September 18, 2012

A valid approach to feelings

Elizabeth Newman, McKnight's Senior Editor

As a teenager, I took a self-defense class, where a piece of advice stuck with me: Women tend to have more strength in their legs than their arms. If you engage an attacker with your arms in a push-pull linear movement, the instructor said, you'll likely lose.

It strikes me that many conversations, especially with those experiencing dementia or confusion, can escalate in a similar manner and become a back-and-forth attack. Who hasn't overheard a conversation where a caregiver or family member was trying to rationalize that, no, the attendant didn't steal the jewelry, or the dry cleaner didn't destroy the blouse? While the resident might technically lose the fight, no one has really won.

That's why I was particularly interested in some of the techniques in the third edition of The Validation Breakthrough by Naomi Feil and Vicki de Klerk-Rubin, which arrived from Health Professions Press last week. One tip is rephrasing, where the person has to rephrase what the elderly person has said, in the same tone of voice and with the cadence of speech, only with empathy. But the one that really caught my eye was “using nonthreatening, factual words to build trust.”

In Feil's example, an 80-year-old woman is complaining that the housekeeper keeps stealing her jewelry. Instead of trying to argue with her, the daughter focuses on the who-what-where-when-how and asks: “Who is stealing the jewelry? What does she take?” When the mother says that she stole black earrings her husband gave her, the daughter responds, “When did he give them to you?” Soon they are reminiscing. The daughter redirected the attack.

Feil makes it clear, however, that caregivers should avoid “the therapeutic lie.” This can happen a lot with the best intentions — a resident asks, “When will my son come? Is my apartment all right?” not remembering that her son is dead or the apartment was long-sold. The caregiver responds with “Your son will be here soon,” or, “The apartment's fine.” But it comes up over and over again because, as Feil points out, at some level the elder knows the truth.

By asking, “What's your son's name? What did he like to do?” or asking where the apartment was and what the resident missed about it, the caregiver is validating the resident's feelings of loneliness.

Validating also can work with facilities working on reality orientation. Even small steps — having the CNA walk into a room and say, “Good afternoon, Mrs. Goldberg, today is Tuesday, Sept. 18, and you are in the Lakeside Nursing Center” — can allow the resident to feel more oriented.

If there's an overarching theme in the theory of validation, it's one of acceptance. It's the idea that caregivers, as busy as they are, can ask questions and engage in active listening. It's not entirely altruistic either — by using some of Feil's techniques, I suspect nurses may acquire additional techniques for approaching the MDS 3.0 resident assessment interview.

Have you used validation techniques in your facility? If not, do you think it would work? Those who leave a comment below will be eligible to receive a copy of The Validation Breakthrough and Patricia Osage's Connecting with Socially Isolated Seniors.