Off North Road
Naomi Feil's "Validation"
A funny thing happened on my way to Windemere, Martha's Vineyard Nursing and Rehabilitation Center, when I started my hospital training at the Rhode Island Hospital in 1952. My way had in fact begun on July 1, when I walked to my assignment, the emergency room, as a fledgling intern. I was full of excitement, some apprehension and considerable naiveté concerning the practice of medicine. Drowning out all other distractions, a continuous shout emanated from the basement emergency ward: "Tom, Tom, I'm over here, come help me ... Tom, Tom, help me, help me." As I walked, I noted no one seemed alarmed, no one rushed to the source of the plaintive cry. My destination, according to directions, by-passed doorways leading to the sound. I continued on my way. As I remember, those cries for help permeated the corridors in the basement for days without much let-up except for the deep hours of night when the voice fell silent in exhausted sleep.
Over the first days of my hospital assignment, once I found my legs and felt free to poke about, I discovered the cry came from an elderly woman lying in a bed with side rails and with loose restraints at her wrists. Nurses and attendants came in frequently to ease restraints, feed her, bathe and turn her in bed and to help her drink with a straw. She received sedation at intervals and at bedtime. However, after several days the ER remained quiet. The woman died quietly one night of "natural causes," meaning multiple small strokes and arteriosclerosis.
Well into my career in medicine now on the Vineyard, I met Naomi Feil, M.S. A,C.S.W. who had written a book in 1982 called "Validation." She described her development of validation "as a response to her dissatisfaction with traditional methods of working with the severely disoriented old-old people who were her clients." She published several more books and with her husband she made many films and videos for the Feil Method. She became a popular speaker and workshop leader throughout Europe and North America. Her work has been translated extensively in Europe. (George Feil, M.D., who practiced internal medicine in Vineyard Haven for many years, was her husband's brother.)
Windemere sponsored one such workshop for our staff, which I attended and watched Ms. Feil's fascinating dexterity and ability almost to enter the persona of the patient we had asked her to observe in a demonstration of the Feil Method. We could hear the patient shouting form her room to go home when she suddenly bolted from her door and ran pell-mell down the long corridor toward the exit. Three attendants followed with loud voices trying to make her stop and shouting to others to stop her. One grabbed at her hand and almost pulled her down, such was the momentum. "Leave me alone," she bellowed as another nurse brought up a chair and entreated her to sit down and have a cup of tea and some biscuits. "That will help you calm down, Dearie," she said. Now Feil raced after the patient and managed to put her arm around hers and accompanied her at the same pace down the hall and with the same physical appearance of terror. "You must be frightened to death. What is the matter?" Feil asked.
"My husband, my husband, I must get to him. Our house is burning and he is alone. I need to get to him. Someone must save him. He cannot get out by himself," and she pulled away. Ms. Feil's face was contorted in pain and her eyes flashed. "No wonder you want to rush home. Poor woman, you must be frantic." Feil's face changed, softened a bit. Initially her voice had come out at full volume. Now it was almost a purr. At the same time the patient's voice broke and she sobbed. "Oh, thank you, thank you, but will someone be there?" "Of course," Feil answered. "The firemen are on the way and the ambulance is coming. Here, sit down. You are very upset and your heart is beating too fast. You must stay well to help your husband." The slowing of the panicked behavior and the expression and entire attitude of both patient and Feil were now relaxed. Tea arrived. The patient slumped into a chair and sipped her tea.
Feil continued with the class. "Put yourselves, care-givers, if you can, into this woman's head. She really feels her husband is dying at home in a fire. Her care-givers do not hear her fears and she is terrified that you are not addressing her real concerns, To try to make her sit down to drink tea when she truly thinks her husband is about to die in a fire sounds preposterous but we have all done similar things in our ministrations. We need not believe the delusion, but we can respond in a fashion that will curb the fear and disorientation the delusion fosters."
These are the concepts I understood Feil to be teaching. Care-givers need to accept their patients as they find them, at their own level of lucidity and adopt the same tone which would be appropriate for them if indeed you knew exactly what they were experiencing. The patient otherwise thinks the nurse is crazy.
In the 1990s I met Sophie, a Polish woman of 90 who had been admitted to Windemere for failure to thrive at home and required acute nursing care. She was childless and widowed and was confined to bed and chair activity. I first heard her crying in a loud and terrified voice, first in English, then desperately in Polish. I heard these plaintive cries almost every day. The staff asked often for help in managing her distress. Nothing seemed to assuage her grief or pain or terror. We could not make out the cause or causes of her distress. Several medications were tried but none seemed to do more than add confusion and make her drowsy most of the time. I was called at noon one day to see Sophie because she was unusually upset, screaming at the top of her lungs and inconsolable, trying to get out of bed. "Sophie," I cried as I rushed into the bedroom and stood at her side grasping her hand without trying to hold it still. "I'm here to help you." I was breathing fast and speaking loudly and urgently "You sound frightened to death." I couldn't adopt the exact tone or sincerity, which Sophie's voice carried, but I tried and her hands relaxed and her head sunk back on the pillow. I continued to talk as if responding to a life or death crisis; the urgency of her cries began to die down. As her loud babbling became quieter, I pitched my voice lower and spoke more slowly; gradually we both took on the appearance of calming. She returned to speaking in English and looked at me. She stopped crying out and settled down. Over the next few minutes with my hand rubbing her hand but not interfering with her motion, I managed to control my voice in a calmer tone while maintaining the seriousness of my being at her side. "Sophie, you been very upset; you cry many times; always you get better; better now; lie quiet; breathe easy, slow; that's good, very good; no need cry much now. Go sleep." She continued to quiet down. She turned over and grasped my hand and kissed it over and over again. "You such good man," she blurted out.
Another day, a retired business executive, Harris, started at a clip toward the elevator, screaming that he was leaving NOW! I was the only staff in sight and the corridor was a long one. I caught up with Harris and ran for a bit with him. "You're in a terrible rush," I shouted. "You must have very urgent business. Tell me and I'll try to help." Harris looked at me in surprise but slowed his gait as I myself slowed a little but holding his arm firmly. "Hey, I'm getting short of breath and I'm an old man," I said, more quietly this time. He slowed to a walk and looked confused. He was breathing hard too, older than I was. "Let's find a seat for the two of us," I said as we reached the end of the corridor where two chairs appeared miraculously in time before either one of us fell. "There, we both made it. "Let's sit down and talk a bit." And we did.
There is no easy way to follow Feil's advice to find a level of understanding and act it out with a patient but I have observed her program's merits. We were not successful in carrying out her evangelical message to the "T" by any means but I think most of us have taken a few small steps along the way to Windemere. The satisfaction for me of Sophie's kisses and short chat with Harris was well worth the extra time and effort."