BASIC ATTITUDE

1. BASIC ATTITUDE VALIDATION THEORY TECHNIQUES

2. Validation Principles

3. 1. Maloriented and disoriented old peopleare unique and worthwhile. Example: A 90 year old woman lives in a nursing home. The caregiver calls her "sweetie’ or mama or grandma."Validation Caregivers address her as "Mrs. Smith." V/W action: we address older people in a respectful way and treat each person as an individual. Theory: from Humanistic psychology (Maslow, Rogers, etc.): know your client as a unique individual.

4. 2. Maloriented and disoriented old people should be accepted as they are: we should not try to change them. Example: a 90 year old woman demands her breakfast after she has just eaten. The nurse does not say: “Honey, its 8 o’clock. You just finished all your breakfast. You can’t be hungry’. Validation: we know that this woman is perhaps psychologically hungry for her family, for love. We ask, `what fills you up?’

5. V/W action: we do not try to change the person’s behavior; we accept it and try to help the individual fulfill the needs that are being expressed. Theory: from Humanistic psychology (Rogers, Maslow, etc.): accept your client without judgment. Additionally, Freud said that the therapist cannot give insight or change behavior if the client is not ready to change or does not have the cognitive capacity for insight.

6. 3. Listening with empathy builds trust, reduces anxiety and restores dignity. Example: A woman angrily declares that the caregiver threw a basin of water over her clothes and now she’s all wet. The trusted, familiar Validation caregiver rephrases, asks, ‘Does that happen every morning? ‘Yes, every morning.’ ‘Is there a morning when she doesn’t throw water over you?’ ‘Well, only when the very, nice, young lady comes to look in on me in the night. She asks if I need to go to the toilet. You see, I’m getting older now and I have a problem sometimes with pee-pee.’

7. V/W action: we understand that this woman is ashamed of being incontinent and empathize with the feelings of the older person without concentrating on the ‘truth’ of the facts. Theory: from Humanistic psychology, most especially Rogers who focused his client-centered approach on using empathy.

8. What is empathy? • How does empathy differ from: • Sympathy • Confrontation • Insight oriented therapy • Condescension • Behavior modification (reinforcement theory) • Diversion • Reassurance Oh, you poor thing. (Pat his/her hand) It will be OK. What is causing the problem? Shall we go have a coffee/tea?

9. 4. Painful feelings that are expressed, acknowledged and validated by a trusted listener will diminish. Painful feelings that are ignored or suppressed will gain in strength. Example: An old woman gets up at 3.30 every afternoon to go home to her children. When staff says, ‘Sit down. Everything’s OK.’ She gets more and more nervous and upset. When staff asks, “What is the worst thing that can happen to your children?” The old woman expresses her vivid memory of having left her children alone. Her fears are expressed to a validating caregiver and the old woman feels relieved.

10. V/W action: we are open to all feelings that are expressed by older people. Through empathy we share these feelings and encourage expression. We acknowledge that disoriented older people freely express emotions in order to heal themselves. Theory: from Psychoanalytical psychology (Freud, Jung, etc.): “the cat ignored becomes a tiger”

11. Universal Feelings love/pleasure/joy/sex hate/rage/anger/displeasure fear/guilt/shame/anxiety sadness/misery/grief

12. 5. There is a reason behind the behavior of very old maloriented and disoriented people Example: A woman accuses the cook of poisoning the food.  The nurse does not say, "We have the best cook from Paris." The nurse knows the old woman may have been overfed by her mother (instead of loved), and now she expresses anger against the cook. The validating caregiver asks, “What does she put into the soup?” Example: An old woman refuses to eat soup and vomits each time she is forced to do so. As a Jewish woman during WWII, she hid her identity papers in the soup tureen during a raid at her home.

13. V/W action: although we do not always know why the person behaves in a certain way, we help him or her express emotions to resolve unfinished business. Theory: The brain is not the exclusive regulator of behavior in very old age. Behavior is a combination of physical, social and intrapsychic changes that happen during the life span. (Adrian Verwoerdt is the original source for this, but this idea has been generally accepted by most geriatricians.)

14. 6. The reasons that underlie the behavior of maloriented or disoriented very old people can be one or more of the following basic human needs: • Resolution of unfinished issues, in order to die in peace • 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.

15. 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, 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 And so they are drawn to the past or are pushed from the present in order to satisfy their needs. They: resolve, retreat, relieve, relive, express.

16. V/W action: We accept that very old people are in the final life stage, ‘Resolution’; we accompany them in the process; we accept that they are often in a personal reality and see this as a wise and healing response to an unbearable present reality. Theory: several theories back up this principle: Maslow’s hierarchy of needs Erikson’s life task theory From Humanistic psychology: human beings struggle for balance/ homeostasis, and are motivated to heal themselves (Rogers particularly)

17. 7. Early learned behaviors return when verbal ability and recent memory fails: Example:-movement of tongue, teeth and lips create new word combinations – it is often an expression of basic human needs; an old woman sucks on her fingers to feel safe and pleasure (like she felt as a baby) and it is self-stimulating – she is alive. - early learned movement can replace speech when verbal ability fails. A woman moans: HEALVEN.  She tells the worker she needs help from heaven.  Her mother is in heaven. She combines images and sounds to form, HEALVEN. The worker asks, “You really miss your mother. Was she always with you when you needed help?”

18. V/W action: We calibrate the breathing, movements, gestures, body tension, mirror movements and sounds. That allows us to get onto the same wavelength as the old person and meet them where they are in that moment, even if we can’t explain their behavior logically. Theory: Piaget’s theory: movement comes before speech in human cognitive development.

19. 8. Personal symbols used by maloriented or disoriented elderly are people or things (in present time) that represent people, things or concepts from the past that are laden with emotion. Example: Person: An old man who has been oppressed by his father, accuses the administrator of tying him up at night; a doll is treated like a baby. Concept: A wedding ring can represent love, a handbag, the identity or self. Object: An institutional hall can become a street, a wheelchair can become an auto, an old man who used to be a car mechanic gets under his bed everyday to repair a car.

20. V/W action: we accept that symbols are used to express needs and feelings; we try to explore and react with empathy. Theory: Freud and Jung wrote extensively about symbols, describing them as representations.

21. Piece of Jewelry or Clothing Shoe Handbag or purse Cane a Hand or finger a Cloth Arm of a wheelchair Open space, the hallway Rocking movements Self-worth, Identity, work Container, male or female sex organ Identity, femininity, work Identity, male power a Baby, Father, Mother, feet to walk, children Important papers, children’s clothes, bread dough a Street, the Neighborhood, Safety, pleasure, Mother Symbols often used by disoriented old-old

22. 9. Maloriented and disoriented old people live on several levels of awareness, often at the same time. Example: An old woman runs out of the nursing home calling, ‘mama’; she needs to find her mother. When asked, ‘Where is your mother?’ the old woman says, "My mother is with the dear Lord." V/W action: we never lie to older people because we know that on some level they know what is the truth. Theory: Freud, preconscious, conscious and unconscious

23. 10. When the 5 senses fail, maloriented and disoriented elderly stimulate and use their ‘inner senses’. They see with their ‘mind’s eye’ and hear sounds from the past. Example: A mother hears her children calling her – she wants to be a good mother to her children. The validating caregiver asks, “How many children do you have?” Example: An old mother hears her daughter crying next door. This happens every night. Her 17 year old daughter died and the mother never had enough time to grieve. She wants to express her guilt. The caregiver asks, “What do you miss the most?”

24. V/W action: when older people see or hear things that we do not, we accept those as being part of their personal reality and understand that they are trying to meet their human needs. Theory: Wilder Penfield: Human beings can stimulate their brains to recreate vivid visual, auditory and kinesthetic memories.

25. 11. Events, emotions, colors, sounds, smells, tastes and images create emotions, which in turn trigger similar emotions experienced in the past. Old people react in present time, the same way they did in the past. Example: A woman hides behind the sofa scared to death each time the meal cart clatters onto the department. She feels the same fear she felt when tanks clattered through the streets of her hometown and bombed her home when she was 4 years old. The worker asks, “Did something terrible happen?”

26. V/W action: we accept and acknowledge that experiences from the past can be triggered and explore the feelings without judgment and with empathy. Theory: Early, well-established emotional memories survive to very old age. Schettler & Boyd. Proust Was a Neuroscientist, by Jonah Lehrer, 2007, published by Houghton Mifflin Co., NY

27. Loss of family members through accidents Loss of a loved pet Loss of ones home Loss of a job/work Loss of the partner, of sexuality, Starvation Prison experience, forced labor Combat experiences, escape/ war Loss of an organ or body part Abandonment, solitary confinement Quarantine for infectious illness Loss of job/usefulness through deficits Ignored by parents, children, authority figures Rape cruel children’s pranks Problems or fights with siblings Lost friendships Extortion or blackmail Loss of social-economic situation Placed in an environment with ‘crazy people’ Catastrophe (ex: flood, hurricane, fire, earthquake) Legal battle ( fear of loosing everything) Threatening illness, pain and death Brute force (ex: child abuse) Religious delusions (ex: brainwashing by sect) Possible unresolved Life Events

28. Normal Aging • Short term memory loss • Cells regenerate much slower • Muscles lose elasticity • Friends and loved ones die (increasing isolation) • Physical and medical problems increase • Senses (sight, hearing, smell, taste, touch) decrease • Social roles, job or feeling of purpose decreases • Often mobility is more limited (increasing isolation) • Increasing desire to review one’s life and find peace

29. Gerotrancendence Going beyond everyday activities: Engaged in more metaphysical andphilosophical issues Old-old Age Normal Aging Coping well with happy and sad moments Old Age Adult Young Adult Adolescence School Age Play Age Early Childhood Infancy Understanding people who respond best to Validation Erik Erikson’s Life Stages and Tasks + • Losses • No coping skills to handle losses Integrity Generativity Intimacy Identity Industry Initiative Autonomy Trust Dispair Stagnation Isolation Identity Confusion Inferiority Guilt Shame Mistrust

30. Understanding people who respond best to Validation Losses that come with aging Physical: Short-term memory Eyesight Hearing Circulation Illnesses increase Often ability to walk is reduced Social/psychological: Death of loved ones, friends Isolation Loss of job or role in life Lack of status respect No one listens Lack of sensory stimulation • Losses • No coping skills to handle losses

31. Despair Stagnation Isolation Identity Confusion Inferiority Guilt Shame Mistrust Understanding people who respond best to Validation Losses No coping skills to handle losses Feil’s Resolution Stage of Life Task: to die in peace + 4 Phases of Resolution Malorientation withdrawal Time Confusion withdrawal Repetitive Motion withdrawal Vegetation Disorientation

32. Understanding people who respond best to Validation There is a reason behind the behavior of the maloriented and disoriented: Feil’s Resolution Stage of Life Task: to die in peace Retreat... ...from the present which is painful, not stimulating or does not meet their needs Relieve... ...pain, boredom, unhappiness Resolve... ...traumatic events or life tasks Relive... ... positive or negative moments from the past Express unfulfilled needs... 4 Phases of Resolution Malorientation withdrawal Time Confusion withdrawal Repetitive Motion withdrawal Vegetation

33. Understanding people who respond best to Validation Basic Human Needs: To reduce pain and discomfort To have sensory stimulation To be nurtured, feel safe and secure To belong, to be loved To express emotions and be heard To be listened to and respected To be useful To be recognized, status, identity and self-worth To restore a sense of equilibrium To live in peace To die in peace Retreat... ...from the present which is painful, not stimulating or does not meet their needs Relieve... ...pain, boredom, unhappiness Resolve... ...traumatic events or life tasks Relive... ... positive or negative moments from the past Express unfulfilled needs...

34. Early onset Alzheimer Patient: Progressively deteriorates no matter what method is used  Can show symptoms of disorientation at a very young age (40, 50, 60)  Displays unexpected behavior, can hit without reason  Moves without purpose, mechanically, robot-like  Does not withdraw to the past in order to resolve unfinished issues  Eyes are often empty and show no signs of recognition  Loss of speech can often occur quickly  Disorientation stems from a biological disease A Disoriented Very Old Person:  Can improve, does not necessary deteriorate in orientation  Shows signs of disorientation at +/- 80 years  Behavior is predictable once you know the individual  Retreats to the past in order to resolve unfinished issues  Disorientation comes from physical, psychological and social losses The difference between a person with Alzheimer’s disease and a disoriented very old person

35. The Validation Process Accompany the client in the resolution of unfinished issues. Support feelings of self worth  An empathetic relationship allows the expression of feelings. Clients are motivated to increase verbal and non-verbal communication.  Create trust. Do not judge. Explore the personal reality of the disoriented elderly.  Create security and offer structure. Maintain integrity. Reduce physical and chemical restraints.

36. Increase verbal and non-verbal communication Increase alertness (eyes open, sit more erect) Improve ability to move and physical well-being Give joy and energy to caregivers Reduce stress to caregivers and disoriented elderly Validation goals – in the short term

37. Validation goals – in the long term Increase a sense of self-worth Support the process of resolving unfinished conflicts from the past Prevent withdrawal to vegetation Eventually, decrease anxiety, anger Increase social controls Decrease the use of chemical and physical restraints Increase feelings of well-being Maintain older people in their own homes Help families communicate with disoriented and maloriented relatives

38. “Goals” of the Client Retreat... ...from the present which is painful, not stimulating or does not meet their needs Relieve... ...pain, boredom, unhappiness Resolve... ...traumatic events or life tasks Relive... ... positive or negative moments from the past Express unfulfilled needs...

39. Four Phases of Resolution • Malorientation • Time confusion • Repetitive motion • Vegetation

40. Physical characteristics Eyes are clear and focused Stance, body and muscles are often tense or rigid Movement in space is definite, sustained, precise Face is often tense, jaw jutting out Voice tone is often harsh, whining or shrill Senses are relatively intact (sight, hearing, smelling, tasting and touch Needs a respectful distance (normal social distance) Malorientation

41. Malorientation Psychological characteristics Cognitive ability is relatively intact, can categorize, have a concept of time Hold onto present reality Want to understand and be understood Can play games with rules Is aware of occasional confusion Often denies confusion or confabulates (makes up stories to fill in memory gaps) Resists change Denies feelings Blames others Can not achieve insight in the reasons behind their behavior

42. Techniques for Phase Oneverbal Validation techniques • Center yourself • Observe the person • Use "who, what, where, when, how" questions • Rephrase using the key words • Use the preferred sense • Use polarity - ask the extreme • Imagine the opposite • Reminiscing, explore the past • Find a familiar coping mechanism

43. Preferred sense • Word choices • Eye cues • Breathing • Tone of voice

44. Preferred sense – word choices Auditory: loud / soft ringing ask / speak say sing tone hum noise snore banging drumming quiet scratchy Kinesthetic: Feel Warm/cold Soft/hard Pressure Touch sensitive Excited, tense Smooth/rough Dry/wet, damp Visual: See Dark Light View Light Cloudy, misty Clear Red, blue, green, etc. Bright Blind Glittering Stare

45. Guidelines for videos In principle you can use any sort of camera. In order to play the tape in class, be sure that the format is VHS otherwise, bring an adaptor or the camera with necessary cables. The Worker and Client should be clearly visible and audible. We need to see both faces and the upper bodies so that the use of verbal and non-verbal techniques can be seen and heard. Shooting from a profile angle is usually the best. The length of the video is dependent on the length of the Validation session. Do not make it longer or shorter only for the video.

46. For testing purposes, please tape 2 sessions with 2 different clients. Make sure that there are good demonstrations of both verbal and non-verbal techniques. Do not edit the video. Start taping at the beginning of the session and stop after you have ended the session.

47. Time Confusion Physical Characteristics Body and muscles are often loose. Graceful movements Eyes are often unfocused, gazing into the distance Movement in space is often slow, indirect and often questioning Speech can be slow Increased deterioration to the senses

48. Time Confusion Psychological characteristics Reality is blurred, time, place and persons are confused Express emotions freely; lose social controls Metaphoric thinking is lost, can no longer categorize Have an intuitive knowing Long-term memory is strong and short term memory is lost Use unique word combinations that express needs and feelings Cannot play games with rules Have a short attention span

49. Techniques for Phase TwoNon-verbal Validation Techniques Use touch Genuine, direct eye contact, clear, low, warm, loving voice tone Observe the emotion, match their emotion Express their emotion - with emotion Use ambiguity Link the behavior to the need Use music and movement

50. Preferred sense – eye cues visual auditory kinesthetic