Martin Neal1, Philip Barton Wright. 1. Research and Development, Leeds Mental Health Trust, North Wing, St. Mary's House, St. Mary's Road, Leeds, UK, LS7 3JX.
Abstract
BACKGROUND: Validation therapy was developed by Naomi Feil between 1963 and 1980 for older people with cognitive impairments. Initially, this did not include those with organically-based dementia, but the approach has subsequently been applied in work with people who have a dementia diagnosis. Feil's own approach classifies individuals with cognitive impairment as having one of four stages in a continuum of dementia: these stages are Mal orientation, Time Confusion, Repetitive Motion and Vegetation. The therapy is based on the general principle of validation, the acceptance of the reality and personal truth of another's experience, and incorporates a range of specific techniques. Validation therapy has attracted a good deal of criticism from researchers who dispute the evidence for some of the beliefs and values of validation therapy, and the appropriateness of the techniques. Feil, however, argues strongly for the effectiveness of validation therapy. OBJECTIVES: To evaluate the effectiveness of validation therapy for people diagnosed as having dementia of any type, or cognitive impairment SEARCH STRATEGY: The trials were identified from the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG) on 8 January 2003 using the terms validation therapy, VTD and emotion-oriented care. The Specialized Register at that time contained records from the following databases: MEDLINE, EMBASE, CINAHL, PSYCLIT, and SIGLE and many trials databases. SELECTION CRITERIA: All randomized controlled trials (RCTs) examining validation therapy as an intervention for dementia were considered for inclusion in the review. The criteria for inclusion comprised systematic assessment of the quality of study design and the risk of bias. DATA COLLECTION AND ANALYSIS: Data were extracted independently by both reviewers. Authors were contacted for data not provided in the papers. Psychological scales measuring cognition, behaviour, emotional state and activities of daily living were examined. MAIN RESULTS: Three studies were identified that met the inclusion criteria (Peoples 1982; Robb 1986; Toseland 1997) incorporating data on a total of 116 patients (42 in experimental groups, and 74 in the control groups (usual care 43 and social contact 21, 10 in reality orientation). It was not possible to pool the data from the 3 included studies, either because of the different lengths of treatment or choice of different control treatments, or because the outcome measures were not comparable. Two significant results were found:Peoples 1982 - Validation versus usual care. Behaviour at 6 weeks [MD --5.97, 95% CI (-9.43 to -2.51) P=0.0007, completers analysis] favours validation therapy. Toseland 1997 - Validation versus social contact. Depression at 12 months (MOSES) [MD -4.01, 95% CI (-7.74 to - 0.28) P=0.04, completers analysis], favours validation. There were no statistically significant differences between validation and social contact or between validation and usual therapy. There were no assessments of carers. REVIEWER'S CONCLUSIONS: There is insufficient evidence from randomized trials to allow any conclusion about the efficacy of validation therapy for people with dementia or cognitive impairment.
BACKGROUND: Validation therapy was developed by Naomi Feil between 1963 and 1980 for older people with cognitive impairments. Initially, this did not include those with organically-based dementia, but the approach has subsequently been applied in work with people who have a dementia diagnosis. Feil's own approach classifies individuals with cognitive impairment as having one of four stages in a continuum of dementia: these stages are Mal orientation, Time Confusion, Repetitive Motion and Vegetation. The therapy is based on the general principle of validation, the acceptance of the reality and personal truth of another's experience, and incorporates a range of specific techniques. Validation therapy has attracted a good deal of criticism from researchers who dispute the evidence for some of the beliefs and values of validation therapy, and the appropriateness of the techniques. Feil, however, argues strongly for the effectiveness of validation therapy. OBJECTIVES: To evaluate the effectiveness of validation therapy for people diagnosed as having dementia of any type, or cognitive impairment SEARCH STRATEGY: The trials were identified from the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG) on 8 January 2003 using the terms validation therapy, VTD and emotion-oriented care. The Specialized Register at that time contained records from the following databases: MEDLINE, EMBASE, CINAHL, PSYCLIT, and SIGLE and many trials databases. SELECTION CRITERIA: All randomized controlled trials (RCTs) examining validation therapy as an intervention for dementia were considered for inclusion in the review. The criteria for inclusion comprised systematic assessment of the quality of study design and the risk of bias. DATA COLLECTION AND ANALYSIS: Data were extracted independently by both reviewers. Authors were contacted for data not provided in the papers. Psychological scales measuring cognition, behaviour, emotional state and activities of daily living were examined. MAIN RESULTS: Three studies were identified that met the inclusion criteria (Peoples 1982; Robb 1986; Toseland 1997) incorporating data on a total of 116 patients (42 in experimental groups, and 74 in the control groups (usual care 43 and social contact 21, 10 in reality orientation). It was not possible to pool the data from the 3 included studies, either because of the different lengths of treatment or choice of different control treatments, or because the outcome measures were not comparable. Two significant results were found:Peoples 1982 - Validation versus usual care. Behaviour at 6 weeks [MD --5.97, 95% CI (-9.43 to -2.51) P=0.0007, completers analysis] favours validation therapy. Toseland 1997 - Validation versus social contact. Depression at 12 months (MOSES) [MD -4.01, 95% CI (-7.74 to - 0.28) P=0.04, completers analysis], favours validation. There were no statistically significant differences between validation and social contact or between validation and usual therapy. There were no assessments of carers. REVIEWER'S CONCLUSIONS: There is insufficient evidence from randomized trials to allow any conclusion about the efficacy of validation therapy for people with dementia or cognitive impairment.
Authors: Clive G Ballard; Serge Gauthier; Jeffrey L Cummings; Henry Brodaty; George T Grossberg; Philippe Robert; Constantine G Lyketsos Journal: Nat Rev Neurol Date: 2009-05 Impact factor: 42.937