Journal of Gerontological Nursing

VALIDATION THERAPY: A Case Against

John S Kelly, RGN, RMN, MSc, BSc

Abstract

Validation therapy is a method of communicating with older persons who are disoriented. In essence, it is the converse of reality orientation. Reality orientation strives to maintain disoriented older persons in the "here and now." Validation therapy is based on the assumption that the disoriented older person can be "helped" by "validating" (acknowledging and accepting) his or her feelings and personal views of the world, even if those reelings and views appear to conflict with accepted reality. It is accomplished by the validation worker's ability to demonstrate a degree of empathy tor the disoriented older person, to "tune into feelings, pick up rhythms, listen to verbal clues, observe nonverbal clues" (Feil, 1982).

Abstract

Validation therapy is a method of communicating with older persons who are disoriented. In essence, it is the converse of reality orientation. Reality orientation strives to maintain disoriented older persons in the "here and now." Validation therapy is based on the assumption that the disoriented older person can be "helped" by "validating" (acknowledging and accepting) his or her feelings and personal views of the world, even if those reelings and views appear to conflict with accepted reality. It is accomplished by the validation worker's ability to demonstrate a degree of empathy tor the disoriented older person, to "tune into feelings, pick up rhythms, listen to verbal clues, observe nonverbal clues" (Feil, 1982).

Naomi Feil, the originator and exponent of validation therapy said: "The validation worker receives pleasure when the disoriented old person's eyes light, when speech returns, when gait improves, when people no longer need physical or chemical restraints, and do not withdraw inward to vegetation" (1991).

The evidence for the success of validation therapy remains largely anecdotal and comes from Feil, herself. There remains little or no convincing scientific evidence that validation therapy is effective or has any beneficial impact on disoriented older persons. Robb and associates (1986) showed that validation therapy was labor-intensive, expensive, and had no significant effect on mental status, morale, or social behavior.

Morton and Bleathman (1991) attempted a systematic evaluation of validation therapy and suggested that validation therapy may not be the ideal therapy for everyone. Bleathman and Morton (1992) acknowledged that it remained to be established how much of the improved functioning witnessed in validation groups was due to the interactive validation therapy techniques described by Feil (1982). Scanland and Emershaw (1993) were able to confirm that validation therapy neither had any significant impact on mental status nor had any effect on the level of depression or functional status. Remarkably, Ronaldson and Savy (1992) still were able to commend the approach, suggesting that "validation techniques offer an effective practice option to augment current nursing interventions for confused older people."

A FURTHER BASIS FOR DISSENT

It is probably sensible to occasionally reassess and question the fundamental assumptions underlying all the various forms of therapy that are used to "help" individuals. Validation therapy is no exception, especially as it is underpinned by a number of assumptions that appear to be, at best, open to question and, at worst, verbiage or the meaningless use of words. For instance, "Disoriented old-old humans must tie up living to prepare for dying. They restore the past to make closure and justify their lives" (Feil, 1982).

Is it really safe to assume that all disoriented old-old individuals (those age 85 years and older) must "tie up" living to "prepare" for dying? Do they really need to "justify" anything at all? Where is the evidence for these processes? There is none. It is claimed that "when emotional memories are validated, the old-old person regains dignity" (Feil, 1982).

In reality, how can this be shown? It cannot. It is suggested that with empathy, the validation worker is able to build trust in the disoriented older person, and the extrapolation is thus: "Trust brings safety. Safety brings strength. Strength renews feelings of worth. Worth reduces stress. Some disoriented oldold no longer need fantasy when they feel strong and worthwhile in present time. Adult controls return. Speech improves. They tap sleeping brain cells. They interact" (Feil, 1982).

It might be argued that a basic prerequisite to the successful establishment of a trusting relationship is the ability to remember who can be trusted. Unfortunately, it is often the case that the short-term memory of the disoriented older person is severely and permanently compromised by damage to the brain. The equation simply does not work. The idea that a conscious or unconscious choice is made to return to reality also makes the whole approach unfalsifiable (i.e., "heads I win, tails you lose"). Thus, if the individual undergoing validation therapy temporarily shows any "improvement," it might be attributed to the validation interventions, whereas, if no "improvement" is shown, this might be attributed to the individual's conscious or unconscious "choice." Either way, the integrity of validation therapy is preserved.

It is misleading to assert that disoriented older persons have "sleeping" brain cells that can be "tapped." It is beyond the scope of this article to discuss at length the many contentious points made by Feil; however, many statements made in relation to older persons and validation therapy have no empirical support. It should be remembered that "the feelings of being certain and of being unable to doubt a proposition are by themselves no sufficient ground of their truth" (Korner, 1969).

WHY VALIDATION?

Masson (1989) is skeptical of anyone who profits from another person's suffering. This skepticism seems to be a reasonable precaution when one considers the potential profit, both academic and financial, to be made in health care.

Validation therapy persists despite a lack of research-based support for its effectiveness, perhaps because it has been more of a commercial success than a scientific one. It costs more than $100 to attend a validation workshop/training day, and there is no shortage of those willing to pay to achieve recognition as validation therapists. The pleasure and pride afforded by the status of being a "therapist" allows for the whole approach to become self-perpetuating as nurses and others accept and pass Feil's propositions on as profound truths - even in the absence of evidence. This is not to say that all nurses who subscribe to validation therapy are doing so out of pure self-interest. Most nurses working with older persons do so because they are genuinely concerned for the interests of those persons and may sincerely believe that validation therapy helps. While it makes sense not to antagonize persons with continual "reality orientation" and contradiction, if, through neural damage, they are never again likely to fully appreciate the consensual reality, the rejection of reality orientation should not necessarily mean the unconditional acceptance of validation therapy.

Another reason for the persistence of validation therapy may be related to the general climate surrounding the desperation for a breakthrough in the treatment of cognitively impaired older persons. Validation therapy may provide primary caregivers with a sense of hope in what often seem to be hopeless situations. Caregivers may believe that they are helping, even if they are not actually making any difference. Dietch and associates (1989) stated that one of the original purposes of reality orientation was to give staff a sense of "doing something" with patients who have bleak futures. They suggested that the success of reality orientation in any particular treatment setting may depend upon the staff's belief in and enthusiasm for the technique. This may be equally true of validation therapy.

CONCLUSION

It is important that the effectiveness or therapeutic value of any form of treatment be objectively assessed before it is adopted and a widespread commitment be made to its use. Just as we should be "open" to new methods of treating elderly disoriented persons, we also should be able to dispense with "therapeutic" methods that prove to be ineffective. Persisting with ineffective or inadequate fad therapies ultimately may be at the expense of the very individuals we seek to assist. Only by critical analysis of all "therapy" can we find what is ultimately best for our confused older clients. As Greek orator Demosthenes said, "The easiest thing of all is to deceive one's self; for what a man wishes, he generally believes to be true."

REFERENCES

  • Bleathman, C., & Morion, I. (1992). Validation Therapy: Extracts from 20 groups with dementia sufferers. Journal of Advanced Nursing, 17, 658-666.
  • Deitch, J.T., Hewett, L.J., & Jones, S. (1989). Adverse effects of reality orientation. Journal of the American Geriatrics Society, 37, 974-976.
  • Feil, N. (1991). In S. Ronaldson, H. McLaren, A time to care. Melbourne: High Plains Press.
  • Feil,N. (1982). Validation: The Feil Method. Cleveland; Edward Feil Productions.
  • Korner, S. (1969). What is philosophy? London: The Penguin Press.
  • Masson, J. (1989). Against therapy. London: William Collins and Sons & Co., Ltd.
  • Morton, L, & Bleathman, C. (1991). The effectiveness of validation therapy in dementia - A pilot study. International Journal of Geriatric Psychiatry, 6, 327-330.
  • Robb, S.S., Stegman, C.E., & Wolanin, M.O. (1986). No research versus research with compromised results: A study of validation therapy. Nursing Research, 35, 113-118.
  • Ronaldson, S., & Savy, P. (1992). Validation therapy: A communication link with the confused older person. Australian Nurses Journal, 21, 19-21.
  • Scanland, S.G., & Emershaw, L.E. (1993). Reality orientation and validation therapy: Dementia, depression, and functional status. Journal of Gerontological Nursing, 19(6), 7-11.

10.3928/0098-9134-19950401-08

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