Mrs M sat constantly rolling up her cardigan, twirling and pulling at the buttons on her clothes until they finally came off. Frustrated care staff spent their time repeatedly asking Mrs M not to do this, which distracted her from her state of wellbeing. Conflict continually arose between the two parties and the relationship was clearly breaking down. During her life, Mrs M had worked hard, and now, aged 83 years, she finds herself surrounded by unfamiliar faces in the bewildering care home environment. She had no visitors, so we knew very little about her.  She refuses to take part in daily care routines and attending to Mrs M’s personal daily activities was challenging and distressing for all concerned. Care staff described her as ‘angry’ and ‘difficult’.

Crucial moments can arise regularly in our helping capacity. Here are a few examples of crucial moments:

1: The resident in the care home insists that she wants to go home.
2: The man who insists he will drive but is no longer safe on the road.
3: The man who refuses to get into the ambulance.

So, what can we do?

We can use validation skills to understand the person’s experience of dementia. We (person with dementia and helpers) can often feel uncomfortable when a conversation becomes emotional or resistant. There is a perfectly valid reason why we feel this way, a stressful situation triggers an automatic response to fight (overreact), flee (run away) or freeze (do nothing due to fear) and by doing so, we keep ourselves safe from harm.

Crucial moments happen when communication breaks down and the well-being of everyone is under threat because:

1. Two different realities exist.

a) The person with dementia is trying to meet their needs by any means they can in a bewildering and changing world.

b) The helper is in the here and now, desperately wanting to calm the situation down, and often under pressure from conflicting tasks, responsibilities, time restraints and expectations.

2. Emotions are running high (anger, confusion and fear in both parties).

When it matters most, helpers under pressure can often respond in the worst way.  When crucial moments happen, we frequently avoid, correct, try to orientate and rationalise, lie or collude with the person. At best we blame the dementia.  But the fact is; we are not listening!

Communication that works

Person-centred validation is a process that hears and explores an individual’s experience of dementia to enable a therapeutic change.  An easily learned acronym has been created, called iCARER. It is a set of compassionate validation skills, that are warmer and richer in feeling than those used normally in everyday life.

By using such interactions, the helper is conveying “You are important to me, I am listening, I want to understand.”

What is iCARER?

Centre  Associate  Reflect  Explore  Restore

i – as in me, you, us – is where it starts and finishes. A person when faced with a crucial emotional moment is prepared to listen and respond from the heart and does not blame the diagnosis of dementia.

Centre yourself, breathe deeply and put aside all distractions, fears and logical thoughts, allowing  you to be totally present for the individual who is expressing the emotion.

Associate with what the person is feeling. Pay attention, watch and listen to their body language, and ask yourself, “If that were me, how would I feel and behave?”

Reflect back or match the person’s feelings and words in your expressions, gestures and voice tone. As an example, the person says; “I’m going round and round in circles,”  The helper responds with “Round and round (pause), it’s frustrating.”

Explore the person’s experience or reality by asking, “What happened?” and “Tell me more.” This will encourage them to tell their story and express their feelings (it’s okay to show emotion), helping you understand their perception of the world at that moment.

Restore confidence by acknowledging something positive about the person and thank them for their help. If you know the person, then reminisce together.

By using the person-centred validation process (iCARER) care practitioners learnt to experience Mrs M’s internal world and acknowledge her sense of self and value. This led to Mrs M’s unmet needs being fulfilled and the relationship being therapeutic instead of caring or ‘challenging.’ We must ask ourselves what business we are really in, care or relationships? By reframing the business as developing relationships, we can focus our energy and skills on developing connections that deliver the right care through conversations that resonate and truly matter.

Communication is an essential part of our daily lives, but when people feel vulnerable, feelings can run high.  The iCARER process is for everyone going about their daily routines, for example, in a shop, supermarket, post office, bank, on a bus, but particularly family members and those working within a care team, a hospital or in a GP surgery.

There is a growing demand for training in how to explore and deliver effective emotional care that equips helpers with skills to engage in therapeutic conversations. Person-centred validation fills this skills gap.

To learn more, contact Julia Pitkin at Dementia Sense


Julia Pitkin (Dip COT, BA(Hons), PgCert in Dementia Studies) is an Occupational Therapist, Dementia Care Trainer (CIPD), Validation Teacher and Person-Centred Counsellor.

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