Foundational Techniques When Working with People with Dementia

Naomi Feil, retrieved from https://vfvalidation.org/about-us/our-team/

When working with very elderly people, I draw from the techniques of Validation Therapy. VT, otherwise known as the validation method, was developed in the 1970s by Naomi Feil (pictured), a social worker who grew up in Montefiore Home for the Aged in Cleveland, Ohio. VT is a person-centred approach used when working with people in very-old age, approximately 85 years or over, living with a neurocognitive disorder.

The brief overview of VT techniques I present here shows that VT employs techniques similar to those of some person-centred counselling modalities.

No summary I offer can supplant Feil's own explanations and examples. Before reading the below, you might want to watch this TEDx talk, "Validation, Communication Through Empathy".

Techniques

Centering

The caregiver first releases their own anger and frustration by focussing on their breathing for several minutes.

Open Questions

Avoid questions that force the person to confront their emotions. Do not enter into arguments. Focus instead on the factual who, what, where, when, and how questions.

Rephrasing

Using the same key words, the caregiver repeats, in the same tone and cadence, what the person has said. In the YouTube video linked above, Feil says, "Rephrasing is exquisite listening".

Polarity

Encourage the person to think about the most extreme example of their present complaint. This allows them to feel heard, and possibly open up to the following two techniques.

Imagining the Opposite

Find solutions to complaints by encouraging the person to think of particular instances when their complaint did not occur.

Reminiscing

As the person is no longer likely to develop new coping skills, retrieve old ways of handling present stressors through recalling earlier memories. Questions of ‘always’ and ‘never’ can trigger memories. Imagining the opposite and reminiscing are used together.

Genuine, Close Eye Contact

Feil encourages looking directly into the person’s eyes. While therapists are trained in the importance of eye contact, the eye contact in VT is very close. Here is an example of close eye contact, paired with 'the mother touch' (see 'Touching' below). My own feeling is that this should be used with respect for the person’s tolerance for eye contact, as well as one's own.

Ambiguity

When a person uses phrases the caregiver cannot understand, the caregiver can respond with questions using ambiguous pronouns (‘What did they do?’ ‘Did they say anything?’). This keeps the questioning open, and the conversation going even when it is not clear what the person is saying.

Tone of Voice

Feil says it is important to use a clear, low, loving tone of voice for ease of hearing, and to limit the person’s withdrawal and further disorientation. When the person is expressing strong emotions, however, mirroring should be used.

Mirroring

Feil encourages caregivers to observe the person’s posture, breathing, and how they move and speak, and to mirror this through their own body and speech. This allows caregivers to enter the person’s world and can create a relationship of trust with verbal and nonverbal people.

Linking Behaviour to Need

A person might engage in behaviours that seem odd to caregivers, but these behaviours could be expressing their deep need for love, nurturance, activity or engagement, or communication. When a person “pounds, paces, rubs, or pats”, the caregiver should connect that to the need for love, usefulness, or expression.

Using the Preferred Sense

Feil says each person has a preferred sense, and if caregivers identify and then use words invoking that sense, it can help them enter the person’s world, and build trust. Listening carefully to how the senses a person talks about will help the caregiver identify their preferred sense.

Touching

This technique is not for use with people who are in the early stages of neurocognitive decline, but for people experiencing more advanced decline who have lost some ability to hear or see, and to recognise people. Feil recommends certain ways of touching to induce pleasant memories and establish “an immediate intimate relationship”, with the caveats that people should be approached from the front, not from the back or the sides, and that people who do not wish to be touched should not be touched. I will not reproduce the ways of touching here (see the image of 'the mother touch' above), as beyond touching the hand or the upper arm, this is not a technique I use.

Music

People can be invigorated by familiar music even in advanced stages of cognitive decline. Caregivers can validate people by, for example, joining with them in singing their preferred songs or melodies.

Summarised from Naomi Feil and Vicki De Klerk-Rubin, The Validation Breakthrough: Simple Techniques for Communicating with People with Alzheimer’s and Other Dementias, Baltimore: Health Professions Press, 2022.

Naomi Feil founded the Validation Training Institute. Her daughter, Vicki de Klerk-Rubin, is its Executive Director.