Validation

By learning to improve communication with dementia patients can avoid challenging behavior. A good place to begin is by remembering that communication is always a two-way street. You are sending information signals to another person while at the same time receiving signals from the other person. Improving communication means not only changing what you say and how you behave but also doing a better job of translating the sometimes confusing signals sent by patients for whom language skills have declined. It is also useful to remember that the quality of an exchange with a patient is influenced by the context and by the emotions that come into play on your part as well and as on the part of the patient. They will not only hear what you say, they will also read your face and when the signals do not match you may elevate the confusion level. So it is essential that we set a positive mood or any communication. You need to know what you are feeling so that you can in ensure that your body language and facial expression as well as your tone of voice send the right message.

Naomi Feil was the creator of a unique approach to working with patients with Alzheimer’s and other related disorders. Her approach has come to be called Validation Therapy. She is the Executive Director of the Validation Training Institute in Cleveland, Ohio. She earned her MSW from Columbia University and has studied at the new school for Social Research, Case Western Reserve University and the University of Michigan. Early in her work as a gerontologist she became dissatisfied with traditional methods and thus began to develop methods of her own to improve success. Her book the Validation Breakthrough: Techniques for Communicating with People with Alzheimer’s type Dementia was a major development in improving care for these patients. She is now internationally recognized and more than 7000 facilities in Europe, the United States, Canada and Australia have adopted her methods. The best way to begin is by defining validation, which is acknowledging and accepting the emotional reality of another person in a nonjudgmental way. We are not requiring that they adopt our reality, rather we are trying to better understand their view, even if that view is influenced by illness. The two active words in the definition are acknowledging and accepting. Acknowledgment is required in order to communicate understanding and acceptance is required in order to avoid being judgmental.

The basic steps in a validation exchange are:

1. Centering- when a challenging behavior occurs it is usually in the context of stress and the encounter between the staff and the patient can be full of stress.  Therefore it is important that those caring for the patient prepare for the exchange.  If we are extremely tense when we try to talk with the patient who has dementia we may find that they respond more to the emotions we present into the content of what we say. We should begin by using deep breathing and relaxing are muscles.  Sometimes thinking of our favorite color or our favorite relaxing music along with the deep breathing can be quite sufficient.  This takes only a few seconds but can make a big difference.
2. Observe- it is important to observe the patient with some care before beginning an intervention.  That means looking at the whole person from the hair to the feet. We should look carefully at the eyes, the forehead, lips, jaw and mouth. The facial expression is very important it can tell a great deal about the internal events associated with challenging behavior.  We should ask ourselves what is this facial expression saying about what they are feeling?
3. Find appropriate distance- we all have territory or space around us into which we do not like others to intrude. If our movements are slow and methodical there is time to let the patient tell us about the space they would like between us and them.  At times of stress the preferred space may be expanded so we need to avoid lurching at the patient which can be threatening and provoke behavior that will become troubling. As we approach the patient we should be sure that we can see their face so that we can immediately see their reaction. Approaching the patient from behind on the side is particularly risky.  We should look carefully at the face before we do anything else.
4. Find empathy- try first to connect with what the patient is feeling at the moment.  Is it anger?  Is it fear?  Is it simply confusion? One way to make that connection is to actually try to match our own facial expression to the facial expression of the patient. It is actually a very natural events that occurs in social interactions all of the time.
5. Communication- use appropriate methods of verbal and nonverbal communication. Ask simple questions and use gestures appropriately.  We have to be very careful about questions that involve memory, particularly short-term memory.  When the patient is unable to recall they become frustrated and this may lead to agitation and challenging behaviors.  Never ask why. Use touch as part of the communication but be sure you can see the patient’s face the judge their reaction and never touch patient who does not want to be touched or who is already upset and agitated.  It is useful to recall that a touch on the cheek is equated with the mothers touch and that option is only available for women staff.  A touch on the top of the head is perceived as the fathers touch but the safest option for male staff is a touch on the shoulder which is brother/sister touching. Touching can be reassuring but when a patient is already agitated it should be avoided.
6. Emotional exchange- the most important part of the validation episode is the acknowledgment by the caregiver of the emotion the patient may be experiencing. We should be observing carefully the facial expression and body language of the patient in order to make accurate inferences about what they are experiencing. The best test for a caregiver is to try to match in themselves the emotion the patient may be experiencing and then  acknowledge verbally by saying:
   1. It seems to me that you are sad.
   2. It seems to me that you are angry.
   3. It seems to me that you are somewhat fearful.

Whether you hit the emotion precisely is not as important as the effort to do so. Once we have acknowledged the emotion we simply say that no matter what they are feeling we just want to be of help.

Quality of Life in Long Term Care

The overriding goal in long term care should be to improve the quality of life for residents and a major feature of quality living is psychological well-being. There are two sets of factors that must work hand-in-hand to produce psychological well-being. One is the quality of care provided. These are the processes of care that are the focus of most quality programs. Another set of factors, however, too often ignored are the quality-of-life factors that take into account what the residents actually bring to the equation. For example, coping patterns help residents preserve their individuality and spite of declining health. We will apply a developmental theory called selective optimization and compensation and discuss how a greater understanding of how older people adapt to the changes of aging can serve to refine quality of care strategies. Research in Positive Psychology suggests at least 16 specific factors that seem to influence a resident’s is subjective sense of well-being.

Quality Care and Quality of Life

In many cases quality care patterns have a direct impact on resident quality of living. A safe and timely pattern of care with can lead to a sense of security. Technically proficient healthcare can lead to optimal health and increased levels of functioning. Personal attention and individualized care programs that engage the individual in their own care lead to a sense of autonomy and self-determination. Patterns of care which are respectful of individual needs and values into affirm personhood and reinforce the continuity of the self concept. A higher-quality life comes from recognition by caregivers of individuality as does respect by caregivers to the right to privacy. Even for dementia patients there needs to be continuity with the past and respect for the continuation of social roles important to the individual earlier in life. People are not constituted in a way that allows them to lie in bed hour after hour, day after day, week after week, month after month as the months turn into years. An environment must provide opportunities for activities appropriate to age and skills no matter what the disability.

Preservation of the Self

Sheldon Tobin in his book Preservation of the Self in the Oldest Years points out that those who design and long-term care must take into account the way older people, particularly those over the age of 85, strive to cope with the stress of changes that threaten their sense of self. He divides the coping methods into two classes: rational coping techniques in less than rational coping techniques. The preservation of the sense of self is served by ensuring residents are involved in affirming meaningful activities. They need to have at least a measure of control over daily activities and over social interactions. In too many nursing homes neither of these is the case. He points out that successful coping with the challenges of advanced age involves a contraction of one’s personal space, sense of time and the numbers of people with whom one has significant relationships. However contraction cannot mean elimination and providers of care in LTC must realize this. For example, a couple may have traveled widely and sailed all along the East Coast in earlier years but now must confine their travel to radius 60 miles from their assisted living facility. But travel they can. At the age of 30 that are decades of future ahead at the age of 85 the future is a matter of years at best. In earlier years a person may associate with hundreds or even thousands of people but in the older years associations may be restricted to family and only the closest of friends. Such constrictions are appropriate ways to cope. However, Tobin also points out that are less rational coping techniques. The older person may deny reality completely. Is as an example they may continue to believe in their driving ability well beyond the point at which they should recognize this limitation. Under stress the older person may become more aggressive because this gives them the illusion of continued control. When that is the case punishment of the aggression only leads to more aggression. The older person may blame others for things other than admit to themselves that they are vulnerable. There’s no better example of this in the dementia patient who blames thievery by staff for items they have misplaced or lost. In short older people will go to great lengths to protect their sense of self.

Psychological Well-being in Long Term Care

Psychological well-being is a subjective point of view defined as person’s cognitive and affective evaluation of life. The dimensions of well-being include a balance between positive and negative affect. Affect is a psychological term for emotions. Negative affect involves such emotions as anger, fear and depression. On the other hand positive emotions include such things as joy and happiness. How much time in any given day we spend feeling depressed needs to be balanced with time feeling happy. If more of our day is filled with positive emotions than with negative we have a sense of subjective well-being. Well-being is also dependent on how well we meet our fundamental human needs. That includes basic needs like food, shelter and safety. There can be no sense of positive well-being if we feel hungry or fear for our safety. However, given that those needs are met higher level needs like autonomy and self-esteem become important to our sense of well-being. It also seems very important to our sense of well-being that we have a purpose. For the oldest among us it is just as important to have goals even though it may be necessary to limit those goals as we age. Careers are behind and there is increasing limitation on the pursuit of wealth. However, those with a sense of positive well-being continue to set goals and pursue those goals. Activities also seem very important as dimensions of psychological well-being. There may be some constriction in the options available; however, activities within the framework of current skills can make a great difference. For example, one patient of mine in a nursing home and only the use of his upper body. However, to help of his family he arranged an entire world all within the reach of his own arms. Finally, optimism and hope are essential elements for a positive sense of well-being.

Paul Baltes of the Max Plank Institute for Human Development in Berlin and his wife Margaret Baltes of the Free University of Berlin have conducted extensive research on what they characterize as ‘Successful Aging’ and they have proposed that success is in part dependent on the selection process in which strengths are optimize in older people learn to compensate for losses in appropriate ways. For example, they become more discriminating in the choice of activities while which to spend their time and energy. Interactions with family become increasingly important in that may restrict themselves to a few real friends other than a large number of acquaintances. Optimization involves building resources needed to cope through self-education and continued learning. For example memory skills training can help in compensating for some of the losses that are associated with aging. Compensation involves doing whatever is needed to mitigate limitations and losses. Visually impaired older people use reading machines which magnify the written word. If they cannot read that can begin to listen to audio books. To avoid falls they can learn to use a walker, a wheelchair or a cane. To the extent that quality care processes facilitate selective optimization and compensation residents in long term care are more likely to experience a positive sense of well-being in spite of losses.