Julie Casey MSW, RSW

Wellness Care Farm

Nourishing Hearts

Animal-Assisted Validation Therapy with Dementia

What is Validation Therapy?

The Validation Method was created by Naomi Feil, an American gerontologist. This the description of Validation Therapy from the book  Validation Techniques for Dementia Care (2006), written by Vicki de Klerk-Rubin:

Validation is a method of communicating with and helping very old people with dementia in their final stages of life. The goal is not to make disorientated elderly better but rather to help caregivers to change themselves so that they can enter the personal reality of the person for whom they are caring. Through a caring, empathetic relationship, caregivers can reconnect or connect in a new way and give their disorientated relative more ease and pleasure.

When caregivers have an intimate conversation, shares a laugh or a tear, or finally understands behaviour that has seemed bizarre, it can be profoundly rewarding. Caregivers experience a feeling of relief when they do not need to fight or struggle to change their relative. Their self-respect increases as they feel more competent. The elderly benefit from less stress and from feeling accepted and valued for who they are now. Encouraged to communicate about issues that matter to them, they can keep connected instead of withdrawing further into themselves.

Validation does not require a lot of time, but it does ask a great deal from practitioners. To practice Validation, you must be honest with yourself, face your own feelings, be able to set those feelings aside for a short period of time, and be willing to deal openly with the feelings of the elderly person.



Validation brings relief to and honours the humanity of the elderly.




Principles of Validation


  • All people are valuable, including those who are disorientated
  • Disorientated old-old should be accepted as they are
  • There is a reason behind the behaviour of very old people
  • Very old disorientated people are in the final life stage: Resolution
  • When recent memory fails, older adults try to restore balance to their lives by retrieving earlier memories
  • When eyesight fails, older adults use the Mind’s Eye to see
  • When hearing goes, they listen to sounds from the past
  • People live on several levels awareness, often at the same time
  • When present reality becomes painful, some elderly people survive by retreating and stimulating memories of the past
  • Feelings experienced in the present can trigger memories of having felt similar in the past
  • 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
  • Listening with empathy builds trust, reduces anxiety, and restores dignity



Theoretical Foundation

Humanistic Psychology

  • Maslow’s hierarchy of needs
  • Erikson’s life task theory
  • Know your client as a unique individual
  • Accept your client without judgment
  • Client-centered approach on using empathy
  • Human beings struggle for balance/ homeostasis, and are motivated to heal themselves 


Psychoanalytical Psychology 

  • “The cat ignored becomes a tiger”
  • The brain is not the exclusive regulator of behavior in very old age. Behavior is a combination of physical, social and intra-psychic changes that happen during the life span. (Adrian Verwoerdt is the original source)
  • Preconscious, conscious and unconscious
  • Symbols, describing them as representations.


Piaget’s Theory

  • Movement comes before speech in human cognitive development.


Wilder Penfield

  • Human beings can stimulate their brains to recreate vivid visual, auditory and kinesthetic memories.


Basic Human Needs Underlying the Behaviour of the Maloriented or Disoriented 


  • 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.
  • 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.



Resolution: The Task of Life’s Final Phase

In this stage of life, people struggle to resolve unfinished “business” so that they can die in peace. It is a process, not an end point. The four phases of this process: malorientation, time confusion, repetitive motion and vegetation. The opposite of resolving is moving deeper and deeper inward, withdrawing from reality and the surroundings. It is not always progressive and people do not always go through all of the four phases. The four phases describe a process of retreating from the here and now, from the people around them, from what is going on, and from the environment. It is a survival mechanism that is connected to a deep need to resolve, retreat, relive, and relieve.

Malorientation
Expressing past conflicts in disguised forms

Time Confusion
No longer holding onto reality; retreating inward

Repetitive Motion
Movements replace words and are used to work through unresolved conflicts

Vegetation
Shuts out world completely and gives up trying to resolve living


Summary of Validation Techniques

Centre

  • Clear yourself of inner “noise”
  • Quiet your thoughts
  • Finding your inner strength and resourcefulness
  • First step towards empathy


Observe

  • Physical characteristics
  • Identify the state of being
  • Recognize feelings from nonverbal clues


Find the Appropriate Distance

  • Normal social distance is required until trust and an intimate relationship is built
  • Time confusion often requires more closeness to make contact
  • Touching is often needed for acknowledgement as being present
  • Touch is critical for making contact during the vegetation phase


Use Appropriate Verbal and Nonverbal Techniques

  • Ask open-ended questions
  • Rephrase what the person has just said, using their key words
  • Ask the extreme to find out the boundaries of what is going on
  • Explore the opposite to find out what would happen if the opposite were true
  • Finding a familiar coping mechanism
  • Use the preferred sense of sight, sound, smell, taste or touch



Evidence-Based Approach to Animal Assisted Validation Therapy with Dementia

Majic, Gutzmann, Heinz, Lang and Rapp (2013), reports non pharmacological strategies have been suggested for the treatment of behavioral and psychological symptoms of dementia. According to Nordgren and Engstrom (2013), non pharmacological treatments, as an alternative or complement to medications are needed; reporting there is a growing number of alternatives being recognized as non pharmacological interventions, including physical training, caregivers’ singing, music therapy and animal-assisted interventions. Animal assisted interventions are increasingly being implemented in LTC as a non pharmacological intervention, specifically to help ameliorate the symptoms of dementia.

During human-animal engagement, researchers have discovered the production of the human oxytocin hormone, which has widespread neurological, biological, emotional and social effects, including attachment, trust and social processing, while also decreasing anxiety, stress and aggression (Netherton & Schatte, 2011). By stimulating the parasympathetic nervous system, oxytocin calms  the fight-flight-freeze stress response, reducing the secretion of cortisol, aldosterone and adrenaline, while also increasing pain tolerance, lowering blood pressure, increasing vagal tone, decreasing inflammation, improving wound healing, facilitating learning, and lowering anxiety (Chandler, 2012).

Animal Assisted Therapy (AAT) is defined as a goal oriented, planned and structured therapeutic intervention delivered by health, education and human service professionals, with a focus to enhance physical, cognitive, behavioral and/or socio-emotional functioning (IAHAIO, 2014). According to Bernabei, Ronchi, Ferla, Moretti, Tonelli, Ferrari, Forlani and Atti (2013) seven of the ten AAT studies investigating the impact on the behavioural and psychological symptoms of dementia (BPSD), demonstrated positive results. Nordgren and Engstrom (2012), reported AAT can help to decrease agitated behaviors and increase social interaction among people with dementia; reporting the presence of a dog can reduce aggression and agitation, while also increasing the amount of smiles and laughter, along with significantly more social behaviors such as looks, leans, and touches. Hendy (1977) additionally reports, visits with pets increased both alertness and smiling in residents.  AAT participants are reported by Nordgren and Engstrom (2013), to be filled with joy and well-being and indicated AAT effects could be an effective method to promote quality of life for people living with dementia. Majic, Gutzmann, Heinz, Lang and Rapp’s (2013) research exploring the impact of AAT on agitation and depression symptoms of residents with dementia, found the therapy to enhance social behaviours; stating AAT was “a promising option for treating symptoms of agitation/aggression and depression in elderly demented nursing home residents” (p. 1058).  Richardson’s  (2003) pilot study tested the AAT intervention’s effect on agitated behaviours and social interactions of older adults with dementia; although the study was not randomized and the sample size was small, limiting the generalizability, the results are promising. Sellers (2005) evaluation of an AAT intervention for elders with dementia in LTC facilities also demonstrated a decrease in agitated behaviours during AAT interventions. Research is suggesting AAT interventions may be a viable non pharmacological intervention to decrease BPSD and appears to be a promising strategy to enhance social behaviours.

Animal Assisted Therapy to Improve Social Interactions

AAT has been identified to aid in the social interaction of the cognitively impaired, in the following ways: (a) reminiscences to stimulate long-term memory; (b) increased social interactions; (c) providing a stimulus for verbal responses; (d) sensory stimulation; and (e) providing a vehicle for nonverbal communication and emotional expression (Curtright & Turner, 2002). Due to the fact that so many individuals have fond memories of animals within their personal history, Curtright and Turner (2002) reports, the presence of animals within the environment may lead to accessing early life memories, which could potentially enhance communication by taking advantage of intact cognitive processes and automatic responses. AAT as a structured activity include socializing, feeding, petting and grooming the animal, while also discussing previously owned pets and animal experiences (Cherniack & Cherniack, 2014). Additionally, Cherniack and Cherniack (2014) note, research is indicating animal assisted therapy can have a positive effect on cognition and mood in cognitively impaired older persons and can improve their ability to socialize, leading to longer conversations and improved social interactions.

Motor, Multisensory and Reminiscent Stimulation Through Animal Assisted Therapy

According to Cruz, Marques, Barbosa, Figueiredo and Sousa (2011) with the progression of dementia, there is a lack of appropriate environmental, sensory and social stimulation which causes a simulation deprivation that leads to continued deterioration of motor and sensory skills. Motor stimulations are described as specific exercises to improve mobility and delay the decline of activities of daily living, and multisensory stimulation are described as activities that stimulate the senses without the need for higher cognition which helps to reduce behaviours and apathy while also increasing alertness and engagement (Cruz, et al., 2011). Casey (2016) suggests, AAT activities such as the petting, grooming and walking the therapy animal, provides meaningful and motivating movements, while also providing visual, olfactory, auditory and tactile stimulation through direct and indirect contact.

Reminiscence therapy, according to Kim, Cleary, Hopper, Bayles, Mahendra and Azuma (2006), is the process of recalling personal experiences from the past, and because with dementia there is a greater preservation of remote rather than recent memories, the act of reminiscing can improve function by “decreasing demands on impaired cognitive abilities and capitalize on the preserved ones” (p. 1). AAT provides stimulation of remote memories and an opportunity to share meaningful experiences with animals (Nordgren & Engstrom, 2013). Reminiscent therapy is a strength-based approach that builds on a residents preserved abilities rather than cognitive impairments. Woods et al. (2012) reports,  reminiscence is gaining importance in the care of people with dementia, due to its potential to draw on early remote memories which often remain intact for people with dementia. Studies on reminiscence therapy, is suggesting the therapy can help to improve cognition and mood in people with dementia, as well as having a positive effect on quality of life (O’Shea, Devane, Cooney, Casey, Jordan, Hunter, Murphy, Newell, Connolly & Murphy, 2014).

Animal Assisted Validation Family-Based Intervention as an Innovative Social Work Practice

AAT is increasingly being utilized in health care settings and is one of the innovative approaches to help reduce behavioural and psychological symptoms of dementia. When combined as an adjunct to family-based validation therapy interventions, AAT has the potential to improve the quality and success of family visits with residents living with dementia, while also helping with continuity, to maintain meaningful relationships. Seller (2005) explains, AAT is an effective intervention because the animal is an adjunct to therapy, as a focal point for the therapy session and the animal acts as a bonding agent; stating, “this promotes the relationship between the elder and therapist. The use of an animal as a creator of immediate intimacy may be based upon the animal’s ability to provide the attention that is the foundation of all social interactions” (p. 63). Piechniczek-Buczek, Riordan and Volicer (2007) states, care providers in LTC facilities, should make every effort possible to improve the quality of family visits for the residents with dementia. I propose AAT could be an adjunct to social work practices in LTC, creating an innovative approach to support both residents and families during visitations. Animal Assisted Validation Family-Based Therapy, could facilitate effective family visits with residents living with dementia, by providing an oxytocin surge to calm the parasympathetic nervous system; creating a calm and relaxing environment for structured family visit activities; that provide motor, multisensory and reminiscent therapy, that stimulates remote memories for meaningful conversations and interactions. During this facilitated visit, the social worker could address communication barriers in dementia, by role modelling effective validation techniques and communication strategies that are tailored to the resident’s cognitive abilities and needs as the disease progresses. The goal is to relax the resident while validating their reality and helping with their resolution of their life lived. The goal is also to help reduce the family’s anxiety by improving empathy and communication through the stimulate of memories that nourish connection; ultimately making the visit more pleasurable, and improving the overall perceived success of the visit. In the end, animal assisted validation family-based therapy could foster quality and frequent family visitation that improves the quality of life for both the family and resident, as they live with dementia.


References

Bernabei, V., De Ronchi, D., La Ferla, T., Moretti, F., Tonelli, L., Ferrari, B., Forlani, M.,  & Atti, A. R. (2013). Animal-assisted interventions for elderly patients affected by dementia or psychiatric disorders: A review. Journal of Psychiatric Research, 47(6), 762-773.

Chandler, C. K. (2005). Animal assisted therapy in counseling. New York: Routledge.

Cherniack, E. P., & Cherniack, A. R. (2014). The benefit of pets and animal-assisted therapy to the health of older individuals. Current Gerontology and Geriatrics Research, (2014), 1-9.

Cruz, J., Marques, A., Barbosa, A. L., Figueiredo, D., & Sousa, L. (2011). Effects of a motor and multisensory-based approach on residents with moderate-to-severe dementia. American Journal of Alzheimer's Disease and Other Dementias, 26(4), 282-289.

Curtright, A., & Turner, G. S. (2002). The influence of a stuffed and live animal on communication in a female with alzheimer's dementia. Journal of Medical Speech-Language Pathology, 10(1), 61-71.


De Klerk-Rubin, V., (2006). Validation Techniques for Dementia Care: The family guide to improving communication. Baltimore: Health Professional Press.


Feil, N., & Klerk-Rubin, V. d. (2012). The validation breakthrough: Simple techniques for communicating with people with alzheimer's and other dementias (3rd ed.). Baltimore: Health Professions Press.

Hendy, HM. (1987). Effects of pet and/or people visits on nursing home residents. International Aging and Human Development.  25, 279-291.

International Association of Human-Animal Interaction Organizations (IAHAIO). (2014). Definitions for animal assisted Intervention and guidelines for wellness of animals involved. Retrieved from http://iahaio.org/new/fileuploads/4163IAHAIO%20WHITE%20PAPER-%20FINAL%20-%20NOV%2024-2014.pdf

Kim, E. S., Cleary, S.J., Hopper, T., Bayles, K. A., Mahendra, N., Azuma, T., & Rackley, A. (2006). Evidence-based practice recommendations for working with individuals with dementia: Group reminiscence therapy. Journal of Medical Speech-Language Pathology, 14(3), xxiii-xxxiv.

Majić, T., Gutzmann, H., Heinz, A., Lang, U. E., & Rapp, M. A. (2013). Animal-assisted therapy and agitation and depression in nursing home residents with dementia: A matched case-control trial. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 21(11), 1052-1059.

Netherton, E., & Schatte, D. (2011). Potential for oxytocin use in children and adolescents with mental illness. Human Psychopharmacology: Clinical and Experimental, 26(4-5), 271-281.

Nordgren, L., Engström, G., Medicinska och farmaceutiska vetenskapsområdet, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Uppsala universitet, & Centrum för klinisk forskning i Sörmland (CKFD). (2014). Animal-assisted intervention in dementia: Effects on quality of life. Clinical Nursing Research, 23(1), 7.

Nordgren, L., Engström, G., Mälardalens högskola, & Akademin för hälsa, vård och välfärd. (2012). Effects of animal-assisted therapy on behavioral and/or psychological symptoms in dementia: A case report. American Journal of Alzheimer's Disease & Other Dementias, 27(8), 625-632.

O'Shea, E., Devane, D., Cooney, A., Casey, D., Jordan, F., Hunter, A., Murphy, E., Newell, J., Connolly, S., & Murphy, K. (2014). The impact of reminiscence on the quality of life of residents with dementia in long-stay care: Reminiscence and dementia. International Journal of Geriatric Psychiatry, 29(10), 1062-1070.

Piechniczek-Buczek, J., Riordan, M. E., & Volicer, L. (2007). Family member perception of quality of their visits with relatives with dementia: A pilot study. Journal of the American Medical Directors Association, 8(3), 166-172.

Richeson, N. E. (2003). Effects of animal-assisted therapy on agitated behaviors and social interactions of older adults with dementia. American journal of Alzheimer's disease and other dementias, 18(6), 353-358.

Sellers, D. M. (2006). The evaluation of an animal assisted therapy intervention for elders with dementia in Long-term care. Activities, Adaptation & Aging, 30(1), 61-77.

Woods, R. T., Bruce, E., Edwards, R. T., Elvish, R., Hoare, Z., Hounsome, B., Keady, J.,  Moniz-Cook, E., Orgeta, V., Orrell, M., Rees, J., and Russell, I. (2012). REMCARE: reminiscence groups for people with dementia and their family caregivers–effectiveness and cost-effectiveness pragmatic multicentre randomised trial.

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