In 1999, two social workers by the names of Beach and Kramer coined the term “therapeutic fibbing.” They described “therapeutic fibbing” as a quick way to counter repetitive or perseverative behavior that is distressing to the person with dementia or the caregiver. I admit, I used both the term and the technique in my own practice and research. It seemed like a good idea at the time. While completing my first research study in a nursing home, I daily encountered a sad lady who would stand at the nurses’ station, in tears, asking where her husband was. Her family tried to “present reality” by showing this poor lady a photograph of her standing next to her deceased husband’s grave.
No, that most definitely did NOT work.
One of the nurses had an inspiration. She knew that the woman’s deceased spouse was a WWII naval officer. The nurse smiled and said to the lady, “Your husband has been deployed. Please sit in the room over there (pointing to the dining room) and wait with the other wives.” The lady brightened and walked over to the dining room. About 30 minutes later, she was at the nurses’ station, looking for her husband.
Since it worked the first time, and seemed a kind and gentle way to “redirect” the behavior, all of us began using that stock response for the distressed lady. I remained at the facility for another week, and I saw that the deployment response used multiple times a day.
Lies & Vibes
About 15 years later, I was still a big fan of therapeutic fibbing and was using it as one of my strategies. Until I became more familiar with Naomi Feil and her validation approach. Dr. Feil argues that lying to people with dementia fails to get to the underlying cause for the repeated questions. At the same time I was reading up on Dr. Feil’s Validation Therapy, I had my own personal experience with why therapeutic fibbing may not always be a good idea.
Once again, I was working in several nursing homes as part of a large research study. I was helping one of the residents living in the Memory Care Unit brush her teeth. She was asking about her mother. Automatically, I responded that her mother would be back “later, because she was at the store.” The resident suddenly stopped brushing her teeth and abruptly said, “My mother died years ago.” She then fixed me with a hateful stare. My stomach just dropped.
The next day, I hoped that I would be operating from a clean slate. Sort of. Everything started out smoothly but then she became very resistant towards my mouth care attempts. I excused myself and had another person approach her. No problems. Hmmm.
I know that people’s voices and vital signs can change when they are being deceitful. I also know that our “vibes,” our energies, can be uplifting or depressing. Did my vibes alter when I engaged in therapeutic fibbing?
Grab-bag of Memories
I also wonder if we need to be careful about “therapeutic fibbing” because one never knows which memory will become accessible–which happened with the resident I described in the above section. I’ve had people with dementia not recognize their spouse one moment, then suddenly make the connection a few moments later. I suspect that I may make things worse if I am “caught” in a lie because a certain memory happens to surface right as the wrong words spill out of my mouth.
Therapeutic Fibbing as a Lost Opportunity
So, back to Dr. Feil. She asserts that therapeutic fibbing may rob us of the chance to explore the emotions and unmet needs underlying the requests to “find my mom” or “go home.” No matter how old I become, or how frail she becomes, my mother is linked to feelings of safety, of being loved, and of being cared for. Every time something serious happens, who do I call? Mom. It would make sense, then, that if I become very forgetful, I would be looking for and asking for my mother.
Entering Their Reality
Now, when I work with family caregivers and with people who have dementia, I use some of Dr. Feil’s strategies. My team and I call it “entering their reality.” This strategy has two sides to it. On one side, when someone is asking to go home or looking for a long-lost relative, we reminisce: “What do you like most about xx?” “What favorite food did your grandmother make?” If we are faced with care refusals, such as “I just brushed my teeth” when it is very obvious that the teeth have not been brushed for some time, we enter their reality and produce a reason that makes sense in their world.
When you think about it, we enter everyone’s reality all of the time. It is a way to provide feedback that is helpful, affirming, and kind. Here’s an example: I’m trying on different dresses for an important event. My daughter is helping me. I pick up two size 12s. I try on the first one, and think, “Eww.” So I ask my daughter, “Does this dress make me look fat?” The obvious answer is “Hell, yes!!!” but she is a kind soul. Her response is, “I don’t think the dress matches your shape. It does not flatter you. Try the other one on.” So I do. The second one looks a lot better. I received help selecting a nice dress, she kept the mood good by thoughtful feedback, and everyone feels great. She did not lie. She presented me with a version of reality that made sense to me. Maybe the cut was significantly different. Maybe the dresses were mislabeled, and the first one was really a size 10 while the second was really a size 14. Again, doesn’t matter.
So many times we get bogged down by silly ass details. Especially as caregivers.
Nearly every week, I get pushback from at least one caregiver: “Why do I have to keep changing how I communicate? Because YOU CAN, the person with dementia CANNOT. Or, you can keep swallowing big, heaping scoops of THIS FREAKIN’ SUCKS. Your choice.
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Dr. Rita Jablonski
Rita Jablonski, PhD, CRNP, FAAN, FGSA is a nurse practitioner, researcher, tenured professor, and former family caregiver. Her research and practice involve all aspects of dementia management; she is best known for non-drug strategies to address dementia-related behaviors.