When I first started working in dementia care, I learned the same things that everyone else learns. I learned about Teepa Snow’s philosophy of redirection and distraction, as part of her Positive Approach to Care technique. I also learned about Naomi’s Feil’s validation technique. I learned that lying wasn’t allowed, but that you could dance around someone’s reality by saying things like “Sounds like you miss your mom,” or “Tell me how you feel about that.”
Validation Doesn’t Always Work
Early in my career, a patient of mine was asking about her husband. “Where is my husband? He was supposed to pick me up an hour ago!” she cried. Using what I’d learned, I sat down with her and began to engage.
“Sounds like you miss your husband,” I offered.
She looked me dead in the eye, and said, “Yeah, and I want to know where he is. Why does no one actually tell me anything around here?”
This shocked me. But, I did what I’d learned: I validated her feelings and asked her how she felt. I realized, though, that I had not answered her question. I’d just redirected her. I validated her world, but I didn’t go to that world with her.
When Distraction Fails
In another example, I spent two hours trying to get a very irritated resident off a bus. The bus had taken Eileen to the doctor’s office. This had not been a particularly enjoyable ride, and by the time she got back to the community, she was not in a good mood.
We tried everything but could not get this woman off the bus. I tried to redirect her. I tried to distract her. I tried to chat with her about where she’d been and even tried to explain that the bus was not going to be able to take her to her house, which is where she wanted it to go.
Finally, I asked the bus driver to drive us around for a little bit. He ended up taking us to the back of the building a few minutes later, and I told her that we had to get off, so that we could transfer to another bus to eventually take her home. Hearing this, Eileen got off the bus. We went inside.
My staff was thrilled that she was safely inside the building, but I was completely exhausted. I was also confused: Had I done this whole thing the wrong way?
New Ways to Communicate
This was when I started developing a theory around embracing the reality of the patient.
Embracing someone’s reality is not the same thing as simply saying, “Sounds like you miss your mom.” When you say, “sounds like,” you’re not embracing their reality, you’re just validating what they said because you’re afraid to lie. You’re not going there with them and you’re not being helpful. This is where it really starts to get challenging. What does it mean to lie or not lie to someone? This is exactly where the beauty of this concept lies. Simply telling families and care staff never to lie to people with dementia is too confusing.
Dementia care is full of gray areas, and telling people to “always do this, not this, but sometimes this” just doesn’t work. And if providers were really sticking to the concept of not lying, they would never introduce baby dolls and stuffed animals, because that involves telling your clients that they are real when their caregivers see them as not-real.
‘Yes, And’
I’m all about the tangible. I want you to be able to apply this concept and feel good about it. I want you to succeed in your journey to positive dementia care.
When you embrace someone’s reality, you understand that their reality has shifted, and you must shift with it. Here’s my favorite (and very true) example:
I had a client whose son had died a few years earlier. This was obviously devastating. The good news is that she had forgotten that he died.
One day, she came to my office. “Hey hon,” she said. “Do you know where my son is? He hasn’t called in a while.”
I paused and considered this. “Where do you think he could be?” I asked.
“Well, I guess he must be busy with work,” she replied.
“That makes sense, he’s probably at work,” I nodded.
“Can I call him?” she asked.
“Sure,” I said, and picked up my work phone. I dialed my own cellphone number and let it go to voicemail. As soon as it did, I handed her the phone. “Here, you can leave him a message,” I said. She left her son a voicemail on my phone.
“Thanks, hon, I feel a lot better,” she said. And it never came up again.
Notice what I did here: I asked her where her reality was. I let her answer, and then I agreed with, and added on to, her answer. When we take the time to listen and to ask where someone’s reality is, we don’t need to make anything up or get creative, and, most of all, we’re doing what’s true for them. This isn’t what a lie is.
Even when someone is hallucinating, you can help them resolve their reality.
In an encounter I had with one of my clients, she believed the building was on fire, so I pulled up a fire truck sound on my phone and played it. She calmed down immediately.
Was it lying to indicate that a fire truck was coming to save us from a nonexistent fire? Other professionals in the dementia care world will say that you can tell a “therapeutic lie” or a “fiblet,” but you can’t actually lie.
That’s pretty confusing, and I think that many professionals are underestimating how intelligent their audience actually is.
Embrace Their Reality
Below, I lay out some of the methods I use to embrace the reality of people living with dementia:
- Throw out the word “lying.” Getting hung up on this word will only stress out you and other caregivers. You’re not lying when you learn just where your client’s reality is and then go there with them.
- Caregivers are living in their patients’ reality. Just because it’s not true for you, doesn’t mean it’s not true for your clients.
- When someone asks you a direct question, find out what they believe the answer is, and then do that.
- You don’t need to get creative and make something up, but you do need to be able to say “yes, and” to your clients with dementia. Agree and then add on.
- Using phrases like “therapeutic lying” or “white lies” or “fiblets” only confuses caregivers further. No one wants to feel like they’re lying.
There’s more to dementia care than just “redirect, distract, validate.” And I think we can all learn to embrace the client’s reality—and make everyone’s caregiving a lot easier in the process.
