Therapy for the Disoriented

“Help! I have to go home. Get me out of here!” yelled John. …“I have to go see my husband,” screamed Mary, whose husband has been dead 12 years. …“I want to go home! I have to feed my children,” cried Esther.

Such outbursts are common among the disoriented aged. People having difficulty distinguishing reality from fantasy are not mindless or demented. There is a reason for all behavior, no matter how bizarre. However, such cries are difficult for caregivers who want to help the disoriented. The purpose of the Feil Method is to help caregivers relate to the person trapped in fantasy. According to the proponents of this approach, caregivers can help the confused gain a sense of well-being in a relationship of trust.

The Feil approach: Validation/Fantasy (VF) Therapy

Naomi Feil began helping the disoriented elderly in 1963 at the Montefiore Home for the Aged in Cleveland, Ohio. Her initial goals were to help people face reality and to relate to each other. She soon found that helping people face reality was unrealistic because they withdrew and became more irritable. Thus, she abandoned her goal of reality orientation in 1965.

In the years that followed, she discovered the disoriented would respond to those who supported or validated their feelings. In an atmosphere of trust, and using techniques that explored their fantasies—rather than reality, Feil observed that tensions were relieved and feelings were openly expressed. After a 5-year study completed in 1973, she found other changes in behavior; people were less incontinent, improved in speech, were less negative (cried, pounded and hit less), were more positive (smiled, talked, helped others more), became more aware of external reality, and showed greater contentment. Her approach which has become known as validation/fantasy therapy or the Feil Method is summarized in this publication.

Fantasizing – Coping by Retreating From Life

Denial is the common lifetime defense against stress. The disoriented choose what to remember and what to forget. They forget painful experiences, names of people and things with little emotional meaning. They remember pleasant people or things.

When people of any age face great stress, it is natural for them to retreat from life to a degree. The disoriented elderly are not so different because they use fantasy to retreat from the stress of threatening and intolerable life situations. Trapped in a geriatric chair, nursing home or lonely apartment, having suffered loss after loss after loss, they seek to relive the past to restore dignity and integrity. They also fantasize about pleasant memories of early childhood.

Emotions and feelings from early years—rather than intellectual thinking—greatly determine the behavior of disoriented people. Infants and young children select impressions from among what they see, hear and feel. These impressions, feelings and emotions are repeated and reinforced. They become permanently recorded and are embedded in the pathways or circuits of the right hemisphere of the brain. As children grow, the left hemisphere of the brain becomes the place where recent memory and logical thought occur. Later in life, if recent memory fails, early learned memory returns and is vivid. As intellectual capacity weakens, feelings and emotions become dominant and remain longer than logical thought.

Flexible lifestyle and healthy aging. Each stage of life requires different tasks, and when these have been accomplished successfully, people find satisfaction and can proceed to tasks of the next stage.

For example, children who learn to trust their environments can become independent quicker than those who do not trust. Avoiding tasks in successive stages results in dissatisfaction, frustration and difficulty in meeting later tasks. Continuous patterns of avoidance are signs of inflexibility and lead to disorientation in old age. Because inflexible people do not generate new activity, they retreat from reality and in fantasy recreate the old job or reincarnate the loved one who was lost.

Flexible lifestyles can prevent disorientation, claims Feil. Flexible people can compromise, face small losses and find alternate routes when chosen ways no longer work.

For example, the middle-aged person who can roll with the punches can switch jobs when stricken with cataracts, deafness or arthritis. Flexible persons express genuine feelings when they suffer losses, change life goals, reorganize and move on. By meeting tasks in each stage of life, solving problems, and resolving conflicts as they arise, people can stay flexible and oriented.

The disoriented are aware that society does not reward fantasy, so they retreat to find their own rewards and goals.

The Goals of the Disoriented Elderly

Typical Goals of the Disoriented Elderly

• face present reality
• be productive
• communicate clearly
• figure things out
• accept minor frustrations without loss of control
• accept social roles
• make clear decisions
• think

Goals of the elderly disoriented include:

• resolving business from the past
• tying up loose ends
• expressing emotions that have been repressed
• reliving past roles to regain dignity
• avoiding feeling useless
• restimulating past pleasures in words, body movement, melodies
• retreating from pain through fantasy

Goals of the Feil Method

Validation/fantasy therapy enables caregivers to help the disoriented reach their goals before death, rather than insisting they conform to middle-age goals. The satisfaction of the disoriented increases when caregivers understand and validate feelings—whether based on fantasy, reality or a combination.

The goals of the Feil Method are to:

• help the disoriented old regain dignity, self-worth and identity
• reduce their stress
• help them resolve life’s unfinished business before death
• help them justify life

…Each stage of life requires different task…

Feil’s Four Realms of Feeling and Thinking

When someone loses the rational thinking centers through brain damage, functioning continues by employing the emotional realms. Feil believes these realms reside in everyone, but that energy is concentrated on different realms at different times. Understanding these realms of feeling and thinking explains the motivation of the disoriented.

1. Universal feelings are rooted in all of us from birth—love, hate, fear of separation, the struggle for identity. Through universal feelings, the disoriented can sense who truly cares about them. They know from a touch, a tone of voice, a look in the eye. This intuitive wisdom comes without effort or reasoning.

   Caregivers can share these universal feelings with the disoriented by tapping their own universal feelings. With empathy they can understand an older person’s cries as “They always want attention.”

2. Personal repressed feelings are buried instincts of shame, guilt and rage at parents and others who implanted bad feelings for bad behavior. These instincts are often buried as long as there are adult controls, but they may explode into bizarre behavior when brain control centers are damaged.

   For example, an old man may drop his pants to prove he is still potent or to express aggression at parent figures (relatives or staff members of a nursing home) or maybe to gratify sexual needs repressed in youth. His need is to resolve unfinished, once-buried business of life.

   Instead of expecting the confused person to think rationally, consider the repressed feelings and then relate to feelings which can help the disoriented resolve the disturbing business of the past. Remember that these aged are out of touch with reality, including present time (clock time). To them time moves when one feeling triggers another feeling. This is called “feeling time.” In other words, the past can become the present. They may slip from past to present and back again, unable to tell which is which.

   For example, a daughter’s facial expression or voice can trigger the sudden memory of an angry mother. The daughter, at that moment, becomes the angry mother to the disoriented person. On the other hand, empathy and one caring look can trigger feelings of comfort that were felt 50 years ago. Feil urges caregivers to relate in feeling time rather than clock time.

3. Sensory feelings are expressed through repeated body movements and sounds (sucking, humming, tapping, rocking). These expressions come from early personal memories when as children they learned through the five senses. Now, the memories may be triggered by certain physical movements. The body moves, then the mind remembers satisfying sensations.

   For example, an old woman rocks back and forth, murmuring “ma, ma, ma,” remembering the mother who rocked. Another old woman moves to regain lost dignity. She folds a paper towel instead of stuffing an envelope. The folding motion substitutes for her lost job as a secretary.

   To these two women, all time becomes feeling time as day and night overlap. Sounds and movement help when there is no one to do anything for any more, nothing to do, no place to go.

4. Rational thinking begins in late childhood as reason develops. The ability to think things through, to weigh alternatives, to compare and classify things, and to judge the goals of rational thinking. The rational thinker tries to remain logical at all times and does not want to wander off into feeling time.

   For example, by rational thinking standards, a napkin is made to wipe and remains a napkin. Anyone using a napkin to represent a baby is demented. Thus, anyone who retreats to inner feelings rather than rational thinking is labeled senile—demented.

   Rational and controlled behaviors go first in old age. The disoriented aged have no reason to think reasonable. They get no rewards for producing anything and have little energy for rational thinking.

Caregivers who cannot lay aside their logical thinking about rules and expectations for adult behavior will be unable to build genuine, trusting relationships with the disoriented. Sadly, some caregivers judge, patronize, baby or “parent” the aged with what they “should or should not” do. Such caretakers also get embarrassed or laugh at bizarre behavior. If they play along, seeming to understand, the discerning aged cannot trust the person because they feel the insincerity. Such caretakers judge when they ridicule the disoriented old man who drops his pants to show he is still a man. Caregivers using the VF approach understand this man’s desperate need for identity as a potent man. They know that the old act out their feelings when they lose the use of words.

Stages of Disorientation

Naomi Feil has identified four stages of disorientation. Characteristics of each are on the chart below.

When caregivers recognize the characteristics in each stage they can more easily determine ways of relating to the disoriented. Help is given as follows:

• Stage 1 – Reality orientation, if not done in a patronizing way, can help those in this stage of mild confusion.
• Stage 2 – Persons in time confusion will retreat further inward to the next stage of disorientation when they are urged to face reality, tranquilized or restrained or if no effort is made to understand their fantasies. Validate and respect their feelings! This keeps them in the second stage with many moments of rational thinking.
• Stage 3 – Use of reality orientation with those in perpetual motion is frustrating and creates more withdrawal inward. Persons in perpetual motion need empathy, in this more than other stages, to prevent movement to the final stage.
• Stage 4 – Prevention of vegetation is important because so little can be done once the aged reach this stage. Even so, vegetation people still need touch, recognition and nurturing from another human being. Use of VF therapy, in earlier stages, may prevent movement to the final stage.

Feil’s Stages of Disorientation

	Stage 1 Mild Confusion	Stage 2 Time Confusion	Stage 3 Perpetual Motion	Stage 4 Vegetation
Dominant Realms	Rational thinking is primary.	Universal feelings, repressed feelings and childhood memories are more dominant than rational thinking.	Universal feelings of love, hate, and fear of separation drive person to constant motion. Childhood memories and repressed instincts surface sometimes.	Need for touch and basic nurturing.
Self-Awareness	Is aware of self and of confusion, yet denies it; is threatened by confusion of self and others.	Loses some self-awareness.	Increasing damage to sensory cells decreases sense of identity; person loses awareness of self; moving reassures existence.
Memory, Intellectual Capability	Substitutes or makes up excuses for memory loss; can read.	Excellent memory for past events having emotional meaning; remembers voice tones, movements and feelings from the present more than facts, names, places. Nurturing touches trigger responses; cannot distinguish differences or similarities (a hand that feels soft like a baby, becomes a baby).	Increasing damage to recent memory circuits; remembers early life and events; loses desire and ability to think; can no longer read or write.	Will not recognize family or staff who visit daily.
Adult Control	Holds rigidly to familiar patterns of behavior; resists change; shuts off feelings with strict obedience to rules; holds self together to keep in control.	May lose adult controls; sometimes demands immediate satisfaction of instincts (food, attention, love, sex).	Repressed instincts surface through body movements, repetitive sounds, fantasies and symbols.	No longer cares what people think and withdraws.
Time and Place	Holds onto reality; wants reminders of present time and place in a nonpatronizing way.	Loses track of time; past time becomes present time; travels in feeling time instead of clock time; often does not know he moves in past time.	Fantasizes and looks for yesterday.	No longer talks to people.
Capacity for Relationships	Blames others when feelings are threatened; accuses others of stealing or hurting to ward off fears of aging; identifies often with staff or authority, but “puts down” others.	Heightened sensitivity to feelings; can respond on a genuine gut-level; eye contact triggers recognition; when supported in a trusting, respectful way, capable of tapping rational thinking, adult control, or relating to others in present time with speech.	Is resigned to isolation and self-stimulation.	Struggles alone and shuts off the outside world.
Speech and Symbols	Usually carries a cane, blanket, purse, sweater or other object to ward off loneliness; voice harsh, accusing or whiny.	Feelings are expressed through movement and symbol; person thinks and communicates in vivid images, repetitious sounds, rhymes, melodies and movements as well as with words. Objects and people in the present become part of the past; voice tone is low, seldom harsh or whiny.	No longer motivated to communicate; little or no use of commonly understood words or sentences; speech is gone with disuse; repeats sounds, phrases, moans; uses body parts to represent people (example: a hand can become a baby; uses objects to stimulate self for survival; can retain some speech with a loving relationship; voice is low, steady, even and melodic.	Gives up word sounds; no longer acts with symbolism.
Personal Care	Can dress, toilet and control self most of the time.	No longer puts things in proper place according to use; has fewer physical complaints.	Is incontinent; can feed self.	Totally dependant.
Sensory	Retains at least hearing or seeing; eyes clear and bright.	Loss of at least one of these; eyesight and hearing.	Severe losses of two or more senses; shuts out stimuli from the outside world.	Eyes closed; will not respond to eye contact or touch unless stimulated repeatedly day after day.
Motion and Movement	Movement is quick, direct; wants to participate in activities; has high energy capacity, especially in the morning.	Movement is slow, sustained, indirect, questioning which way to go; moves well and gracefully in space or with walker; repeats sounds and movements to exercise lips, tongue and jaws.	Fingers and hands always pounding, beating, tapping, in definite rhythm, anguished touching and slapping of self; wailing, pacing restlessly; moves freely and gracefully when dancing and free of anxiety and panic; movements give sensory pleasure.	Moves slowly in halftime; moves a finger and strokes; gives up body movements; self-stimulation is minimal.
Decisions	Shuts out unwelcome feelings of loneliness, uselessness, fear; holds tightly to possessions.	Continues to withdraw, creating own rules of behavior.	Has long ago decided to retreat when needs remained unmet in second stage; expresses longings to return to womb...to early childhood sensory experiences; wants to leave the institution.	Gives up the struggle to resolve living; sleeps to ward off despair; no longer expresses unresolved business; vegetation happens when those in perpetual motion are left alone, drugged, restrained or reality oriented.
Music, Rhythm and Humor	Can sing. Retains sense of humor some of the time.	Loses ability to sing on key; voice pitch becomes distorted. Loss of sense of humor, voice distorted when laughing.	Can dance and sing with energy; responds to music. No longer has a sense of humor; will not play games.
Posture, Muscles	Stance rigid and unmoving; muscles tight; jaw often thrust forward to ward off possible attack.	Muscles loose, eyes often unfocused and downcast; facial muscles relaxed; breathing slow gestures and movements match feelings.	Head bent forward in wheel chair, often leaning on chest; eyes closed, body slumped; breathing is shallow, but beat is in steady rhythmic, even beat; ambidextrous when freeing self of restraints.	Face often without expressions; sits in geriatric chair or is in bed with little movement to vegetate until death, often many years.

Stimulate energy. Listen with energy, giving full attention. Transmit energy through a touch or nearness. Such tactile senses release power, stimulating physical and mental activity. Use music and movement as enjoyable ways of stimulating energy.

Mirroring. Match the person’s body language to stimulate self-awareness. For example, if Mrs. May is unbuttoning her dress, demonstrate buttoning and unbuttoning your shirt or dress to help Mrs. May become aware of her behavior. If done out of empathy, the person understands the action as acceptance and support.

Use music and movement. Use old familiar, culturally significant songs such as “The More We Get Together,” “You Are My Sunshine,” and so forth. Holding hands, swaying or moving to the rhythm can help the person feel linked to another human being. It can energize and be uplifting.

Explore unique word combinations, rhymes, “nonsense syllables.” When disoriented persons ramble with unique combinations, ask questions about the words they use that you do not understand. Find the meaning of symbols they use.

Consider this example. Mrs. G. says, “Those curtains are simofile.” Remembering Mrs. G. worked as a secretary, the caregiver responds with, “Mrs. G., the curtains feel soft. Do the curtains remind you of soft memos?” Mrs. G. replies, “The similar curtains file, too.” Thinking of filing papers, once a large part of Mrs. G’s life, now gives her identity. Combining word-sounds of the present with the past, Mrs. G. creates sounds that give personal meaning to her as she combines the word SIMILAR with FILE and with FEIL (the worker’s name). The caregiver says, “The curtains here are like the company’s curtains?” Mrs. G. nods, “Simofile-feil.”

Build trust by speaking their language. Follow the sensory clues people give as they talk. For example, one person may respond to a situation with “I see,” another with “I hear what you mean,” and another with “I feel I understand.” With people whose language is visual in nature, use words such as: see, look at, imagine, picture, appear, show. In using seeing words, you are tuning into their view of the world.

With people whose language is feeling in nature, use words such as: feel, touch, light, out of touch, how does that strike you, does that hit you hard? They feel that you understand them, and will more readily respond to you. The eyes of feeling people are often unfocused, looking straight ahead.

With people whose language is auditory in nature, use words such as: sound like, loud, listen, quiet, clear, tell, talk, hear. These people will often look down and to the left.

When language is wordless, disoriented people use symbols to express feelings. A symbol can become an object with special meaning. A person, a sound, a movement can mean many things and have deep emotional significance from the past. Any person or object can take the place of someone or something from the past. For example, a voice can become the voice of someone who died long ago; a folded blanket can become a baby to rock.

Repeat person’s last words. Repeating last words stimulates recent memory and helps the person continue the thought. Example: When the person in the nursing home says, “I have to leave to see my mother,” the caregiver might respond, “Mrs. Brown, do you want to see your mother?”

Centering. Centering is a method of relieving tension. Centering is used by the caregiver. To center: concentrate on the center of gravity which is 1 inch below the navel; breathe in through the nose, out through the mouth; stop all inner “talk,” paying attention to center of the body, breathing slowly five to ten times.

Summary

The ability of the disoriented aged to set goals for themselves depends on: 1) the extent of brain damage, 2) the will of the person and 3) the empathy, knowledge and drive of the caregiver. Caregivers can help by understanding realms of feeling, stages of disorientation and principles and techniques that can be employed for helping the old-old reach their goals in this final stage of life.

Principles and Techniques of Validation/Fantasy Approach

Implementing validation/fantasy therapy depends on values held by each caregiver. Basic to the method are the beliefs that:

• each person is unique and deserves respect regardless of age or disorientation
• each person has the right to justify his life by returning to his past
• feelings have the right to expression in old age when goals change
• human beings can change and grow through a genuine, loving relationship.

Though there are numerous principles and techniques used in VF therapy, some are highlighted here.

Assess the condition of the person

Observe body language and actions to determine the stage of disorientation. Note which realm of feeling or thought is dominant. In using the V/F approach, understand the physical, emotional and social losses that lead to disorientation.

Link

Find the reason behind the feeling or action. Remember, people turn to their feeling realms for healing of wounds inflicted by reality. Linking or relating to the person is the therapy he needs. Linking has occurred when the person responds with trust.

Respond to feelings, not facts

Assess the person’s feelings. Tune into these feelings which are more basic to their everyday functioning than the intellect. This means establishing a gut level relationship with the person.

Be empathetic

Know your own inner feelings. Never pretend to understand or play at empathy. Use intuition and the wisdom of your own feelings. After assessing their feeling realm, tap that realm within yourself. For example, match the person’s universal feelings with your universal feelings.

Validate feelings

Respect the person’s feelings and assure him that you accept his creative free associations and feelings. Validation is caring and supporting his behavior and feelings as legitimate, acceptable and sanctioned. Validating reduces anxiety, heals and stimulates thinking.

Do not contradict the disoriented person

A person may insist that her mother is alive and waiting for her. The clear, visual image of the mother, waiting, is real to this person. If denied, it is invalidated. In doing so, the relationship is destroyed and the elderly person’s feelings of self-worth reduced.

Get close on some level

Touch the person as you speak to him. Use a resonate, distinct, adult non-patronizing, warm, energetic tone of voice so that hearing is easy and welcomed. To give adult identity, repeat their names often using the names they prefer. Bend down or kneel, if necessary, to maintain direct, close eye contact which immediately produces a relationship.

Use life review themes

Explore the past to help people gain a sense of identity and self-worth. This helps them resolve unfinished business, justify life and interact on a feeling level. It builds trust. Stimulate people to explore the past with life review themes, such as: relationships with parents and siblings; happy or sad childhood experiences; immigration or geographic locations of the past; schooling, jobs and roles; husband-wife relationships; romances, sexual feelings; adult homes; experiences with children; religion. Show meaningful objects and talk about them as a means of stimulating feelings and associations with the past.

Implementing validation fantasy therapy depends on values held by each caregiver.

Use questions that tap free expression of feelings

Explore feelings directly by asking questions beginning with “what, when, where, how or who.” Never use “why” questions requiring intellectual capacities which may be damaged. “Why” questions cause anxiety and withdrawal. An example of what not to say: “Why did you break the window with your cane?” Tap feelings instead, with “You must have felt very angry when you broke the window with your cane.”

Use non-aggressive questions. “Whom do you want to see at home?” Help them imagine the opposite by asking, “What if you didn’t go home? What would happen?”

Use questions that “tie together” thoughts

After building trust by exploring the past, use themes that focus on past-present, such as:

• how to find joy in a home that is not your own
• how to love people that are not your family
• how to substitute friends for family members
• how to cope with anger, sadness, loneliness
• how to cope with yelling, swearing of others
• what the person did to be happy (or content) in the past...in the here and now
• how does she feel when she loses words in her mind...or sees images from the past...or loses body functions
• how does he feel when people who are close die
• what kind of place is this
• how to cope with living here.

 

For Additional Information:

Feil, Naomi. Validation/Fantasy Therapy, 1980.