Reality Orientation vs Validation Therapy
Last month we explored the reasons behind memory loss and the changes that occur in the brain. This month we are going to focus on how to approach memory loss in our loved ones. First it is important to understand what the definitions of Reality Orientation and Validation Therapy are.
Reality Orientation is presenting information about time, place or person to help a person understand their surroundings and situation. For example, a person with dementia would be continually reminded that she is 89 years old and that her mother passed away 20 years ago. The goal with reality orientation is to maintain and sustain as much cognitive functioning for as long as possible at a higher functional level. Reality orientation strives to assure the person that they are safe and that the world makes sense.
Validation Therapy emphasizes empathy and listening and is not concerned with orientating a person back into our reality. The thought process behind this approach is that instead of focusing on correcting a misconception, it places the emphasis on the possible feelings and thoughts behind a person’s behaviors and the underlying emotional needs.
One basic idea behind validation therapy is that people who are in the late stages of life may have unresolved issues that drive their behaviors and emotions. The way caregivers and family members respond to these behaviors and emotions can either make them worse or help resolve them.
Reality vs Validation: In truth, both approaches have their purpose and place in responding to a person with dementia. The trick is to be able to discern what approach should be used within any situation. Within the early stages of dementia, using reality orientation to remind a person of the time of day, location or upcoming events is completely appropriate. Reality at this stage can help a resident regain their bearings and regain control. In later stages, it is still appropriate to orient to the time of day.
“No it is not bedtime, it is morning, do you see the sun shine outside? Now we are going to eat breakfast.” However, as the dementia progresses, and the memory loss becomes more significant, Validation Therapy begins to lead the way in our responses.
What’s the best way to respond to someone with dementia if she’s anxious and yelling out for her mother who passed away many years ago?
Reality Therapy is logical and instinctual. The thinking is that things would be all right if only the person with dementia could get the facts straight However, for Reality Therapy to work, people with dementia need to have fully functioning memories — which is exactly what they have lost. (Moore, 2010, Alzheimer’s Association, 2011, n.d., Snow, n.d.)
Tell a dementia patient that her mother has died, and one of two paths will unfold, both with the same outcome. Either she will deny that her Mother is dead (“I just saw her this morning before school, and she was fine!”), or she will believe it to be true, grieving and in shock as she takes in the news for the “first time”. In either case, there will be high emotional turmoil. Soon, she will entirely forget the incident, though she will still carry with her a feeling of great upset. Later, she will again be 8 years old, waiting for Mother to pick her up after school. Repeated applications of Reality Therapy end no differently. So, what should care givers and family do instead? Validation Therapy gives the highest value to the emotional well-being of the person with dementia. (Alzheimer’s Association, n.d., p. 66) It also leads us to ask: is it really a problem that sometimes this woman with dementia believes that she is 8 years old and that her mother is just about to arrive? (Alzheimer’s Association, 2011) What if we didn’t try to correct these errors? Wouldn’t that allow care partners to help preserve her emotional well-being, dignity and calm?
Not attempting to drag the dementia patient out of their reality can be the most difficult aspect of using Validation Therapy for caregivers. It requires them to knowingly accept what is not “true,” and sometimes even to actively tell lies. To do so goes against all training to always tell the truth — especially to one’s elders.
Do care givers really need to let untruths stand unchallenged? Yes. Sometimes this is truly the wisest path. Lies are not told to mock the person with dementia, hurt their feelings, or exploit their weaknesses. Instead of looking at our responses as “lies” we can look at our responses as higher truths. The person with dementia is living in a former time in their memory, and as caregivers, we are going back to live in their truth from the past. The goal is to give any person with dementia a high-quality life where they are safe, comfortable, and can live with intact dignity and positive experiences. (Alzheimer’s Association, 2011)
Important information about unmet needs is buried in dementia patients’ mistaken information. (Moore, 2010, Alzheimer’s Association, 2011) Take the example of the 89-year-old woman who believes she is 8 and waiting for her mother after school: She is making an important communication about how she feels and what she needs. This is information that, when uncovered and used strategically, can help prevent difficult behaviors, and allow her to function at her best.
To uncover this information, care givers need to know something about her life. In this example, it turns out that going home after school at age 8 to milk the cows made her feel she was fulfilling an important, grown-up function in her family. Connecting with and living in that time in her life may be the only way she can still communicate today how she feels and what she needs.
Care givers should consider this “meaningless” information to be an important metaphor for her life today. She might be saying, “I want to feel useful again,” “I am afraid I don’t have a purpose anymore,” or “I miss the feeling of working with others toward a common goal.” It could be that focusing her on simple, repetitive tasks around the house and praising her for her helpfulness would work toward satisfying these emotions. This is vital, because if care givers do not find safe and possible ways for unmet needs to be satisfied, the needs do not simply go away. Instead, they continually re-emerge and may eventually assert themselves with force in the form of anxiety, depression, withdrawal, rage, or other painful and difficult behaviors. (Snow, n.d.)
Therefore, an appropriate response in this example might be to tell the woman something like: “I got a phone call from your mother a little while ago, and she said she was going to be late. Why don’t we go and have a cup of tea and wait for her together? And you can tell me all about your life on the farm. Was it hard to learn how to milk?” As a result, the woman gets to revisit and feel proud of her usefulness on the family farm. She is received by a caring listener and can enjoy sharing a time that is still clear in her memory. In the process, her troubled feelings may pass as her immediate emotional needs are met. It is likely that soon she will forget that she is 8 and waiting for her mother to arrive.
When researching Reality Orientation and Validation Therapy, I found a lot of support and research for each approach. The importance should always be placed on using genuine warmth and empathy to sustain emotional well-being and dignity in our interactions. Using this as the compass when navigating misconceptions and memory loss will help guide us to the appropriate response. By Heidi Lohre RN
References: Nugent, Pam M.S., “REALITY ORIENTATION,”
in PsychologyDictionary.org, April 28, 2013,
https://psychologydictionary.org/reality-orientation/ (accessed September 26, 2018).
Alzheimer’s Association, Massachusetts/New Hampshire Chapter. (n.d.) Caring for People with Alzheimer’s Disease: A Habilitation Training Curriculum. Watertown, MA: Alzheimer’s Association.at is REALITY ORIENTATION? definition of REALITY Alzheimer’s Association. (2011b). 2011 Alzheimer’s Disease Facts and Figures. Alzheimer’s & Dementia, Volume 7, Issue 2.
Moore, B. L. (November 20, 2010) StilMee™ Certification for Professionals: Working respectfully and effectively with people with Memory Loss [Training Course] Burlington, MA.
Snow, T. (n.d.) The Art of Caregiving. [Video] Florida: Pines Education Institute of Southwest Florida.
RIENTATION (Psychology Dictionary)
- Country Music Month
- Positive Attitude Month
- Popcorn Poppin’ Month
- Guardian Angels Day October 2
- Presentation on Incontinence Products
Thursday October 18th 3:00pm
Let's Go Fishing
Music with Brad Ray
Olive Branch went on it’s first outing late this spring! Several of our gentleman expressed an interest in going fishing so fishing we went. What a great time was had by all not to mention the great memories! Next up is a special trip to the Minnesota Arboretum for our ladies.
We are looking forward to having Children of Tomorrow out on October 29th at 9:30am for some Halloween fun. They will be assisting us in making Halloween masks for a parade while enjoying cookies and milk. I almost forgot to mention we enjoyed live music this past month with Brad. Busy times and great fun! Stay tuned for updates on our latest adventures!
As always, if you have suggestions or ideas or see a photo you would like, please send me an email to firstname.lastname@example.org.
In astrology, Libras are those born between October 1–22. Libras, symbolized by the scales, strive for balance, avoid conflict, and desire fairness for everyone. To achieve this, they are sociable, strategic, charming, and diplomatic. Those born between October 23–31 are Scorpios. Scorpios are passionate and deep, qualities that help them counsel others in meaningful ways. Resourceful and determined, Scorpios make good managers.
Groucho Marx (comedian) – October 2, 1890
Desmond Tutu (archbishop) – October 7, 1931
Eleanor Roosevelt (first lady) – October 11, 1884
Paul Simon (musician) – October 13, 1941
Lee Iacocca (executive) – October 15, 1924
Evel Knievel (daredevil) – October 17, 1938
Mickey Mantle (ballplayer) – October 20, 1931
Dizzy Gillespie (musician) – October 21, 1917
Minnie Pearl (comedian) – October 25, 1912
Dylan Thomas (poet) – October 27, 1914
Jonas Salk (doctor) – October 28, 1914
Dan Rather (journalist) – October 31, 1931