Effective Interventions with Dementia and Difficult Behaviors

In this section, we will discuss reality verses validation or non-reality based communication. Understanding the five tenets and six domains of validation is an integral part of implementing this approach.

The five tenets of validation are make the physical environment work, know that communication is possible, focus only on remaining skills, live in the patient’s world, and enrich the patient’s life. The six domains of the validation represent the physical or mental locations in which the five tenets can be implemented. The six domains of validation are the physical, functional, social, communication, sensory, and emotional domains.

As you listen to this section, consider how to help a caregiver of an aging client implement validation or non reality based communication. Also, you might consider how to implement this approach during individual or group settings with clients with dementia to foster clear communication.

As you are aware, Validation is a humanistic approach to treating clients with dementia. Validation or non-reality based communication was developed specifically for use with an Alzheimer’s patient. Later, Coste improved on her method to develop a more versatile approach to treating aging clients with dementia. Sound useful?

Reality Orientation
The following case study regarding Marvin, age 91, illustrates reality orientation. Reality orientation is still commonly used today in nursing homes and in home care situations. Marvin, age 91, had Alzheimer’s disease and relied on his daughter, Sarah, for help. One morning, Marvin was asking for his mother. Sarah reminded Marvin that his mother had been dead for years.

Marvin stated, "Don’t be so fresh! You don’t know what you are talking about!" In order to implement what she thought was ‘appropriate care’ through reality orientation, Sarah tried to help Marvin remember his age and what year it was. As she guided him by the arm toward the calendar in the kitchen, Marvin stated, "No! I don’t want to go!" Sarah tightened her grip, angering and frustrating Marvin. Marvin swung at her. Sarah was shocked and deeply hurt by her father’s reaction. For the rest of the day, she didn’t go near Marvin.

Sarah’s care was based on the theory of reality orientation, in which she was taught to enforce a sense of the here and now. Because Marvin of the progression of Alzheimer’s Disease, it was becoming less possible for him to process the information his daughter was trying to communicate. Reality orientation is the antithesis or direct opposite of validation or non-reality based communication.

Coste states five tenets which make up validation or non-reality based communication. I like the term validation because rather than correcting a client when he or she makes a non reality statement like "I need to go to work," you validate their need and state, "Well, let’s eat breakfast first." As a client progresses into further states of dementia within one conversation the caregiver may need to bounce back and forth between reality based and non reality based communication.

5 Tenets of Validation
As I list the five tenets of validation or non reality based communication, consider how you might implement them with a client you are treating. Here are the five tenets of validation or non reality based communication as I explained to Marvin’s daughter, Sarah.

Make the physical environment work. Simplify Marvin’s environment. Accommodate his perceptual loss by eliminating distractions.
Know that communication remains possible. Remember that the emotions behind Marvin’s failing words is far more important than the words themselves and needs to be validated. Although many losses occur with dementia assume that Marvin can still register feelings that matter.
Focus only on remaining skills. Value what abilities remain. Help Marvin compensate for any lost abilities without bringing them to his attention.
Live in the client’s world. Never question, chastise, or try to reason with Marvin. Join Marvin in his or her current place or time.
Enrich the client’s life. Create moments for success. Eliminate possible moments of failure and praise frequently and with sincerity. Attempt to find humor wherever possible.
These five tenets of non-reality based communication require regular assessment, which, as we discussed in section 4, can lead to productive treatment. Compare what you have experienced in dealing with clients with dementia to both reality orientation and non reality based communication. How does your most effective approach differ? How is it similar?

For example, had Marvin’s daughter implemented validation, his experience could have differed greatly. When Marvin mentioned his desire to see his mother, Sarah could have simply asked Marvin what he liked about his mother. Perhaps Marvin would state, "She’s a great cook." By adhering to the five tenets of non reality based communication, the Sarah could have asked Marvin what he liked best about his mother’s cooking. Maybe Marvin liked her pies the best. Thinking of food may have made Marvin hungry. Sarah could have seated him with a cup of coffee and a slice of pie.

Marvin might stop thinking of his mother. As his memories fade, Marvin would be left with a reflection of the Sarah’s kindness. Clearly, aging clients with dementia such as Marvin tend to mirror the feelings of others. By implementing the five tenets of validation, caregivers can utilize mirroring to get productive results. Do you agree?

As you can tell, the validation requires less time and fewer headaches than traditional reality orientation. But how are the five tenets of non reality based communication implemented in other situations?

Coste explains how the five tenets may be implemented by relating them to the six domains of validation. The six domains of the validation represent the physical or mental locations in which the five tenets can be implemented.

Six Domains of Non-Reality Based Communication
The six domains of the validation are:
1. Physical
2. Functional
3. Social
4. Communication
5. Sensory
6. Emotional Domains

The client’s ability to perceive his or her environment relates to the physical domain. The functional domain concerns the level of care needed in relation to the level of care given. The emotional domain is related to the caregiver’s ability to influence the client’s emotions.

Do you agree that in most cases a caregiver can only influence behavior indirectly either by changing the client’s environment or adjusting their own attitudes?

Think of your Marvin who is advancing into Alzheimer’s induced non-reality. In what ways could your client benefit from validation? If validation or non reality communication is already being implemented with your client, have you found that the six domains are closely related and possibly co-dependent? Would it be beneficial to play this section for a care giver you is working with someone who has Alzheimer’s?

In this section, we have discussed validation or non reality based communication. Understanding the five tenets and six domains of validation is an integral part of implementing this approach. The five tenets of validation are make the physical environment work, know that communication is possible, focus only on remaining skills, live in the patient’s world, and enrich the patient’s life. The six domains of validation represent the physical or mental locations in which the five tenets can be implemented. The six domains of validation or non reality based communication are the physical, functional, social, communication, sensory, and emotional domains.
Reviewed 2023

Peer-Reviewed Journal Article References:
Batthyány, A., & Greyson, B. (2021). Spontaneous remission of dementia before death: Results from a study on paradoxical lucidity. Psychology of Consciousness: Theory, Research, and Practice, 8(1), 1–8.

De Lucia, N., Grossi, D., Milan, G., & Trojano, L. (2020). The closing-in phenomenon in constructional tasks in dementia and mild cognitive impairment. Neuropsychology, 34(2), 168–175.

Di Nuovo, S., De Beni, R., Borella, E., Marková, H., Laczó, J., & Vyhnálek, M. (2020). Cognitive impairment in old age: Is the shift from healthy to pathological aging responsive to prevention? European Psychologist, 25(3), 174–185. 

Kuemmel, A., Haberstroh, J., & Pantel, J. (2014). CODEM instrument: Developing a tool to assess communication behavior in dementia. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 27(1), 23–31.

McDowd, J., Hoffman, L., Rozek, E., Lyons, K. E., Pahwa, R., Burns, J., & Kemper, S. (2011). Understanding verbal fluency in healthy aging, Alzheimer's disease, and Parkinson's disease. Neuropsychology, 25(2), 210–225. 

Schall, A., Haberstroh, J., & Pantel, J. (2015). Time series analysis of individual music therapy in dementia: Effects on communication behavior and emotional well-being. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 28(3), 113–122. 

QUESTION 4
What are the six domains of validation? To select and enter your answer go to Test.