driveway to the mailbox, hoping for a letter from her son. Tenaciously, her arthritic fingers would grip the railing her son had finally installed from the house to the street.

“She’ll get a big kick out of my birthday card!” Rudy chuckled, his black moustache twitching, anticipating Millie’s joyful response. Rudy finished sorting his mail and drove off to deliver Millie’s mail.

At that moment, Millie was busy shopping. First in line at the grocery store, she shifted her shopping bag to ease the ache in her shoulder. Bursitis sent flashes of pain through her body. Bravely, Millie Stonewall blinked away the tears, refusing help.

“Please, Mrs. Stonewall, you’ll trip on the sidewalk. Let Mike carry it for you.” The cashier signaled the grocery clerk.

“No, dear. Mike’s too busy. I can handle the bag. I’m used to it. It’s just my shoulder.” Millie’s voice dropped to a whisper fraught with agony. She clutched the cashier’s arm and bent close to her ear to deliver each word. The six people waiting in line leaned forward to catch a stray phrase. “My shoulder hurts so bad that I forgot to get the lettuce. You know how Tweety loves lettuce. She’ll be so disappointed. And I won’t get to come back for another 3 days because my driveway can’t take all that pummeling from my tires. It’s a gravel driveway, and every time it rains, my driveway disappears. I told Harry before he died to spend the money to put in asphalt, but you remember Harry? My husband? He taught you geography. I think he gave you an A. He was a wonderful teacher but a very cheap man. Saving money on a driveway is no saving. Believe me!”

The woman behind Millie could not squelch her mounting irritation. “Please, I have to pick up my son from school, and you’re making me very late.” The people in line realized that they had been tricked by Millie’s urgent whispers. Her social chit-chat began to grate, and people began to complain.

“Oh, I’m so sorry. I’ll forget the lettuce. But Tweety only eats lettuce.”

The cashier was speechless with frustration. Oblivious, Millie went on, “Do you think he’ll try cabbage? I still have a head of cabbage. Cabbage looks like lettuce. And his eyes are bad. Canaries have very poor eyesight. I’m sure I read that somewhere. Probably in a nature magazine.”

Millie turned to confide in the woman behind her, who was becoming more and more frantic thinking of her child waiting at preschool.

“Mrs. Stonewall, why don’t you finish checking out while I get the lettuce?” Mike, the 22-year-old grocery clerk, instinctively knew how to validate Millie. His quiet tone reassured her. She paid for her groceries and scurried out the door with Mike. On the way to the car, Mike carried the bag of lettuce, and Millie lugged the rest of her groceries. The young man understood that this old woman had to show the world that she was still strong because she was terrified of losing her strength. He listened gravely as Millie rambled.

“It’s not for me; it’s for Tweety,” she said. “You know, I got that canary to keep me company after Harry died. Harry hated birds. ‘Filthy, dirty birds leaving their droppings and God knows what diseases,’ Harry used to say. Harry studied rare diseases. He taught geography—did you know that, Mike? I’m sure that he gave you an A. You’re such a bright boy. Did you know that Harry was a geography teacher at the high school?”

“Yes, Mrs. Stonewall. My dad told me that Mr. Stonewall was a terrific teacher—the best he ever had.” Mike knew that 85-year-old Millie was losing her recent memory, often repeating herself without realizing it. He did not expect her to remember, so he did not embarrass her by reminding her of her repetition. He had learned to admire her storehouse of knowledge and ignore her recent memory loss. When she rambled, frantically moving from one thought to another, Mike understood that she meant to lure him into listening. Millie Stonewall was lonely. The least he could do, thought Mike, was give her a few quality minutes.

“How come Mr. Stonewall never liked canaries?” he asked, encouraging Millie to express her irritation with her husband.

“Harry got food poisoning from eating a bird. He was never the same after that. He never let me cook a duck, or even a chicken, or anything with feathers. He was sure that he swallowed a feather. That’s what did him in. After that, Harry was a very fussy eater. But he always had a delicate stomach, you know, even as a child.”

Millie patted Mike’s cheek, reminiscing about Harry’s allergy, her muddy driveway, the chemical composition of feathers, and the benefits of eating lettuce. Satisfied that this young man cared about her, she cheerily waved goodbye and drove off.

Rudy reached Millie’s mailbox just as she pulled into her driveway. Vaguely disappointed that she wasn’t eagerly waiting for him at her mailbox, or at least trudging down the driveway to meet him, Rudy drove up to the house to help her. Millie remembered that Rudy arrived promptly at 3:00 p.m., Tuesday through Saturday. She even remembered the holidays when there was no mail. She timed her grocery shopping accordingly. They got out of their cars and shook hands. Rudy took the groceries out of her car.

“Rudy, you are the sweetest man. But I am perfectly capable of carrying my own groceries. It’s just my bursitis that acts up when I carry too much in one hand. But I can switch hands, and then I’ll be fine.”

“You’re 86 today, Millie. Happy birthday!” Rudy beamed, bending over to kiss Millie’s cheek and give her his birthday card.

Millie Stonewall stopped dead in her tracks. She stared at Rudy, her face white. “Rudy, I’m 68, not 86. You’re mixed up. Today is not my birthday. My birthday is September 4th, 1946.”

“That’s right!” Rudy nodded happily. “And today is September 4, 2022. Look, here’s the paper.” Rudy showed Millie the headlines, with the date in bold print.

“That’s not today’s paper. I just read the paper in the supermarket, and those are not the headlines. Rudy, you better see the eye doctor. I think your eyes are not as sharp as they used to be. Harry’s eyes started to go when he was about your age. Glaucoma set in. Harry never listened when I told him to get his pressure checked. No, Harry knew better. Where do you think his diabetes came from? Not from his family. No one in Harry’s family ever had diabetes.”

Rudy grew quiet. He carried Millie’s groceries from her car into her kitchen. With a sudden flash of insight, Rudy saw Millie as she was—an old woman fighting old age; unable to ask for help; fooling herself to keep from falling apart; cleverly manipulating him to help her carry her groceries, read her mail and make little repairs around the house. Millie wasn’t helpless. She was a survivor.

No one knew Millie better than Rudy’s wife, Tessie. Tessie had been Millie’s hairdresser for 25 years. That night, Tessie gave her husband a blow-by-blow description of her last encounter with Millie.

“Tessie,” Millie had wailed, “you’re putting some chemicals in that bottle that make me lose my hair. Look, Tessie! This whole side is getting bald. I had a full head of hair when I walked in here.” Millie squinted, her nose pressed to the mirror, as she showed Tessie her bald spots. “I always had beautiful hair. My crowning glory, Harry used to say. You know what that means, Tessie? Crowning glory? That means I always had a lot of hair. Those chemicals are making it fall out, little by little.”

Tessie understood Validation. She knew not to argue with Millie. She knew that Millie was afraid of losing her hair. When Millie asked about getting a wig, Tessie rephrased Millie’s words. “Do you think that some chemicals are making you lose your hair?”

Mollified, Millie nodded. Tessie then used polarity. “Which side do you think is the worst? The right side or the left side?”

“The right side,” responded Millie, peering closer to the mirror, squinting her eyes, adjusting her trifocals, then frowning. “No. The left side. The left side is the worst. What are we going to do, Tessie? Can you get a different shampoo?”

Tessie reminisced with Millie. “What kind of shampoo did we use when your hair was not falling out? Do you remember, Millie?”

“I think it was that yellow bottle. The one with the conditioner in it. But I don’t think they make that anymore. That was almost 10 years ago, remember, when Harry was still alive?”

“What color was your hair then? Was it blonde or light brown? Did Harry like it blonde?” Tessie continued to explore the past, knowing that Millie missed her husband more than she missed her hair. She needed to grieve to keep on going.

Millie would continue to complain and to manipulate her neighbors. Her memory loss worsened, but people in the community like Rudy, Mike, and Tessie helped her continue to live independently in her own home. Their sensitivity kept her fighting spirit alive. She died 6 years later, at 92.

Validation can be used in homecare settings, which allows older adults to remain in their own homes longer. The Validation practitioner is not afraid of emotions being expressed. This caregiver accepts the woman’s grief and connects using anchored touch.

The Doctor, the Meals on Wheels Volunteer, and Samuel Goode

“Kindly remove yourself from my fridge.” Samuel Goode, J.D., former professor of law, spoke stiffly, his husky voice clipped, his plaid bow tie quivering. The recipient of his subdued hostility, Maureen O’Connell, a 63-year-old novice volunteer for the Meals on Wheels program, shrank, almost disappearing into the refrigerator.

“But, Mr. Goode, everything in here is spoiled.” Her muffled voice found its way from her throat to Sam Goode’s good ear. “You’ll get food poisoning if you drink that milk. It’s 6 months old! And your meat smells terrible. The eggs are all rotten….”

In his curt courthouse voice, Samuel Goode informed Maureen, “I am Professor Goode, and my eggs are not rotten. That is an unfounded accusation. You are smelling your own body odor. Moreover, Madam, you are trespassing. Have the courtesy to remove yourself from my premises. I am a powerful attorney in this town, and I can have you incarcerated, just like that!” Sam Goode tried to snap his arthritic fingers. It was a futile, soundless attempt, but it bore the mark of authority.

Maureen O’Connell would not give up. Her husband had died in a nursing home, and Maureen couldn’t forgive herself. To make amends, she was dedicating her retirement to helping older people like this 88-year-old man stay in their own homes. Poking her gray-haired head into the refrigerator, Maureen pulled out six smelly, rotten eggs, holding each one under Sam’s nose for inspection. With utter disdain, Sam flared his nostrils, turned his back on Maureen and the eggs, and picked up his old-fashioned telephone to dial.

“Professor Samuel Goode here, Sergeant. There’s a woman harassing me. I want her out of my offices within 3 minutes or I will press charges.” Sam Goode did not wait for the police officer to reply. His eyes shot Maureen a warning. She blanched, but stood her ground, dropping the smelly eggs into the garbage. He began to pace, his bushy white mustache bristling. “I will wait you out, Madam. You are about to be punished.” Samuel Goode reached for his cane.

Maureen had had many years of experience in dodging her late husband’s cane. Hastily, she bolted from Sam Goode’s house.

“I can’t go back there. I’m so sorry,” Maureen nearly wept, apologizing to the Meals on Wheels volunteer coordinator. “The man terrifies me. He’ll hit me if I go back, just like my husband used to do. And he refuses to eat our meals. He tosses everything in the fridge and forgets that he put it there. His neighbors told me that he eats out once a day at the Chinese restaurant. If you ask me, Samuel Goode has Alzheimer’s disease.”

The coordinator called the social worker from the Department of Health and Human Services. She referred Sam Goode to a neurologist, Dr. Alan Farley, who administered a battery of medical, laboratory, neurological, and psychological tests—a complete diagnostic workup for dementia.

“Son, I appreciate that you’re doing an excellent job with those test questions.” Sam Goode patronizingly patted the 43-year-old neurologist’s shoulder. “But, young man, don’t you think you should find out the president’s name by yourself? I’m not going to tell you. Just read today’s paper. His name’ll be in there somewhere. Young people have lost their initiative. That is a sad fact.”

Al Farley grinned, valuing the old man’s intuitive wisdom. Subconsciously, on a deep level of awareness, Sam Goode knew that he could not perform adequately and would not risk taking the test. Dr. Farley had insight into the psyche as well as the brain. He understood Validation and applied it in his practice. He realized that this once-brilliant attorney was denying his recent memory loss to maintain his self-respect. Sam Goode was a master confabulator. He could not and would not answer the questions on the Wechsler Memory Scale, or on any other dementia scale. When Dr. Farley asked Sam to count backward from 10, the old man replied, “Son, if you’re going to be a doctor, you better bone up on your mathematics.”

Dr. Farley tried again. “You were an attorney, weren’t you, Professor Goode? And you also taught law?”

“Still do!” Sam Goode shot back. “And I expect that I could teach you a thing or two.”

“I know that you could,” Dr. Farley agreed emphatically. “Where do you live now, Professor Goode?” Al called Sam Goode by his last name. Addressing Sam by his first name would be disrespectful.

Sam had forgotten his address, so he answered quickly, “With my mother. She’s an old lady. My father’s dead. I’ve never been married, so we kind of take care of each other.”

Dr. Farley tried reality orientation to determine the extent of the disorientation. “Professor Goode, you know that you are now 88 years old. Your mother is no longer alive.”

“She’s alive on a technicality!” Sam explained patiently.

“How old would you say you are?” Dr. Farley asked.

“Over 30,” Sam said coyly.

“Do you think you could be 88?”

“Well …” Sam Goode rubbed his mustache thoughtfully, his brow wrinkling. “I could do the work of 88 people, but I wouldn’t say that I’m 88 years old.”

Respectfully, Dr. Farley rephrased Sam Goode’s words. “You can do the work of 88 people?”

“Not at one time, you understand.” Sam Goode was beginning to trust the doctor. Even though Sam was deaf in one ear, he heard the respect in Dr. Farley’s voice. “Young man, you’ve got old chairs. My rump is getting stiff from sitting so long.” Sam pulled himself up from the leather chair and began pacing.

“Will you read this story, Professor Goode, and give me your opinion?” Dr. Farley wanted to try another psychological comprehension test. His trifocals perched on the tip of his nose, Sam Goode peered at the paper, pacing all the while. Dr. Farley waited patiently. Suddenly, Sam straightened his spine, cleared his throat, and shoved the paper under the doctor’s nose.

“Sir, this brief is resplendent with resolutions that have no bearing on the credibility of the witness. These paragraphs are absolutely irrelevant. I move that we dispense with these inane formalities. Let us move to the proper closure of the case, with, of course, preparations for future contacts.”

“I hear you loud and clear,” said Dr. Farley, who had been listening closely. “Are you telling me that these tests have no bearing on your case?” Sam Goode smiled and nodded.

Dr. Farley became thoughtful. “The tests are irrelevant because they don’t measure your wisdom.”

“Son, I told you I’d teach you a thing or two.” Sam was immensely pleased with himself. He added grudgingly, “But, you’re a fast learner. Gotta give you credit!”

“Professor Goode, your students were lucky. Would you object to future contacts with someone who could benefit from your knowledge?”

“I never had any children,” said Sam. “Too busy becoming a topnotch attorney. I wouldn’t mind a young person around, now and then.” Uncomfortable with his yearning, Sam’s eyes shifted to the floor. Dr. Farley nodded with empathy. In Phase Two, Sam’s controls were beginning to loosen. His emotions needed to be released. Sam Goode needed a validating caregiver whom he could trust, someone with whom he could reminisce and express his fears and unfulfilled desires. A validating relationship could prevent Professor Goode from withdrawing inward. Validation could help him continue communicating with others.

“Professor Goode, I probably won’t be seeing you for some time, but I have a colleague who could learn a lot from you. Would you be willing to see that person on a regular basis?” Dr. Farley’s voice was matter-of-fact, full of genuine respect.

“No objection,” Sam Goode’s voice vibrated. The two men shook hands. Professor Goode strode out straight and tall.

Every Friday, from 3:00 to 5:00 p.m., Sam reminisced with a social worker trained in Validation. Together, they reviewed his triumphs and his defeats. They chuckled at judges, sneered at opposing attorneys, and marveled at Sam Goode’s accomplishments. Professor Goode no longer stashed rotten eggs in his refrigerator. Reluctantly, he accepted food from the new Meals on Wheels volunteer. He died at age 91, in his own home.

VALIDATION AROUND THE WORLD

USING THE ESSENCE OF VALIDATION AS A PARAMEDIC

As told by a paramedic in Boston, Massachusetts

I was a fairly experienced paramedic and could handle almost anything but sometimes had a problem when we conducted transfers of older adults from their homes to a hospital or long-term care facility. Most of these people had some cognitive decline, and some of them became what is often called “combative.” I remember one time clearly.

Mrs. M was a rather large woman, 82 years old, who lived by herself in her home. We were called because she had fallen and was unable to get up. Upon arrival I could see that see she was highly distressed and when I looked around, her home looked as if it had last been cleaned a year ago. Mrs. M was wearing a huge Patriots T-shirt and some leggings. Those clothes looked as if they hadn’t been washed in a while. Our initial examination showed significant bruising on her legs plus some heart irregularities. My partner and I needed to get her to the hospital.

With effort, we got Mrs. M up on her feet. She was not stable, nor did she have enough strength in her legs to stand unaided. Her anger grew, and she started focusing it on us. “What are you doing to me?” “Stop pushing me.” “Get the hell out of my house.” When I told her that we needed to take her to the hospital, she responded, “I knew it. You want to lock me up.” No matter what I said to her to explain what was going on, she just kept repeating that we were going to lock her up and she didn’t want to go.

I remembered some of the things I had learned about Validation.

First, her anger was coming from somewhere. This was not some crazy lady saying things out of nothing. I suspected that she didn’t want to lose her independence and was scared by all the weaknesses she developed as she got older. I knew that eyesight, hearing, taste, smell, and even touch can be affected by the aging process. And Mrs. M’s mobility was certainly affected by her weight and age.

Second, it’s important to first build some trust before trying to move her. Supporting her with my arms, I got in front of her and made eye contact at her eye level. I had learned that this helps a lot to build connection. Next, I carefully observed her and listened. I simply rephrased what she said: “You don’t want to get locked up!” Mrs. M looked me straight in the eyes and said, “Right!” I asked her how she felt. “Wobbly. And my chest is pounding,” she said. I leaned a tiny bit closer and continued, “Do you think there’s something wrong with your heart?” She answered with a worried look and short nod. “Okay,” I said, “let’s get you to a doctor so we can get that looked at.”

At each stage of the transfer, she became angry again, and I needed to get down and make eye contact to let her know that I was really listening to her words (and the meaning behind them). It was clear that she kept forgetting what had just happened. I just kept doing the same thing: eye contact, listening, and rephrasing with honesty. I could really understand how scared this woman was.

When we got to the hospital, I was walking next to the stretcher as we entered the building. Mrs. M reached out her hand and touched my sleeve. “Thank you” she said. I turned and smiled. “You’re so welcome.”

I am not trained in Validation but I’ve read a book and talked with Validation teachers. Those simple principles and techniques have helped me in my daily work. I’m not afraid of working with older, disoriented people. It’s not so difficult anymore.

PART III

Validation in Different Care Settings

The following chapters explore how the Validation method can work in different settings. Family caregivers who use some of the Validation techniques enjoy a more satisfying relationship with their relative living with cognitive decline. Those who work in either long-term care or day centers can find out more about Validation group work. Group Validation was actually how Validation developed in the 1960s and 1970s and it remains one of the important ways to help older adults communicate and feel connected to each other. After more than 40 years, many organizations have found creative ways of adopting Validation and integrating it into daily care. Their stories have become case studies for how we can change the culture in long-term care to provide a more person-centered, holistic home for older adults.

CHAPTER 14

Validating Family Members[1]

The Validation method can be effectively used by family members and friends who care for older adults living either at home or in long-term care. Families caring for relatives face different challenges than professionals because there are often deeper connections and triggers that can get in the way of building a trusting relationship. On top of that, family members are experiencing a significant loss. Their loved one—mother, father, aunt, uncle, best friend—is no longer the same person as before. They have changed in significant ways, and that is a loss. Family members struggle with personal feelings and memories connected to the disoriented person. The needs of relatives are different, so they need a different set of techniques to maintain, sustain, or re-create a loving relationship with their family member. Most importantly, they need some basic Validation techniques to keep communicating effectively so that their loved one doesn’t withdraw and fade away.

The preceding chapters have described the basic human needs of old-old people. This chapter considers the many different needs of family members who want to care for or build better relationships with the older adults in their lives. Validating a disoriented relative is difficult for a number of reasons:

- Both the family member and disoriented older adult are acting and reacting based on a long history together. See the previous vignettes throughout this book involving family members.

- Family members often expect the person to be like he or she always was. (“My mother doesn’t swear like that.”)

- Family members may expect the older person to behave in socially accepted ways and may be embarrassed when the person does not behave appropriately. (“I can’t believe you would act this way!”)

- Family members feel angry, disappointed, or helpless because of the disorientation; don’t understand it; or don’t know what to do. (“It’s no use visiting my father; he doesn’t talk to me.”)

- Family members often feel rejected when they are not recognized by the disoriented person. (“My husband doesn’t even know who I am. He locked me out of the house thinking I was some stranger!”)

- Family members often fear that the same changes could happen to them later in life. (“Will I act out and push everyone way just like my father?”)

- The family member often feels guilty about the disoriented relative. (“I should have been there more often.”)

- Family members often shoulder a financial burden when caring for their relative. (“How am I going to pay for the help my mother needs?”)

We all want to be appreciated, understood, and recognized, especially by a loved one. These feelings and expectations are normal, and hopefully all people have them fulfilled at some point in their lives. Several aging-related changes can cause older adults to behave differently. The loss of brain cells can lead to diminished cognitive abilities; Senses of sight, hearing, smell, and taste; and ability to move, diminish and make it more difficult to take in information from the environment. Older adults are in a different life stage, one that is more internally focused. As noted in Chapter 1, Erikson wrote about old age as a time to come to terms with the life already led, to sum up the positives and the negatives and struggle to find integrity. Those who can find peace with the way they have lived may struggle with the physical problems of old age, but they generally will die with integrity. Those who cannot find peace enter the Resolution Stage of Life. It can become difficult to focus on what is going on outside (in our common reality) and easier to focus on the inner process (the person’s needs and feelings). Most people in their late 70s, 80s, and 90s have difficulty learning new things or changing their behavior. Rarely can they let go of habits or patterns that became established decades earlier.

Here are typical examples of patterns that are played out between family members and disoriented old-old people:

- A mother cannot let go of the mothering role and calls her son every day to see how he is doing and check up on him.

- A husband who has always depended on his wife to take care of the house and prepare his meals gets angry at her for letting him down now that she is disoriented and neither he nor she can do those things.

- A father who always wanted his children to be curious and learn about new things clips articles out of newspapers and magazines every day and sends packets to his children. The son, tired of this constant pressure, throws the packets away without even opening them.

Expecting the older adult to change is pointless and frustrating. Most older adults cannot. They are busy with other things, trying to make sense of their lives, resolving old issues, and coming to terms with unfinished business. It can be hard on the family to accept this. But acceptance is the only way to discover how to connect.

For family members, validating means accepting exactly who their relative is in the moment, not judging the person, and understanding that there is a good reason underlying the disoriented behavior. Family members of disoriented relatives need to face the loss of the parent or partner they once knew. When validating their loved ones, it is important for family members to acknowledge their own anger, disappointment, or helplessness and to express those feelings with someone else who will listen, not with the disoriented relative. Feelings of anger, disappointment, and frustration about the situation hamper communication with disoriented relatives. Older adults who are disoriented cannot respond to your feelings in a way that will make you feel better.

Validation Principles That Will Help

Here are a few simple reminders of Validation principles that can help guide the actions of a family member who wants to help:

- All old-old people are unique and worthwhile: This simply means we need to accept the wisdom and folly of each individual as a sum total of a long-lived life and understand that not all older adults are the same.

- Disoriented older adults should be accepted as they are; we should not try to change them: This principle may sound easy to follow, but it is not. It is part of letting go of the relative (mother, father, sibling) we once knew. Expectations need to be changed. We must change because the other person cannot.

- Listening with empathy builds trust: Instead of jumping in with advice, solutions, or explanations of what would be best for the person, simply try to listen. Listen with interest. Listen for the words, needs, and feelings behind the words.

- Painful feelings that are expressed, acknowledged, and validated will diminish. Painful feelings that are ignored or suppressed will gain in strength: You hopefully know this principle from your own experience. When a friend listens to you with empathy when you are very sad or angry, the feelings subside.

There is a reason behind the behavior of disoriented older adults. When people reach the Resolution Stage of Life, their actions are an expression of a deep need. Usually, family members can identify that one of these basic human needs is driving their loved one’s behavior:

- The need to express long-held emotions
- The need to be loved or give love
- The need to be useful and productive

- The need to belong and to have human contact

- The need to feel safe and secure

- The need for recognition, identity, and self-worth

Integrating these principles into your daily life will certainly help you to connect with disoriented relatives. It does ask you to change and give up the idea that you can change your relative. Achieving this acceptance is a process, and not everyone is ready or able to do that yet. That’s okay, but be aware of your own feelings and thoughts and make a conscious choice. Becoming more aware of your own feelings is actually the first step in the process of “what to do” when validating a loved one.

A father and son communicate and maintain a loving relationship that includes the father’s disorientation.

How to Use Validation with Disoriented Loved Ones

The following Validation techniques can be used by family members:

1.Centering: Like professionals, family caregivers must Center themselves before approaching the older person. Centering is a way of putting aside your own feelings and thoughts for the 5–10 minutes that you want to Validate. You can Center yourself in many ways. Perhaps you already have a daily mindfulness practice or meditate regularly. These mindfulness skills are perfect for Validation because you can use them to clear your mind and emotions in order to be open to other people. If you do not have a daily practice, it is important to develop one. You can find a number of Centering exercises to try on the internet, including the Validation Training Institute’s YouTube channel. Find a method that suits you and practice it for 3 minutes every day. This daily practice will help in all areas of life. It also adds a refreshing moment’s pause to your day.

2.Observing and calibrating: This prerequisite technique is crucial and often forgotten in the haste and pressure of daily life. Taking 30 seconds to stop and look carefully at the other person will offer little pieces of information that will help you connect quickly and begin to improve the relationship. Is the person sad, angry, irritable, in pain, or lost? Can you recognize the emotions that are reflected in the face of the other person? If you find your own thoughts or emotions coming up, take a moment, breathe, Center, and try again. So often, family caregivers are triggered by small things—a facial expression, a way of breathing, a look in the eye. These triggers come from the shared history. Recognize them for what they are—history.

Once you have observed your relative, try to match the facial expression that you see. This is what is meant by calibrating. One can also try matching the breathing rhythm of the other person; is it fast and high up in the chest or low and slow? Observing the breath also gives a lot of information and insight into what is going on emotionally in the other person. How about the physical posture? Is there tension in the shoulders, chest, arms, hands, or feet? Is the person leaning forward or sitting back? All this information gives insight into the emotional world of the other person. Calibrating is different from mirroring. It is subtler. It is the pathway to finding empathy.

3.Using Empathy: It can sometimes be difficult for family caregivers to find empathy, and that is okay. If you cannot enter into the emotions of the other person, at least seek understanding of your relative’s emotions and needs. We all experience the same basic human emotions and needs. We all feel anger, joy, sadness, surprise, disgust, fear, and contempt. We also share the basic human needs described above. This gives us the space to find at least understanding, if not empathy. Families know the history of their relative better than anyone, and it is this history that will give clues as to what is going on. Reflect on the losses your relative has experienced throughout a long lifetime. What are some unfinished issues that need resolution? Think about any unresolved guilt, losses, or chances. These insights will help you prepare for interactions.

4.Maintaining respectful eye contact: The type of eye contact needed will differ because it must match the person’s state of being in the moment. Almost always, you need to position yourself at eye level. If the person is sitting, you should bend down or sit as well. You will usually need to be in front of the other person. Some people in Phase One may find frontal eye contact too much, so pull a little bit to one side, which gives the other person room to get away or to look away. For older adults who are withdrawn, using direct, intense eye contact can be a way to connect.

5.Finding a respectful distance: Be aware of your loved one’s need for distance or nearness. If the person is mostly oriented, you can use a normal “handshake” distance. However, if the other person is more withdrawn, you will need to get closer in order to be seen. You can tell if you are too far away if the other person does not react to you, make eye contact, or show other signs of recognition. You can tell if you are too close if the other person retracts, tenses, or looks suddenly angry or fearful. Sometimes you might need to put aside your own need for distance or nearness to find what is most comfortable for the other person. This can be a challenge for some family members.

6.Using a respectful voice tone: We cannot always hear ourselves when we speak. Frustration, irritation, tension, or exhaustion often creeps into our voice tone without us knowing. Older adults, especially relatives, will recognize this immediately and react to the tone rather than the words spoken. How something is said is almost always heard better and faster than what is said. A controlled or controlling voice tone can trigger an angry response. This is another reason why Centering is so important and the critical first step in building a relationship. Try to use an adult-to-adult voice tone with your relative. Think of the many years of experiences that person has built up, the challenges overcome. Find respect before you say anything.

These simple techniques will make a difference in communicating with your relative. All the other Validation techniques can also be used, but without these—the foundation stones of the basic validating attitude—the others will not work as well. They will fall short. Once you have mastered these foundational skills, choose one or two verbal or nonverbal techniques that you like and practice those until you do not have to think about them and can use them appropriately and easily.

Ann and Her Mother, Trudy

The cell phone rings for the 10th time in the last hour. Ann, 56, wearily answers the call, knowing full well that it’s her mother, Trudy, age 82. “Ann, where are you? I’ve been all alone and the Meals on Wheels people haven’t come. They should have been here hours ago. There’s nothing in the house. I can’t go out to go shopping because then I might miss them. Can’t you come over and …”

“Mom, it’s 10 in the morning. The Meals on Wheels people come around noon. You should have gone to the community center this morning. I told you. You’ve called me 10 times in the last hour. You’re just bored.”

“What do you mean, it’s 10 o’clock? My clock says it’s 2 in the afternoon. Have all my clocks stopped working? Oh, God. Who’s going to fix them? I’ll miss all my appointments. I’ll be lost.” Crying, Trudy hangs up on Ann.

Ann sits down, frustrated and furious. Her mother always does this. If it’s not one thing, it’s another—anything to get Ann to come over and take care of her. Her mother has behaved this way her whole life. Whenever there was something wrong, Trudy called Ann, and Ann would come fix it. In the past, that happened once in a while, and Ann was usually pleased to be able to help her mother out. These days, Trudy calls every day, making things up just to get Ann to come to her house. Ann has a family of her own, a husband and three children who need her as well, not to mention a full-time job. Ann feels helpless and doesn’t know what to do. The current situation can’t go on for much longer, and the only thing Ann can think of is to place her mother in a protected living situation.

Validating a Family Member

Remember, validating a close relative is different from validating a friend, a client, or a stranger. Family relationships are complex and filled with emotional pitfalls. Patterns of behavior that were developed early in the relationship continue even when they don’t necessarily fit anymore or work. In this example, Ann is stuck in her role as “fixer-upper.” When her mother calls for help, her first reaction is to fix the situation, whatever it is. It’s a pattern that began very early in the mother–daughter relationship. When Ann’s dad left the family, Trudy turned to her daughter when she had to make big decisions. Even as a little girl, Ann helped shoulder the responsibilities of her mother. Later, when Trudy’s sister died, Ann made all the funeral arrangements. She wanted to help her mother and knew that Trudy couldn’t really handle it all. Now the pattern is set: Trudy can’t handle things, and Ann reacts by taking over and fixing the situation.

Ann and Trudy—With Validation

The phone rings for the third time in the last hour. Ann takes a deep breath as she answers, knowing full well that it’s her mother. “Ann, where are you? I’ve been all alone, and the Meals on Wheels people haven’t come. They should have been here hours ago. There’s nothing in the house. I can’t go out to go shopping because then I might miss them. Can’t you come over and …”

As she was listening to her mother, Ann heard that her voice was high pitched and tight. Trudy was speaking rapidly, and her breathing sounded quick and shallow. Matching her mother’s voice tone, Ann answered, “Mom, where do you think the Meals on Wheels people could be?”

Trudy, speaking slightly slower and a touch deeper, “Uh, I don’t know. They usually are right on time. There’s that nice girl who always spends a few extra minutes talking with me.”

Ann asks, modulating her voice lower, “What do you like to talk about with her?”

“Oh, we talk about our children. She’s got three kids, all in school. She likes to look at my pictures of you kids when you were young.”

“Do you miss those times?”

“Oh, Annie. Sometimes it’s so lonely being old.”

“How about coming over for dinner this Sunday and bringing those old pictures? I bet my kids would love to see those.”

“Can you really handle having me over? I don’t want to be a burden.”

“Yes, Mom. It would be a pleasure. Should I have Ben pick you up at 6?”

“That would be fine. Well, I’ve got to go now. My program comes on at 11. See you Sunday.”

“Bye, Mom. Love you.”

[1] In addition to the suggestions found in the following pages, further information about Validation for family caregivers can be found in Validation Techniques: The Family Guide to Improving Communication, by Vicki de Klerk-Rubin (Health Professions Press, Inc., www.healthpropress.com.)

CHAPTER 15

Group Validation

The use of Validation as a method of communicating with disoriented old-old people originated in 1963 in group settings. Some disoriented old-old people may derive more benefit from participating in a Validation group than from individual Validation sessions. Validation groups can be formed in a variety of settings, including long-term care communities, adult day centers, small group homes, and senior centers.

Leading a Validation group is unlike facilitating any “therapeutic” group. Although any staff member—activity director, direct caregiver, social worker, and so forth—can lead a Validation group, training in special skills is essential for it to be successful.

Groups can be led by those who are trained in group Validation. Training levels and requirements are discussed in Appendix D; information on training opportunities around the world can be found on the Validation Training Institute’s website (http://vfvalidation.org).

The Benefits of Group Validation

For many people who are in Phase Two or Three, groups can offer the following benefits:

- The group experience produces energy, which prevents withdrawal.

- Being in a group heightens attention span. Disoriented old-old people have difficulty concentrating and are losing speech. One-to-one sessions can last only 5–15 minutes, whereas a Validation group often lasts for 1 hour, providing more time for individuals to interact with one another.

- A group helps participants solve problems and care about one another.

- A group setting gives participants the opportunity to restore familiar social roles, work roles, and family relationships.

- Moving, singing, touching, talking, and problem-solving produce group cohesion. Withdrawal turns to involvement. The group develops a rhythm: a beginning, with anticipation; a middle, which engages group members in a common purpose; and an end, which looks forward to the next meeting.

- In a group, participants express themselves verbally and nonverbally. Often, the group stimulates social controls. The participants become motivated to control negative behaviors (e.g., pacing, pounding, swearing) as they regain dignity in the Validation group.

- Group participation helps restore a sense of worth in the participants because they are listened to and respected by others in the Validation group. They regain independence as they perform their group roles.

Example of a Validation Group

This next example shows a Validation group in action and illustrates some ways that group participation can be effective.

The worker moves around the circle, introducing herself and saying the name of each group member. Group members take one another’s hands, responding to the genuine, close eye contact; touch; and nurturing voice tone of the worker. The worker reinforces group roles as she greets each group member. She begins with the Welcomer, Mrs. Flanigan.

Worker:

Mrs. Flanigan, you are our Welcomer. You start us out on the right foot. Will you stand up and say a few words of welcome to make everyone feel at home?

Mrs. Flanigan:

Ladies, we all have flumkin baggin’s disease. That’s a disease of old age. When you get old, you have good imagination and smelly piss.

Worker:

(Centering) That’s a very interesting disease, Mrs. Flanigan. How did you discover that?

Mrs. Flanigan:

I just went to the bathroom, and it came to me.

Mr. Small:

She’s right. That old lady never smelled so bad when she was a young girl.

Worker:

Is that one of the hardest things to take when you get old?

Mr. Small:

I don’t know, lady. I’m just telling you what I smell, that’s all.

Mrs. Kappe:

Well, it’s better to be old; then it doesn’t matter what you do!

Mrs. Falk:

(to Mrs. Kappe) At your age, you should know better.

Mrs. Kappe:

I don’t know what you mean. I’m under 25.

Mrs. Falk:

You should know better than to take other people’s husbands. Bitch!

Mr. Small:

That’s a bad word, lady. Shame on you.

Mrs. Kappe:

You’re crazy if you’re inadequate, and you’re crazy if you’re not, so what’s the difference?

Mr. Small:

I’m burning up, lady. I’m drowning.

Mrs. Smith:

Oh, shut up and drop dead!

A silence falls over the group. The Validation worker rephrases and summarizes, matching the emotion of the group members.

Worker:

Mrs. Falk, you’re angry because “she” stole your husband, and Mr. Small, you feel that people should control their emotions. Sometimes you feel as if you were dead—burning up inside? Mrs. Smith, do you ever feel as if you were dead?

Mrs. Smith:

Drop dead. All of you. And shut up.

Worker:

Are you angry at us all, Mrs. Smith, because we told each other how we feel?

Mrs. Smith:

Yes. Behave. All of you. Nobody acts like a human being.

Mr. Small:

Shut up yourself, bitch.

Mrs. Smith:

Drop dead.

Worker:

Mr. Small, you’re angry at Mrs. Smith because she doesn’t like the way we talk; is that it?

Mr. Small:

That’s it, lady. I can talk any way I like.

Worker:

Mrs. Smith, do you think everyone has a right to talk any way they like?

Mrs. Smith:

Well, if they behave themselves.

Worker:

(to the nurturing Welcomer, who solves all problems for the group) Mrs. Flanigan, can you help us? Shall we say what we think, or shall we shut up?

Mrs. Flanigan:

Both. I think we should do both. And behave.

Worker:

Thank you, Mrs. Flanigan. You always help us out in a tight spot. Do you think we have solved the problem? Have we talked enough?

Mr. Small:

It’s enough, lady. Let’s sing a song, huh?

Worker:

That’s a great idea! You’re our song leader, Mr. Small. What about “The More We Get Together?”

Mr. Small sings in a loud, joyful voice. The worker helps group members hold hands, and they sing lustily together. The group has solved a problem, and they feel close. They sing three or four songs. They have talked enough. The planned topic was to talk about loneliness, but the worker abandons her plan, moving with the rhythm of the group and Mrs. Falk’s need to express anger that had been bottled up for many years. Mrs. Falk’s husband had hurt her by cheating on her many years ago, and Mrs. Falk now uses Mrs. Kappe in present time to vent her anger. Mrs. Falk will express her anger again and again in the group until she feels relieved. She will not try to hit others, and her anger will be expressed with words in a socially acceptable way in the Validation group. Before joining the Validation group, Mrs. Falk would swear and strike women she thought had taken away her husband.

The worker asks the dance leader to lead the group in a circle dance to the rhythm of songs by the Beach Boys. The co-worker dances with the residents in wheelchairs while the worker dances with group members who can stand and move.

After three songs, the worker asks the hostess to serve refreshments. Mrs. Falk, a former entertainer, is the hostess. She passes out the juice and cookies with style, permitting group members to take only one cookie at a time. As she passes out the cookies, she maintains eye contact, and her speech increases. She moves around the circle, relishing her role. Before becoming the hostess, Mrs. Falk would not walk, although she was physically able. In her role as hostess, she is motivated to move, interacting with others both in and outside the Validation group.

Before closing the meeting, the worker asks the song leader to begin singing “Volare.” The group sings three or four songs that they know well, with heightened energy and joy. Energized by the movement, the food, the conversation, and the self-respect that they feel at being heard, the participants feel satisfied. The meeting is now ready to end. The worker summarizes.

Worker:

This was a wonderful meeting. Mrs. Flanigan, you helped us learn that we can say what we feel and still not hurt other people. Mrs. Falk, you felt bad that another woman took your husband. Do you think we can talk about it some more next week?

Mrs. Falk:

Certainly. She should know what she did.

Worker:

(using the ambiguous pronoun “she”) She hurt you very much, and you never told her, and now it’s time to get it off your chest. Is that right?

Mrs. Falk:

You said a mouthful.

Worker:

(planning for the next meeting) Next week, we’ll talk about taking other people’s spouses and what to tell people when they hurt us. Mrs. Smith, we hurt you when we used bad words, didn’t we?

Mrs. Smith:

(nodding) It’s disgusting. Really disgusting.

Mr. Small:

That’s a good one, lady. Nobody hurts me and gets away with it.

Worker:

(to help Mrs. Kappe express her feelings) Mrs. Kappe, when your feelings get hurt, do you tell someone how you feel?

Mrs. Kappe:

I do, honey. I do. Don’t worry about me.

Worker:

Do you think we’re ready to end our meeting?

Mr. Small:

Let’s end it. I’ll sing another song.

Worker:

What about “Stand By Me”?

Mr. Small immediately begins singing, and the group joins in, holding hands and swaying to the music. After the song has ended, the worker asks Mrs. Flanigan, the Welcomer, to say a few words to close the meeting.

Mrs. Flanigan:

Well, we’ve all surrounded ourselves with thoughts. When bad ones come, we spit it out and then we don’t smell so bad. Goody.

The worker shakes hands with each group member, reinforcing each person’s contribution and anticipating another good meeting next week. Care staff who understand the need for the Validation group are ready to take the group members to the dining room for lunch. The nursing staff have seen the benefits of the Validation group. Mr. Small no longer yells at night. Mrs. Falk no longer hits other women. Mrs. Smith swears less, and all group members interact more with others after the group meeting. The Validation group lasts 45 minutes and meets each week. Members keep the same roles until they die. This Validation group has been going for 10 years.

A Validation group creates a feeling of community; see the group members holding hands. The song leader leads the group in singing their opening song.

CHAPTER 16

Validation in Different Care Settings—Case Studies

In this chapter, you will find real-life examples of how Validation was implemented in different care settings and how it has helped both the older adults and those who care for them. The Validation method is used in the United States, Europe, China, Japan, and Israel in long-term care, home care, day care, and community settings. Anyone can learn to practice Validation and use it to improve their communication and relationships with older adults living with cognitive decline, as the following examples demonstrate.

Case 1: Implementing Validation in 10 Long-Term Care Facilities and a Hospital

Hedwig Neu, Validation Master, Diakonissen Speyer, Germany

Diakonissen Speyer is a large, complex health care provider in Germany with facilities for the sick, disabled, children and young people, older adults, including outpatient and inpatient hospices. The Diakonissen Speyer operates 13 homes for older adults with the option of short-term and long-term care, in addition to outpatient and day care facilities. Since 2001, Validation has been learned, taught, and implemented by staff, volunteers, and family carers in eight homes for elderly people. Two more homes for older adults began integrating Validation into daily routines in 2019. Additionally, Diakonissen Speyer is home to an Authorized Validation Organization (AVO), which provides information and training in Validation.

Starting with an inspired head of the Nursing School, Validation was systematically implemented and anchored into this organization. The first goal was to build a team of certified Teachers who could act as role models and offer in-house trainings

The certified courses, as well as the non-certified basic trainings, the theme-centered Validation seminars and the special courses for management, volunteers and relatives are only offered to the employees of the Diakonissen Speyer; they are also open to all persons outside this institution who are interested. Offering courses in this way helps to finance a portion of the costs that the Diakonissen Speyer invests in Validation.

Each home for older adults developed Validation Workers and Group Practitioners. Validation groups became a normal part of the engagement programs offered to residents. In each of the homes implementing the Validation concept, a staff member took on the role of “Validation officer.” This person, usually certified at some level, organizes the Validation team meetings and consults with the Validation teachers of the AVO. Each facility has enough experienced Validation practitioners who can offer support during challenging situations with people with dementia. Most homes already have Validation teachers who take on this role.

All staff are required to take a 3-day basic training in Validation, and those in administration or management receive a specially designed course that suits their needs. In this way, everyone—from the Executive Director to cleaning staff, from dietary staff to engagement coordinator—is on the same page, working toward the same goals and with the same validating attitude. Another important element in the plan was to offer continuing education to those trained in Validation. At least 12 times a year, a special 1-day workshop is held that focuses on “How to Handle Challenging Situations,” “How to Handle Sexual Expressions,” and other specific topics that caregivers face.

A further motivator toward improving the quality of life for residents in these homes was to introduce the Validation Quality Certification. The certificate is given to homes that achieve a high score on evaluation of the following:

- Mission statement and philosophy of care of the organization

- Engagement program

- Physical environment (both inside and outside)

- Dining program

- How validation is integrated into documentation

- Involvement of family and friends
- Volunteer program
- Caregiver skills
- Safety and control issues
- Strategies for maintaining resident dignity

Using the specifics of the questionnaire and getting the entire staff involved in the project turned out to be a fantastic way to motivate everyone to work in a validating way and to be creative in applying those ideas and principles in their departments. At the time of writing, eight homes are certified, and the staff look forward to maintaining their certification every 5 years.

During the development of the certification project, another idea came up: How can Validation be implemented in a hospital? In a working group, the criteria for assessing Validation quality were adapted to hospital conditions. A special area for people with dementia was created on a geriatric ward. A group of so-called “green ladies,” volunteers who accompany patients in the hospital, were trained in a special Validation course for volunteers to guide people with dementia on the geriatric ward. A professional escort service trained in Validation was set up to accompany patients with dementia to the operating room or to examinations, for example. As in the homes for older adults, many employees of the hospital, and especially of the geriatric ward, have been trained in a 3-day basic Validation course. Overall, a growing number of nurses, as well as physiotherapists and occupational therapists, who work not only on the geriatric ward, are Validation users. The specialist for geriatrics, who manages the geriatric ward, has participated in a Validation training for management staff.

Many other Validation projects are in progress, and we are proud of what we have attained so far. We feel that Validation has brought all parts of Diakonissen Speyer a higher quality of living for our residents and our staff. It has proven to be a worthwhile investment.

Case 2: Implementing Validation at Country Meadows Retirement Communities

Rita Altman, RN, CGP, Former Corporate Director of Country Meadows (Dementia Care Programs)

Country Meadows Retirement Communities, founded in 1983, is owned and operated by the family of former Pennsylvania Governor George M. Leader. We have 3,000 residents at 33 facilities throughout Pennsylvania and have a campus in Frederick, Maryland. Country Meadows has been actively using the Validation method since 1999.

In 1998, Naomi Feil was invited to Country Meadows to present her second series of 2-day Validation seminars at each of our 10 campuses. I had the privilege of meeting Naomi at the airport, and on the way to her hotel we stopped at one of our facilities for a brief tour. We visited a Meadows Living Center where all of the residents had some degree of dementia. In less than 1 hour of observing Naomi, I was convinced that Validation was the best method of communication that I had ever seen with this population of residents. Undoubtedly, I was most impressed with the way that Naomi totally immersed herself in conversation with every person that she spoke with, giving each one her total, undivided attention. I believe that each resident knew that someone was genuinely listening to him or her and validating his or her feelings.

Now that I understand Validation, I realize that Naomi was truly Centered as she spoke with each person. Her eyes were wide open and completely focused on each individual, and she seemed to be mirroring the expression on his or her face. Within moments of being Validated by Naomi, each person responded by making better eye contact and standing or sitting more erectly. They experienced being truly acknowledged and valued, which made them appear more self-confident and maintain more dignity. Having observed this, I can recall thinking that I wanted all of our caregivers to be trained in this method of communication because all of our residents deserved to be heard and responded to by caregivers who knew Validation.

Michael Leader, the president and chief executive officer of Country Meadows, believed so strongly in this empathetic form of communication that in 1999 he decided that we should become an authorized Validation Training Organization with the goal of advancing Validation. In fact, since 1999, our co-workers and others from all over the country have attended the Validation training courses that are conducted at Country Meadows. As a result, Country Meadows co-workers are now certified Validation workers and certified group practitioners and Validation Teachers. They provide individual and group Validation at many of our facilities where other co-workers learn about Validation by their example.

Validation principles are also interwoven throughout all of the modules of our company’s dementia care training, which every new co-worker receives within their first 90 days of employment. In addition, we provide ongoing quarterly training programs that also contain Validation principles and techniques. In 2002, we introduced a basic Validation training module at each of our facilities on a quarterly basis.

One of the most requested training sessions is on difficult behaviors. We have developed a Validation approach to difficult behaviors in which our caregivers are trained to link the behavior with the resident’s unmet need. Our co-workers are challenged to enter the world of the resident and to mirror his or her feelings. Instead of diversion and redirection or therapeutic lies, our caregivers are taught that every disoriented person has wisdom and that deep inside they know the truth. We emphasize the importance of establishing trust with each resident. Family members have also been included in this process because they struggle to try to make their loved one remember by using reality with them, which only results in more frustration.

At the most basic level, we are trying to instill the attitude of empathy and the desire to establish a trusting relationship with each resident in each of our caregivers. The paradigm shift from diversion, therapeutic lying, and reality to Validation does not occur overnight. Validation is much more than principles or communication techniques; it is a philosophy of care that requires time to learn and use. However, the benefits to both the residents and caregivers are immeasurable. Our co-workers have reported that using Validation has reduced resident agitation and aggression on many occasions. Validation has also resulted in the use of fewer psychotropic medications. Family members have commented that since their loved ones have been in weekly Validation group sessions, they look happier and are able to better communicate with them. When one family member observed her loved one in a Validation group, she commented that she wished everyone in the family could see how much she was still able to contribute to the group and that she still had so much wisdom.

Although the paradigm shift is slow in occurring, it is nonetheless occurring one Validation moment at a time.

Case 3: Using Validation as a Consultant in a Richmond, Virginia, Continuing Care Retirement Community

John C. Colletti, Psy.D., President, Chapman Senior Care

The Masonic Home of Virginia is home to an ongoing Validation group culled from individuals originally referred as part of a consulting psychology service. This article describes the stages that took place in establishing the group, as well as the logistical and financial obstacles that need to be addressed by a Validation practitioner who is not employed by a long-term care facility.

When I began practicing as a consulting psychologist at several long-term care facilities, I was in a bind when asked to assist in treating residents who were not deemed appropriate for traditional psychotherapy (e.g., those diagnosed with Alzheimer’s-type dementia as well as depressive, anxious, or behavioral disturbances). I could not, in good conscience, simply ask the treatment team to utilize medication without a behavioral intervention and, similarly, could not advocate for traditional behavior management techniques. Behavior therapy requires all shifts to observe the behavioral program’s tenets (a true challenge with the current rate of staff turnover). Also, traditional behavior programs place the resident in the role of having “maladaptive” behaviors rather than simply expressing an appropriate response to the “transfer trauma” many of these residents experience. Finally, because I was not an employee of any facility, I needed to provide a treatment for which there was no payment (i.e., commercial insurance or Medicare/Medicaid do not reimburse for behavior treatment with people diagnosed with Alzheimer’s-type dementia).

My search for a workable, caregiver-friendly approach to treating this population led me to read the first edition of The Validation Breakthrough. I immediately realized the potential of instituting this practice, as it gave me hope and practical advice for the residents, staff, and families with whom I worked. After pursuing certification in Validation, I began instituting short in-service training programs in the facilities that our practice served in order to begin the process of “weaning” the facility staff off the concept of reality orientation.

The first Validation group in Virginia was started at the Masonic Home of Virginia in Richmond. This nonprofit continuing care retirement community campus began in 1890 as a children’s home and was converted to a home for the elderly in 1955. In 2001, there were 259 residents, 58 of them in the Health Care Center, a wing designated for individuals diagnosed with Alzheimer’s. When our team of psychologists began work with the facility, the social services staff immediately resonated with the idea of Validation and, as a result, arranged a series of in-service training sessions for the general staff. This cohesion with the facility staff was instrumental in ensuring an ongoing program. I presented the concept of Validation, showed the videos Communicating with the Alzheimer’s-type Population: The Validation Method and Myrna the Mal-oriented (available through http://www.vfvalidation.org), and disseminated a synopsis of some basic techniques prepared by an intern from Virginia Commonwealth University (VCU). From those in-services, a core group of four staff from the social services and activity departments (as well as the two interns I was working with at that time) volunteered to be part of the Validation team at the facility. I also did some training with our psychologist, who gave me a list of individuals who were originally referred for a psychological evaluation but whose behaviors seemed to reflect problems with Resolution rather than mental illness.

After interviewing residents on the list with members of the Validation team and doing some more intensive training concerning the group methodology, we decided on a core group of eight residents and began to hold weekly group meetings (approximately 1 hour in length with 30 minutes debriefing with the Validation team) in a secluded parlor. Each of these residents was found to have significant dementia symptoms (consistent with Phases Two and Three of Resolution) as was indicated on the Mattis Dementia Rating Scale (DRS). A study is underway to measure the progress of members of the group by comparing their DRS pre- and postscores as well as their weekly progress forms.

During staff training, it was emphasized that Validation is not a “curative” model, and the benefits of Validation should not be measured in terms of “decreased maladaptive behaviors” as is prescribed with traditional behavior therapy. However, the following were seen as qualitative improvements in the residents who were treated with Validation:

- Less need for psychotropic medication

- Fewer symptoms of anxiety/depression/behavioral outbursts

- Increased social activity

Similarly, the staff reported more cohesion with fellow staff members and increased self-fulfillment and satisfaction with their role in the facility. Families were invited to sit in on the sessions and reported increased understanding of their loved ones due to the training they received and the effectiveness of the group intervention they saw. The group continues to meet weekly and to admit new members, and the Validation team continues to meet and grow with the support of both facility departments.

Although lack of funding continues to be a serious problem, the ability to effectively create a program to help underserved residents has helped Chapman Senior Care to grow into a large, effective practice.

Case 4: Using Validation in a 60-Bed Skilled Medicare Facility in the Kansas City Metropolitan Area: An Administrator’s Perspective

Scott Averill, B.S., J.D., NHA, Administrator, Colonial Manor of Lansing/Beverly Enterprises

Colonial Manor, a Lansing/Beverly Enterprises facility near Kansas City, began using Validation after its activity director introduced the administrator to the idea. The facility eventually began three Validation groups—including one led by a long-time volunteer—and holding weekly Validation team meetings.

Josephine became a resident of Colonial Manor the same day I became the Administrator. She was 86, and for some reason she immediately took a liking to a wingback chair located just outside my office. When I tried talking to her, she politely informed me that she lived at 9th Avenue and Spruce and her father was coming by to pick her up. Without giving my response a second thought, I said, “Josephine, you live at Colonial Manor now, and your father is dead,” whereupon she gave me a very indignant look, pumped her arms up and down, and became visibly angry. Although I didn’t know it at the time, my initial responses to Josephine (telling her she no longer lived at 9th Avenue and Spruce and that her father had died) represented a form of reality orientation. And for whatever reason, that is what was natural for me to say at the time. To say anything else would have been lying.

Such incidents went on for about 6 months until the day my activity director, Jennifer Carpenter, returned from a workshop on Validation. After just one conversation with Jennifer and skimming through Naomi Feil’s book, Validation: The Feil Method, my approach to working with Josephine and residents like her was forever changed. My staff and I were so enthralled by Naomi’s book and what my activity director kept sharing with us that we decided to invite Naomi to our area to lead a workshop. On very short notice, we had more than 100 people registered. And what was really amazing is that unlike most continuing education seminars, where participants can’t wait to get out of the room at the end of the day, the people in Naomi’s workshop didn’t want to go home when it ended. They stayed around to talk with one another and waited in line to buy Naomi’s book or ask her questions.

One of the participants in that first workshop was Velma Bass, a woman who had been volunteering at Colonial Manor for more than 15 years. What she heard Naomi say that day really fit with her experience of being with many residents at Colonial Manor over the years. Within a couple of weeks, she was leading the first-ever Validation group at my facility. About 3 months later, one of our Certified Nurse Aides, Lowell Dodson, had started a second group. About 5 months later, my activity director and I started co-leading a third group.

Each of our Validation groups met in a multipurpose conference room. Each meeting usually took 40–60 minutes, and we usually had five to eight residents each time. In the first several months, each group had its own members, and very rarely would members of one group visit another group. Later, this changed, and several residents attended two and sometimes all three Validation groups every week. Documentation was kept for each group meeting on each individual resident. When we began our third group, we began having weekly Validation team meetings at 9:00 a.m. every Friday morning. Validation group leaders and the registered nurse who led our care plan team attended these meetings.

After Validation had been actively practiced in my facility for 18 months, I saw several areas of our operation that had been significantly affected:

1. Staff turnover had fallen markedly. Prior to introducing Validation, our annual turnover was 170%. It decreased more than 80% the first year we began Validation and remained at the lower level in the second year.

2. Staff morale, attendance, and productivity improved: No call/no shows and weekend call-ins became rare. The hassle and frustration of working with residents with dementia became less aggravating when staff members had a new way of approaching and interacting with them.

3. Family members discovered a new way of being with their loved ones that allowed them to continue to express and experience their love for one another. Validation also decreased the friction among family members that is often present when a loved one has dementia.

Within 18 months of using Validation in my facility, including the three weekly Validation group meetings, and the Validation team meeting every Friday, we knew we had barely scratched the surface—which proved to be very exciting. One of the great aspects of Validation is that it can be practiced by anyone on the staff—housekeeping, laundry, maintenance, dietary, and nursing. Our first group leader was a longtime volunteer.

Every nursing home in the United States has a federally legislated mandate to provide an environment in which each resident functions at his or her “highest practicable level.” To achieve this goal is a daily challenge within all nursing homes. The ongoing practice of Validation is one of the best approaches I’ve found to meet this challenge.

Case 5: Using Validation at a 422-Bed Veterans’ Home in Minneapolis, Minnesota

Sheldon Pinsky, Ph.D., Chartered Psychologist, Licensed Independent Clinical Social Worker, Licensed Marriage and Family Therapist, AAMFT Clinical Member, Alzheimer’s & Dementia Unit

The Minnesota Veterans’ Home is a nonprofit facility in Minneapolis, Minnesota, that in the 1990s was home to 422 male residents who had been diagnosed with Alzheimer’s disease. These residents were in the Alzheimer’s and Dementia Unit, which was a separate, locked, secured unit. Some of these residents that were transferred to the Veterans’ Home from private nursing homes were unable to manage their wandering, agitation, and aggressiveness. Others were transferred from Veterans Administration hospitals, other state facilities, and their own homes.

Using Validation, the Veterans’ Home restored dignity and a sense of self-worth to their residents. Our approach to care was to use a multidisciplinary team that used Validation to establish empathy and rapport with our residents. This process allowed these residents to adapt comfortably to the home and taught the team to accept our residents’ behaviors in order to uncover the reasons behind their emotions.

When a new resident entered the facility, I met with him and his family to assess their needs in relation to total care and care planning. As the head of the Validation team at the Veterans’ Home, I then met with the Alzheimer’s multidisciplinary team, which consisted of nursing, social services, dietary, medical, psychiatry, psychology, recreational, and occupational therapy staff, to formulate care plans that involved careful listening, eye contact, touch, trust, and empathy. These care plans addressed the resident’s feelings and needs. I helped the team formulate treatment recommendations with specific goals and daily objectives, weekly progress summaries, and program care plans. These plans reflected the principles of Validation, as well as described the techniques, both of which are instrumental in improving the quality of life for each resident.

We used Validation both in groups and on an individual basis. Sometimes groups were preferred for disoriented residents, whereas individual sessions were used for mostly oriented, combative, or more thoroughly confused residents. Validation was very helpful in restoring our residents’ dignity and in teaching our staff to understand our residents’ reasons for behavior. Residents became less combative, less antisocial, and more cooperative with staff. They were no longer dangerous to themselves or others and participated in and enjoyed recreational activities that utilized the Validation approach.

In 1991, I measured the effect of Validation on the following observable behaviors: 1) yelling, 2) combativeness with other residents, 3) combativeness with staff, 4) agitation, 5) restlessness, 6) delusions, 7) paranoia, 8) repetitive physical movements (e.g., wandering, picking up imaginary objects), 9) depression, and 10) anxiety. Residents who were Validated for 4 weeks showed a decrease in these behaviors and were more communicative, less confused, and more oriented than they were before receiving Validation therapy. In contrast, residents who received reality orientation for 4 weeks showed an increase in these behaviors and were less communicative, more confused, and less oriented following therapy.

I met weekly with family members, the resident psychiatrist, the doctor, nurses, and social workers to review the progress of each resident and to determine how to decrease their maladaptive behavior. I encouraged all families to visit the home at least three times a week during lunch, dinner, or recreational programs so that they could observe how each resident was responding to Validation. My goal was to give each resident and family member a renewed sense of self-worth and to establish communication between residents and families so they could share their feelings and understand their roles in the relationship.

Validation makes it possible for both residents and their families to cope with disorientation. Family members have told me that, following Validation, they are better able to tolerate the label of Alzheimer’s dementia because they see in themselves and in their disoriented relatives a sense of connecting with the past, present, and future.

Case 6: Using Validation at a Newly Purchased Facility in Maine

Mary Bayer, RN-C, co-owner of the Sandy River Alliance Nursing Care Centers; Karen Leary, LSW; Tina Mikkelsen, CTR-S; Meg Nobel, RN; and Cheryl Martin, Recreational Therapist, Woodford Park Nursing Care Center in Portland, Maine

Woodford Park Nursing Care Center was a 154-bed proprietary nursing home located in an established residential neighborhood in Portland, Maine, when it was purchased by Sandy River Alliance Nursing Care Centers in 1989. At the time of the purchase, the facility was experiencing severe staffing problems, the quality of the food was poor, the housekeeping barely met minimum standards, and the physical environment was dark and dingy. Since appropriate gatekeeping had not been practiced in the screening of potential admissions, at least 75% of the residents required a heavy level of care. Throughout the facility, residents were housed randomly, with little thought given to diagnosis or nursing care needs. Many of the residents with dementia appeared extremely disoriented, noisy, frightened, and demanding of other residents, families, and staff. To deal with the unusually large number of disoriented residents, staff used reality orientation, something the new owners sought to change upon taking over.

Before new owners took over Woodford Park, reality orientation groups had been used with all residents, whether they were disoriented or not. The new owners found reality orientation to be of little benefit, since the oriented residents were already aware of what was being discussed and the disoriented residents seemed to pay little, if any, attention to the person conducting the group. Staff failed to listen to residents, but instead tried to convince confused residents that their fears or wishes were not real. The result was agitation, arguing, and outbursts from the residents and increased frustration and burnout on the part of the staff.

The new owners were familiar with the work of Naomi Feil and decided to institute Validation at Woodford Park, since they had had good results with the approach at another home they owned. One Validation group was started by staff familiar with Validation, and a 2-day Validation workshop was held for the administrators, nursing administrators, social workers, and recreational therapy staff in all of the nursing homes owned by Sandy River. Naomi Feil was invited to come as teacher and consultant.

The staff of Woodford Park came back from the workshop with lots of ideas and enthusiasm. All were busy with their jobs, however, and it was not clear how their excitement could be turned into a program. Fortunately, the facility’s administrator took the lead, calling together all of the staff who had attended the workshop and establishing a Validation team. This team consisted of a licensed social worker, a nurse, and a recreational therapist.

The team agreed that the first goal was to assess every resident in the facility who had a documented state of confusion. Using the facility’s computerized care plans, the team easily identified those residents who were potential Validation candidates. So that the interdisciplinary teams would not be overwhelmed, each team was asked to assess one resident for Validation. The needs of each resident would then be addressed in the plan of care and recorded. The resident would also be assessed for appropriateness in a Validation group, and the resident’s name and a copy of the group assessment would be submitted to the Validation team.

A “Song of the Week” was selected and photocopies were distributed on the units so that all staff could learn era-appropriate songs to sing with residents. The words were posted on each unit and nursing assistants were encouraged to sing along with residents as they waited together in the dining rooms before meals. Initially, some of the nursing assistants were a bit shy, but most joined in and appeared to enjoy the experience of seeing the residents perk up and sing old, familiar tunes.

The team also decided to show films about Validation to as many staff as possible. This was done by holding a month-long “Validation Film Festival.” Fliers were posted around the facility and sent to families of residents. Each week, one of the team members showed a different DVD on Validation and led a discussion with the viewers. On the evening and night shifts, the nursing supervisors showed the films. In this way, all interested staff and families were included in the viewing of the Validation films. A brief in-service was held on one of the heaviest care units during a staff meeting. Because so many staff members were convinced that reality orientation was the “way to go” with disoriented residents, the Validation team decided to perform a role-play that would highlight the difference between reality orientation and Validation. The recreational therapist on our team played the confused resident and the social worker demonstrated an intervention using reality orientation. The two ended up in a power struggle with the usual outcome—anger and frustration for both. The two then replayed the same scene using Validation as the means of communication in order to demonstrate the superior effectiveness of Validation. This brief meeting inspired curiosity from other staff, which encouraged us to hold a 1-hour in-service for all interested staff.

As a result of Validation, we grew to have fewer behavioral problems with our disoriented residents and were able to decrease the use of physical and chemical restraints. Notes kept during the first year reveal the results of our groups:

For the past year, our Validation group, the “group of love,” has been meeting every Thursday for 30–45 minutes. Friendships have developed, and the residents are affectionate and helpful with each other. The subject of love and the importance of being loved comes up frequently. This is how our name for the group evolved.

Love and friendship are discussed frequently and the participants talk a lot about childhood memories, husbands, loneliness, death, and family relationships. Hand-holding appears to bring them closer to each other and make them feel more comfortable.

Because of the dynamics of the group, “normal” conversations hardly ever occur. Group leaders are constantly trying to make sense of words they don’t understand. This sometimes leads us astray of the topic, but the group leader knows that this is not important and follows the group’s dynamic.

We try to give everyone in the group a role. These roles include the poet, the song leader, the chairperson, the napkin passer, and the snack passer.

We have had much success with music and songs, particularly songs that trigger memories of the past. Everyone in our group enjoys singing. Even if they don’t know the words they hum along or tap their hands and feet.

During the activity section of the group, we often pass a sponge ball around and the group members have fun laughing, pretending they are going to throw a ball to one person and then throwing it to another. This brings some humor to our group.

The snack at the end of the group is also a time for sharing. One resident has the role of passing out napkins, and another has the role of passing out the snacks. Leaders help pour the juice.

We have had some problems with our group. Often, group members don’t show up to the meetings. Most of the time, this is because they are too sick to attend. When one member is missing, it is noticed by the other members and morale is low.

Another problem is the residents who are hard of hearing and “patter talk.” They don’t seem to know what’s being said unless we repeat it to them. Conversation can’t flow, and we sometimes need to rearrange seating.

Overall, though, our group has been a big success, and our residents look forward to its meeting.

Aside from the cost of the workshops and the purchase of the Validation DVDs, the cost of initiating this program in our facility was minimal. The time and effort spent in providing continuing in-service education regarding Validation was time that we would have had to spend solving the many difficulties encountered if techniques other than Validation had been used with our disoriented residents.

In this facility, both staff and families discovered that there really is a communication approach that works with disoriented elderly people.

Case 7: Using Validation at an Urban Nursing Home in Brooklyn, New York

Stephen Snow, Ph.D., RDT, Drama Therapist

The Wartburg Lutheran Home for the Aging, a nonprofit nursing home located in Brooklyn, New York, had been serving elderly people since 1875. In the 1980s, Wartburg was a gardened oasis in the middle of a tough urban neighborhood and was home to 225 residents. About a third of these residents had some kind of dementia, and all were integrated into the general population of the home. In 1989, a drama therapist on the staff, attracted to Validation because of its use of role playing, started the first Validation group. Several groups, including one conducted in Spanish, were eventually developed.

Validation was introduced at Wartburg after I saw Naomi Feil. At the time, I was completing my doctorate at New York University and was working at Wartburg as a drama therapist. I immediately recognized the connections between Validation and drama therapy. Validation was drama therapy in action!

In collaboration with my colleague, Raymond Johnson, M.S.W., I initiated our first Validation group. Six disoriented old-old residents participated and almost immediately enjoyed and developed the roles they were assigned. It was magical to watch a disoriented 90-year-old man with a “gift for gab” deliver a well-received opening speech as the “chairperson” of the group; to observe a severely withdrawn 90-year-old woman, who had been a singer in her 20s, come to life as the “song leader.” All of the group members responded positively to the peer support approach and to the highly structured ritual of the Validation group.

I led these groups with Ray Johnson. During the weekly group meeting we alternated roles, as one of us led the group while the other took notes on the effectiveness of the techniques, the group dynamics, and the response of the residents. We found this weekly alternating of positions to be very helpful as it allowed each of us to critique the other as group leader.

Perhaps the best way to reveal how effective Validation was at Wartburg is to relate an incident from one of our group meetings:

In the middle of one session, a 90-year-old disoriented woman began to weep uncontrollably. Her son was at home, she said, there was no food in the house, she had no money, and she wanted to kill herself. She was distraught and clearly experiencing painful emotions. In fact, she was reliving a traumatic experience that had occurred 50 years earlier! I will never forget the way her group peers tried to console her. The “nurturing mother” in the group gently reached out to comfort her. The “chairperson” consolidated the efforts of all of the group members to help her resolve the problem. The genuine respect she received from all present enabled her to gain a new sense of peace and self-confidence. The tears went away, her feelings were validated, and she was able to let go of the past.

We had expanded the program to three weekly groups, one of which was developed for the Spanish-speaking residents at Wartburg and was conducted completely in Spanish. Soon we had five regular weekly groups running and the program continued to benefit both staff and residents at Wartburg.

Case 8: Using Validation in a 28-Bed Dementia Unit in Rural Wisconsin

Rose Boron, LPN, CVT, Rural Outreach Coordinator, Wisconsin Alzheimer’s Information & Training Center

In the early 1990s, Heritage Haven Care Center was a 155-bed, for-profit long-term care facility in rural Wisconsin. Of its 66 residents with dementia, 28 resided in a special care unit and 38 were mainstreamed with other residents.

For many years, staff at Heritage Haven used reality orientation with our disoriented residents. Encountering a resident who refused to be fed and instead fed her doll, staff would try to convince the resident that she really didn’t need to feed her doll: “Mrs. Johnson, I know that you like to carry your doll around and pretend that it is your daughter, but it’s time for lunch now. Your daughter is a grown woman with children of her own. So let’s put the doll on your bed for now and you can play with it after you eat a nice lunch.”

Although the intent would have been to orient the resident to reality, the effect of such an approach was to strip the resident of what may have been her most important role in life, motherhood. This approach not only failed to orient the resident to reality but also robbed the resident of the only comfort she had. Disoriented residents like Mrs. Johnson often choose to re-enact a time in their life when they were needed, when they were the best at something, when they had worth. These memories are intact and are more acceptable and more pleasant than the present.

After many unsatisfactory experiences with reality orientation, the staff at Heritage Haven recognized that they seemed to be concentrating on the residents’ losses and weaknesses rather than on their remaining skills. By using reality orientation, the staff only reminded Mrs. Johnson that she no longer had a small baby and that no one depended on her. We reminded her that she was dependent on us.

Our staff also noticed that families seemed to become particularly frustrated by the failure of reality orientation to benefit their relatives with dementia. Many families refuse to accept dementia and are aggressive in using reality orientation. These families deny the fact that their relatives no longer perceive the same reality they do and become frustrated when they cannot “bring Mom to her senses.”

We sought something better for our residents and turned to Validation. We sought an approach that would allow our residents to retain their self-esteem and that would help them find a reason to continue living. We sought a way of preventing our residents from withdrawing further into themselves and deteriorating.

To implement Validation at Heritage Haven, we invited all interested staff, families, and volunteers to attend a workshop in which the concept of Validation was introduced. The role of the Validation team was explained, and staff who were interested in being trained in Validation were asked to contact me. The 15 staff members who expressed interest in Validation included the activities director, a nurse, several nursing assistants, and staff from the dietary, laundry, maintenance, activities, and social service departments.

Having trained our team, we then looked for residents who we thought would benefit from Validation. The cognitive levels of prospective participants were assessed during interviews with the group leader and all of the prospective participants were observed by the entire team. Careful selection and matching of participants allowed residents to play an active role in the Validation group we established. Our purpose in forming this group was to provide a setting in which residents, who may not have felt comfortable interacting socially in the larger nursing home setting, would be able to socialize. The goal was to meet the individual needs of each resident.

Prior to holding our first meeting, goals for each resident were established by the Validation team. These goals became part of the resident’s clinical record.

The Validation group met weekly in a conference room on the memory care unit. These meetings lasted 40 minutes. Validation techniques were used to provide opportunities to reminisce, to talk, and to share common feelings that emphasized the residents’ strengths and needs. Weekly progress notes of these meetings were kept by the Validation team. For individual residents, the team documented what types of behaviors the resident engaged in when upset, what external stimuli seemed to cause the behavior to occur, what Validation techniques were used, and the effects of these techniques.

After several months of Validation, we observed several notable changes:

- Our residents regained their dignity and their behavior changed.

- The number of explosive behavioral responses decreased, and we were able to use fewer physical restraints and psychotropic medications.

- Staff found it easier to work with residents with dementia and experienced less burnout.

- Staff learned to identify residents’ attempts to “tie up” life issues and prepare for death and learned to use Validation to help residents do so.

- Staff morale rose.

- Staff productivity rose.

- Staff turnover fell.

- Staff became aware of their own aging and learned to prepare for their own old age.

- Families of residents gained empathy for their loved ones and learned to cope with their own losses and to assist their family members in resolving past conflicts.

- Families learned to use Validation techniques to help prevent their loved ones from withdrawing.

As a result of the decreased need to medicate our residents, we experienced fewer incidents of falls, decreased wandering, and decreased drug side effects. Most importantly, our residents deteriorated at a slower pace and had a higher quality of life, our staff were more satisfied with their jobs, and our families had a greater appreciation of their loved ones.

Case 9: Using Validation at a Rural Nursing Home in Missouri

Joy Goodwin, Coordinator of Special Services and Educational Ministries, The Baptist Home, Ironton, Missouri

The Baptist Home, a nonprofit, long-term care facility in the Arcadia Valley of Missouri, was home to approximately 200 residents. It had been established in 1913. The home received no funding from the government and operated entirely out of gifts from individuals and the Missouri Baptist Convention, and from the liquidation of residents’ assets. Beginning in 1980, it had used Validation to help residents cope with stress and become more oriented.

In my experience, Validation explains many of the reasons for disorientation in aging. Many people do not understand that we are dealing with the problem of disorientation, not disoriented residents. Validation was significant to us because it helped us stop trying to deal with disoriented residents, which was a very slow and often frustrating process, and start dealing with disorientation.

One of the components of disorientation in normal aging is stress, and many adults never learn to cope well with stress. Two of the greatest stresses older adults face are relocation and dramatic changes in health. During these times of extreme stress, we have applied the techniques of Validation as often as possible before the individual becomes disoriented. This intervention has prevented, slowed, or reversed disorientation in the older adults in our facility.

Although Feil’s target group for Validation is the disoriented population, our effort was directed toward individuals who were experiencing the most stress, whether or not they were disoriented. By using Validation at these times, we believe we prevented our residents from becoming disoriented. Rather than comparing two groups of older adults—one using Validation, the other group not using Validation—to measure the effectiveness of these techniques, we have compared our residents’ status reports after Validation with those before we started using Validation. By providing support/Validation at times of stress, our program made a difference that is measurable.

The results of Validation were dramatic in our facility. Our staff were encouraged to 1) ask questions rather than make assumptions; 2) engage in active listening; 3) believe in the potential of older adults; and 4) develop honest, open, caring relationships with our residents. We found that if the residents knew that they could depend on at least one person to accept them and validate their feelings, they felt safe enough to risk living in reality. Fewer of our residents seemed to pass into Phase Two, and many residents who had previously exhibited poor coping skills remained oriented through very stressful losses. After instituting Validation, our residents lived longer and experienced shorter periods of morbidity before death. Moreover, the overall population of our facility functioned better both physically and mentally.

Although the main focus and the most dramatic improvement from the implementation of Validation was in the area of prevention of disorientation, The Baptist Home also ran a Validation group, which began in 1982. A decade later, there was still a group for those who were disoriented enough to benefit from this type of group, although it had become more difficult to maintain a Validation group when the level of orientation had improved among the overall population.

Our experience showed that older adults living in a facility have great potential to function psychosocially, even when their bodies no longer serve them well. Caregivers who are willing to respect the autonomy of residents will find Validation an effective way of improving the morale of their staff and the quality of life of their residents.

Case 10: An Early Research Study on the Effects of Validation at the South Port Community Nursing Home in Australia

Alan Johns, Regional Director Eldercare, Inc., Black Forest, South Australia, and Colin Sharp, Ph.D., Associate Professor of Management, Flinders University, South Australia

In 1988, the authors conducted a study of the effectiveness of Validation using two nursing homes in Melbourne, Australia. Validation was used with 19 elderly residents at the South Port Community Nursing Home. The behavior of these residents was compared with that of 18 elderly residents at St. Anne’s (Anglican) Nursing Home, whose staff did not have a formal training program in Validation. Both homes were considered to be high quality facilities, and both were willing to try innovative approaches to resident care. Indeed, some staff of both nursing homes knew about Validation. The results showed that more of the residents whose staff received Validation training improved, and fewer deteriorated over the course of the study.

Validation was introduced in Australia in the early 1980s. Although a growing number of practitioners and facilities adopted Validation and recognized its effectiveness, no research had been published in Australia investigating the effectiveness of Validation. To fill that gap, we conducted a controlled study of Validation by comparing two similar groups of elderly nursing home residents. Both of the nursing homes that participated in the study, South Port Nursing Home and St. Anne’s Nursing Home, were nonprofit organizations with high standards of care. Both were located in Melbourne and some staff in both facilities knew about Validation. Residents selected for the study in each facility were similar. The average age of South Port residents was 87.1 years; the average of St. Anne’s residents was 89.7 years.

All appropriate residents in South Port were systematically validated during the staff training program. St. Anne’s staff were not formally trained, nor were residents systematically treated using Validation. Residents in both facilities were excluded from the observation and data collection of the program if they had histories or exhibited symptoms of chronic alcoholism, severe hearing impairment, severe dysphasia/dysarthria, long-term psychiatric conditions, or very poor health. In both facilities, residents whose first language was not English were excluded from the study. These criteria were established in order to minimize the number of variables influencing our results.

Three workshops and a follow-up session were held to train staff at South Port in Validation. These workshops introduced the concept of Validation, identified the types of people who benefit from Validation, described the phases of Resolution, and presented the techniques of Validation. The follow-up session, which was held 1 month after the last workshop, allowed staff to report on their progress in implementing Validation.

In order to evaluate how well Validation works, we used four measures of behavior, including the Benedictine Disorientation Checklist, Moorfield’s Behavior Problem Checklist, and the Goal Attainment Scale (GAS). We also used a subjective measure of change, vis-à-vis staff consensus. Using the checklists, we evaluated the behavior of the South Port residents before and 13 weeks after introducing Validation. The St. Anne’s residents were also similarly assessed at the start and end of the study period.

Both the Benedictine Disorientation Checklist and Moorfield’s Behavior Problem Checklist revealed significant differences between the levels of progress made by the residents in the two facilities, with South Port residents showing more progress overall. Also, South Port staff used a weekly goal attainment scale to monitor improvement of residents, which contributed to the effectiveness of Validation.

Staff consensus at the two facilities indicated that almost half of the participating South Port residents (8 of 19) improved. Staff at St. Anne’s reported that only 1 of the 18 participating residents improved. Of the 8 South Port residents who made substantial improvements, one example illustrates very dramatic results. This resident was virtually mute when admitted to the facility. She engaged in the repetitive motion of hand-sucking and spoke only with her hand in her mouth. Following the introduction of Validation, her hand-sucking subsided, she engaged in some meaningful conversations, and she began to relate to other residents on her ward.

Much additional research needs to be done on Validation. Our study pertained only to relatively healthy residents, and these results cannot be generalized to residents who are in poor health. Our study could look only tangentially at family involvement, an important issue that warrants further study. Research on the potential role of GAS in Validation would clarify its benefits here. For the sample of residents we studied, however, our results suggested that Validation is effective in promoting positive changes of behavior with disoriented residents.

Case 11: Using Validation at a University Hospital in France

Francois Blanchard, Jean Prentczynski, Catherine Wong, Bernard Lamaze, Isabella Morrone, Patrick Bocquet, and Damien Jolly

Hôpital Sebastopol in Reims, France, is a public university hospital. It had a 54-bed geriatric short-stay intensive care ward at the time of this writing. The unit tended to attract very old patients, about a quarter of whom showed signs of mental confusion and/or problematic behavior. The hospital sought ways of dealing with these confused patients, both to ease their anguish and to facilitate medical care.

Although Validation has been used primarily in long-term care facilities, our hope was to introduce it into the hospital in order to achieve the following goals:

1. To offer better care for our older patients suffering from psychological disorders by using alternatives to psychotropic medications

2. To reduce the tendency to hospitalize older people who lose psychological control

3. To prevent older patients from deteriorating psychologically after their hospitalization

4. To give the nursing staff a better understanding of certain behavioral disorders and to familiarize them with an alternative form of communication intervention

In trying to use Validation in an acute care hospital, we recognized that we faced major obstacles. First, the serious medical conditions of patients admitted to an intensive care unit require that medical treatment be the primary concern. Patients admitted to our unit were often very ill. Neither their poor health nor the series of tests these patients were required to undergo was conducive to building a trusting environment, in which Validation should ideally take place. Second, the average length of stay for our patients was only 10 days. This short period did not permit continuous treatment over several weeks or months, as indicated by Naomi Feil.

Despite the obvious obstacles, we ran a pilot study on the effectiveness of Validation in our hospital. Medical and nursing staff who volunteered to participate in this study learned the basic principles of Validation by attending a 2-day seminar. They later attended a 2-day intensive workshop led by Naomi Feil. These volunteers consisted of the head of the ward, the ward psychiatrist, a member of the medical staff, and 15 nurses.

Patients at high risk for rapid deterioration were selected for the study by the ward psychiatrist. Validation caregivers were asked to meet with these patients as often as possible to establish a relationship based on trust and compassion. These 10-minute sessions were held several times a day when no other treatments were being given to the patients. Validation also was used during medical treatments and while hygienic care was being given. Volunteers from the nursing and medical staff met once a week to share their observations about each patient and to assess the changes observed.

Throughout the project, we had to face some unsolved problems:

1. Because the workload in an acute care hospital varies and medical treatment must always be the top priority, it was not always possible to be attentive to Validation techniques. In our hospital, where participation in the project was voluntary, the problem was compounded by the fact that not all nursing staff participated in the program. This led to complex and conflictual situations. It was impossible to ensure continuity of the Validation for each patient. Moreover, caregivers who did try to use Validation became discouraged by the fact that the high level of personal investment they made was not being made by all staff.

2. Selection of appropriate patients for Validation can be difficult in an acute care setting because many of the people admitted suffer from severe organic diseases, and some suffer from other dementias. These patients would not benefit from Validation.

3. Stopping Validation after the patient’s release from the hospital was sometimes problematic. For many of our patients, the positive results of Validation were sustained after their release; others regressed, sometimes very severely (one patient died within 7 days of release).

Notwithstanding the far-from-ideal conditions in our unit, our experience with using Validation was a positive one, and we enjoyed several important changes as a result of its use:

1. Validation metamorphosized our nurses’ view of disoriented older patients and taught them how to treat these patients with more compassion. As a result of Validation, the nursing and medical staff learned to understand certain kinds of behavior that previously had troubled them. Behaviors that staff once derided were viewed with empathy. Validation gave a more human meaning to the care.

2. This attitude contributed to the diminishing of anxiety or aggressiveness and provided a more positive experience of hospitalization to patients who were already physically and psychologically fragile. Some patients even improved their ability to communicate.

3. We reduced the use of psychotropic medications on our unit. In fact, some patients who had been using such medications prior to hospitalization left the hospital free of these drugs.

4. Families and friends of these patients generally looked favorably upon Validation, and some even took an active part in the approach.

5. A better quality of life was provided for our patients during their hospitalization, and the “sliding syndrome,” whereby patients deteriorate during hospitalization, was often prevented. We also observed more satisfying cooperation in medical and physical treatments, which helped reduce the overload of work.

6. Patients displayed less aggressiveness during hospitalization. With some, the ability to communicate improved, thereby enabling them to acknowledge and accept the final stage of their lives.

APPENDIX A

Frequently Asked Questions about Validation

Q: I’ve tried Validation, but my client won’t talk with me. Why doesn’t it work?

A: Which Validation techniques did you use? Did you Center and establish the phase of Resolution? If the older adult is in Phase Three, verbal techniques may not work. If your client feels that you are not empathetic, techniques are useless. Validation practitioners must enter the world of the older person, match the person’s emotions, and then use verbal or nonverbal techniques.

Q: I feel uncomfortable when my client cries when I validate her. Isn’t it bad for older people to get so upset?

A: Remember this basic principle of Validation: When emotions are expressed and someone listens with empathy, the emotions are relieved. The person feels better. If you are uncomfortable with strong emotions and you wish to help your client feel better, you must first Center, release your own discomfort, and then feel with your client.

Q: How do I know when a disoriented old person is using a symbol?

A: When the person uses an object—a piece of clothing, a part of his or her body, or another person—and expresses strong emotions that are not related to present time, then the person is using a symbol.

Q: I’ve been doing Validation instinctively for years. Why should I take a course to learn it?

A: Validation is a theory, a method, and an attitude. You may have the validating attitude—accepting and respecting the old person where he or she is—but to use the techniques, it is vital to learn the Validation method in depth and the principles behind Validation. In a course, you learn to integrate the principles of Validation in practice. Receiving feedback and supervision makes it possible to really learn the techniques. It is very easy to slip into other methods, and new habits take time to practice and learn.

Q: You say, “don’t ever lie,” but does that mean pretending to agree with Mrs. Smith when she says, “My mother is waiting for me?” How do you reconcile these conflicting ideas?

A: Validation does not mean pretending, agreeing, or disagreeing. When you validate someone, you listen to the person without adding your own reality. You enter into the reality of the disoriented old person. You help older adults express themselves to work through unresolved relationships. In your example, you might say, “What do you need to do for your mother?”

Q: Our patients feel good here. Can you prove that Validation will help them feel better?

A: You can use the Validation evaluation form in Appendix C to find out if Validation is restoring well-being. Rate the person from 0 to 4. If, after Validation, the person complains less, communicates more, cries less, smiles more, and so forth, then you know the Validation method is helping.

Q: It seems like you think Validation is the only method there is. Why can’t I use other methods or therapies?

A: You can and should. There is no single, foolproof method for communicating with disoriented older people. Music, movement, and activities are just a few other helping methods. Mostly oriented older adults often respond to discussion and reminiscing groups. Validation is just one effective method to learn and use to help disoriented people restore communication and maintain dignity.

Q: Is Validation a therapy or a method?

A: Validation is a theory, a method, and an attitude—a theory that very old people need to resolve unfinished issues before death; a method of using verbal and nonverbal helping techniques; and an attitude of respect and empathy for the disoriented old person. Unlike “therapies,” Validation does not give the person insight or try to cure him or her. However, Validation is therapeutic in that it lessens agitation, restores well-being, and maintains communication.

Q: How do I know if I’m doing Validation correctly?

A: If your client feels better, is less agitated, complains less, communicates more, and relates to others positively, then you are doing Validation correctly.

Q: How do I handle someone who is acting aggressively?

A: First, Center to rid yourself of your own emotions. Then, if the person is verbal, rephrase while matching the emotion in your voice tone and your body to theirs. Use mirroring if the person is nonverbal. It is important that you not try to calm the person. Everyone has a right to be angry. Try to find empathy by thinking of a situation in your life where you felt angry. You can use this to match the emotion of the other person.

Q: Mr. Tinker doesn’t speak at all. How can I understand him?

A: First, Center to clear away your own preconceptions. Then, observe Mr. Tinker from top to toe. What is he feeling? You can often tell what is going on inside a person by a careful observation of his or her physical characteristics. This is called a calibration. For example, for Mr. Tinker, observe his facial expressions and body language. Are his lips pursed? Quivering? Set in a straight line? If they are set in a straight line, he may be angry. Say his emotion out loud, with emotion. “You are so angry! Did someone hurt you?” If you feel Mr. Tinker’s anger, he will know it. He knows that you are on his wavelength. He will open his eyes and look at you. This is the beginning of communication.

Q: What is the difference between a hallucination and the use of the “mind’s eye” by disoriented old-old people?

A: The “mind’s eye” is a visual image retained in the memory. The image is a projection of old memories and is based on the personal history of the individual. It is usually connected to some unfinished issues from the past. A hallucination does not necessarily have to do with the past or the personal history of the individual. Validation theory states that disoriented old-old people stimulate eidetic images to resolve unfinished issues, thus making this a healthy process.

Q: Validation works best with disoriented people over the age of 80. What about with younger people who have Alzheimer’s disease? Is it possible to validate them?

A: It is possible to use elements of Validation with people who have early-onset Alzheimer’s disease. The validating attitude—using empathy, respect, and honesty—is always a good start for connecting to another person. In the early stages of the disease process, some of the verbal techniques can prove useful. People with early-onset Alzheimer’s disease, however, lose the ability to communicate verbally rather quickly. Keep in mind that people often lash out physically without warning, so be careful about getting too close. Also remember that people with early-onset Alzheimer’s disease are not necessarily in the Resolution Stage of Life, and that the disease symptoms are not related to their inability to handle the losses that come from aging. Rather, the symptoms are the result of physical changes—plaques and tangles—in the brain. No matter what methods are used by caregivers, the process of neurocognitive decline, increasing symptoms, and eventual death are inevitable. Please see Chapter 7, which offers more detail on this subject.

Q: What do I do when my mother treats me like her mother?

A: First, understand that your mother is treating you as a symbol. A symbol in Validation is something or someone in present time that represents something or someone from that person’s history. Your mother is trying to express emotions that have perhaps been bottled up for 50 years. Things she yearned to say to her mother have gone unsaid and now demand attention. It hurts to keep all that inside. With disorientation, long-repressed feelings can come up and finally be expressed. What you can do first is Center. Take a deep breath, clearing out your irritation, sadness, or anger so you can be open and really listen to what your mother is saying. Get in front of her at eye level. Observe carefully and move into the emotions she is expressing. Try using the technique of rephrasing to let Mom know that you are really listening. Do not pretend to be her mother or correct her. Instead, simply explore using open questions, such as “What do you want to say to Mom?”

APPENDIX B

Validation Learning and Training

Most people find that they need training in Validation to integrate the theory and techniques in practice. The Validation Training Institute and Authorized Validation Organizations offer a variety of courses in Validation, as well as films and other resources. These learning opportunities can meet the needs of everyone no matter the time and resources available for training.

Who Can Practice Validation?

For those who wish to become proficient in Validation, there are four levels of certification. Each level builds on the experience and knowledge gained from the preceding course. The requirements are as follows:

Level 1: Validation Worker

- Take part in a Validation training course

- Practice individual Validation for at least 6 months

- Show documentation of practical work experience

- Pass written and practical examinations

Level 2: Validation Group Practitioner

- Show Level 1 certification or equivalent

- Take part in a group Validation training course

- Practice group Validation for at least 6 months

- Pass written and practical examinations

Level 3: Validation Presenter

- Show Level 2 certification

- Have some previous teaching experience

- Take part in a Validation Presenter training course

- Pass written and practical examinations

Level 4: Validation Teacher

- Take an active part in co-teaching a Level 1 course with an experienced Validation Teacher

Level 5: Validation Master

- Show Level 3 certification

- Have at least 3 years of teaching experience with all Validation courses

- Have made a contribution to the development of Validation in some form

- Have demonstrated trustworthiness and the ability to communicate with Validation Training Institute, Authorized Validation Organizations, and other certified individuals

- Certification at this level is made by application or nomination.

Validation Training and Resources

Training Opportunities

Training centers are available in Austria, Belgium, China, France, Germany, Italy, Japan, Slovakia, Spain, Switzerland, Sweden, and the United States. The most up-to-date contact and other information can be found at our website: http://vfvalidation.org

Authorized Validation Organizations partner with the Validation Training Institute to offer training and certification in the Validation method. For further information, please contact Vicki de Klerk-Rubin, Executive Director, vdeklerk@vfvalidation.org.

Films

A collection of DVDs and videos for streaming is available online at http://http://vfvalidation.org. Here are some of the titles available:

- Naomi Feil in Workshop
- Introduction to Validation
- The Four Phases of Resolution
- Myrna: the Mal-oriented
- Looking for Yesterday
- The More We Get Together

- Communicating with Alzheimer’s Type Populations

APPENDIX C

Validation Quick Resources

On the following pages are two resources:

- A summary of Validation for posting or sharing

- Validation Evaluation of Progress, a tool that can be used immediately after Validation sessions to assess and track the progress of the older adult

Validation Summarized

What is validation?

- A method of communication

- One method that is effective with older adults who have some forms of dementia

- A combination of a basic attitude, theory that gives us our goals, and techniques (verbal and nonverbal)

Who responds best to Validation?

People who:

- Are approximately 80 years old or older

- Have no history of psychiatric problems and have lived a relatively normal life

- Do not have the coping skills to handle the losses that normally come with aging

- Most often, are diagnosed with NCD from Alzheimer’s disease

What are possible reasons behind strange or difficult behavior seen in very old people?

- They are in the final life stage: Resolution.

- When reality is painful, they survive by retreating and stimulating memories of the past.

- Feelings in the present can trigger memories of having felt the same in the past.

- These people are trying to do one or more of the following:

Resolve

Re-live

Relieve

Retreat

Fulfill needs

Express emotions in the moment

What are the key elements to creating a trusting relationship with a person in this stage?

- Do:

Center

Observe

Find the right distance

Accept the person as he/she is

Listen with empathy

Use a respectful tone of voice

Use respectful eye contact and a respectful physical position

- Avoid:

Judging

Correcting

Lying

Validation Evaluation of Progress

Instructions: Fill out this form after each Validation session.

Evaluate what happened as follows: 0 – never; 1 – rarely; 2 – occasionally; 3 – often; 4 – a lot.

References

More research on the Validation Method and how it is taught can be found on this website: https://vfvalidation.org/resources/types/research/

CHAPTER 1

Alzheimer, A. (1907). Über eine eigenartige Erkranjung der Hirnrinde [On a peculiar disease of the cerebral cortex]. Allgemeine Zeitshrift für Psychiatrie, 64, 146–148.

American Psychiatric Association (2013). Neurocognitive disorders. In Diagnostic and Statistical Manual of Mental Disorders-5. Washington D.C. APA Publishing.

Arias, E., Tejada-Vera, B., Ahmad, F., & Kochanek, K. D. (2021) Provisional life expectancy estimates for 2020. (NVSS Vital Statistics Rapid Release, Report 0.15). Centers for Disease Control and Prevention. doi: 10.15620/cdc:107201

Erikson, E. (1963). Childhood and society. New York: Norton.

Feil, N. (1967). Group therapy in a home for the aged. The Gerontologist, 7, 192–195.

Feil, N. (1972). A new approach to group therapy: The Tuesday group [Film]. Cleveland, OH: Feil Productions.

Feil, N. (1973). A new life for Rose [Film]. Cleveland, OH: Feil Productions.

Feil, N. (1974). Living the second time around [Film]. Cleveland, OH: Feil Productions.

Feil, N. (1978). Looking for yesterday [DVD]. Cleveland, OH: Feil Productions.

Feil, N. (1980). The more we get together [DVD]. Cleveland, OH: Feil Productions.

Feil, N. (1982). Group work with disoriented nursing home residents. Social Work with Groups, 5, 57.

Feil, N. (1985). Resolution: The final life task. Journal of Humanistic Psychology, 25, 91–105.

Feil, N. (1989). Validation: An empathetic approach to the care of dementia. Clinical Gerontologist, 8, 89–94.

Feil, N. (1991). Validation therapy. In P. K. H. Kim (Ed.), Serving the elderly (pp. 89–115). New York: Aldine de Gruyter.

Feil, N. (1992a). Validation therapy with late onset dementia populations. In G. Jones, & B. M. L. Miesen (Eds.), Caregiving in dementia (pp. 199–218). London: Routledge.

Feil, N. (1992b). VIF Validation: The Feil method (Rev. ed). Cleveland, OH: Feil Productions.

Feil, N. (1992c). Sara’s choice [Videotape]. Cleveland, OH: Feil Productions.

Feil, N., & Flynn, J. (1983). Meaning behind movements of the disoriented old-old. Somatics, 4, 4–10.

Feil, N., Shove, L., & Davenport, S. (1972). Pilot study: A new approach for disoriented nursing home residents in a home for the aged. Paper presented at the International Gerontological Society, Puerto Rico.

Gajdusek, D.C. (1985). Hypothesis: Interference with axonal transport of neurofilament as a common pathogenetic mechanism in certain diseases of the central nervous system. New England Journal of Medicine, 312, 714–719.

Kral, V. A. (1977). In R. N. Butler & M. I. Lewis (Eds.), Aging and mental health (pp. 76–88). New York: C.V. Mosby.

Maslow, A.H. (1954). Motivation and personality. New York. Harper & Brothers.

Miller, B.L. (1988). Clinical aspects of Alzheimer disease. Annals of Internal Medicine, 109, 41–54.

Neugarten, B. L. (1970). Dynamics of transition of middle age to old age adaptation and the life cycle. Journal of Geriatric Psychiatry, 1, 71–100.

Reas, Emilie T. (2017). Amyloid and tau pathology in normal cognitive aging. Journal of Neuroscience, 37, 7561–7563. doi: 10.1523/JNEUROSCI.1388–17.2017

Selkoe, D.J. (1991, November). Amyloid protein and Alzheimer’s disease. Scientific American, 265(5), 68–79.

St. George-Hyslop, P. H. (2000, December). Piecing together Alzheimer’s. Scientific American.

CHAPTER 2

Feil, N. & de Klerk-Rubin, V. (2019 revision) V/F Validation: The Feil Method. Oregon. Edward Feil Productions.

O’Connor, J., & Seymour, J. (1990). Introducing neurolinguistic programming. London: Hammersmith.

CHAPTER 5

Feil, N. (1985). Resolution: The final life task. Journal of Humanistic Psychology, 25, 91–105.

Feil, N. (1972). A new approach to group therapy: The Tuesday group [Film]. Cleveland, OH: Feil Productions.

CHAPTER 8

Alprin, S. (1980). The study to determine the results of implementing Validation therapy. Unpublished study. Cleveland State University, OH.

Dietch, J.T., Hewett, L.J., & Jones, S. (1989). Adverse effects of reality orientation. Journal of the American Geriatrics Society, 37, 974–976.

Feil, N. (1967). Group therapy in a home for the aged. The Gerontologist, 7, 192–195.

Feil, N. (1972). A new approach to group therapy: The Tuesday group [Film]. Cleveland, OH: Feil Productions.

Feil, N. (1982). Group work with disoriented nursing home residents. Social Work with Groups, 5(2), 57.

Feil, N. (1992). Validation therapy with late onset dementia populations. In G. Jones, & B. M. L. Miesen (Eds.), Caregiving in dementia (pp. 199–218). London: Routledge.

Feil, N., Shove, L., & Davenport, S. (1972). Pilot study: A new approach for disoriented nursing home residents in a home for the aged. Paper presented at the International Gerontological Society, Puerto Rico.

Fritz, P. (1986, November). The language of resolution among the old-old: The effect of Validation therapy on two levels of cognitive confusion. Paper presented at the Speech Communication Association, Chicago.

Jones, G., & Miesen, B. M. L. (Eds.). (1992). Caregiving in dementia. London: Routledge.

Kim, P. K. H. (Ed.). (1991). Serving the elderly. New York: Aldine de Gruyter.

Morton, I., & Bleathman, C. (1988). Does it matter whether it’s Tuesday or Friday? Nursing Times, 84(6), 25–27.

Peoples, M. (1982). Validation therapy versus reality orientation as treatment for disoriented institutionalized elderly (Master’s thesis). College of Nursing, University of Akron, OH.

Pichler, B. (2014) Selbstverständliche zwischenmenschliche Aspekte. Pro Care, Geriatrie, Springer Verlag, 09/2014.

Prentczynski, J. (1991). La personne agee en perte d’autonomie psychique: La methode de validation et ses apports dans un service de gerontologie. Unpublished doctoral thesis, Department of Medicine, University of Reims, France.

Ronaldson, S., & McLaren, H. (1991). A time to care. Victoria, Australia: High Plains Press.

Rubin B. (1982). Burnout: Causation and measurement (Master’s thesis, Department of Psychology, Michigan State University, East Lansing).

Sánchez-Martínez, I., Vilar, R., Irujo, J., Ulsamer, D., Cano, D., Casaca, S., Acevedo, Á., Jerez-Roig, J., & Celdrán, M. (2020). Effectiveness of the Validation Method in work satisfaction and motivation of nursing home care professionals: A literature review. International Journal of Environmental Research and Public Health, 18, 201. doi: 10.3390/ijerph18010201

Sharp, C., & Johns, A. (1991, November). Validation therapy: An evaluation of a program at the South Port Community Nursing Home in Melbourne, Australia. Paper presented at the Australian Association of Voluntary Care Associations, Victoria, Australia.

Sindhumathi, R. (2012). Effectiveness of Validation Therapy upon the level of cognition of old age people (Master’s thesis). Tamilnadu Dr. M. G. R. Medical University, Chennai, India.

Söderlund M., Cronqvist, A., Norberg, A., Ternestedt, B.-M., Hansebro, G. (2013). Nurses’ movements within and between various paths when improving their communication skills: An evaluation of validation method training. Open Journal of Nursing, 3, 265–273.

Sung, M. R. (2016). Effects of community based group validation therapy of depression, quality of life, behavioral problems and cognitive function in patients with dementia. Journal of Korean Gerontological Nursing, 18, 22–31.

Tondi, L., Ribani, L., Bottazzi, M., Viscomi, G., & Vulcano, V. (2007). Validation therapy (VT) in nursing home: A case–control study. Archives of Gerontology and Geriatrics [Supplement], 44, 407–411.

Tsumura, N. (2015). Study on the Effects of Validation Training Program for Staff. 11420_9001-2. Available at https://vfvalidation.org/resources/types/research/.

CHAPTER 9

Butler, R. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26, 65–75.

Ebersole, P. P. Reminiscing. American Journal of Nursing, 76(8)

Folsom, J. (1965). Attitude therapy workshop. American Archives of Rehabilitation Therapy. June.

Folsom, J. (1968) Reality orientation program. Veteran’s Administration Hospital, Tuscaloosa, Alabama.

Jones, G. (1964, Winter). Remotivation in the aged. Geriatric Institutions, 5–7.

Pincus, A. (1970). Reminiscence in aging and its implications for social work practice. Social Work. 15, 47–53.