Dementia Insights: Avoiding Burnout in Dementia Care

Burnout occurs when mental, emotional, and physical exhaustion take over;^1-3 this is more than simply feeling stressed. Burnout is a state of believing and feeling, “I cannot continue anymore; I have overstepped my limits,” and as defined, often includes emotional exhaustion, depersonalization, and reduced personal accomplishment.⁴ Burnout is often a result of unrealistic external expectations blended with internal pressures that push an individual to this state of collapse. Therefore, burnout affects not only individuals but also whole systems.⁵ Most often referenced within the context of work stress or work-related conflict, burnout can also occur within the context of any stressful situation, including being a caregiver.

The Validation Method

Validation is a method for connecting and communicating with elders, especially those who have cognitive decline. Validation encompasses a theory of aging, a basic attitude, and techniques that help a validator communicate with the person receiving validation. Since the creation of the validation method (Figure 1) by Naomi Feil in 1970s, it has been implemented around the world in both professional and home-care settings, by physicians, nurses, social workers, direct caregivers and

Multiple studies report increased satisfaction and reduced stress symptoms with use of the validation method, as well as positive qualitative changes in relationships between staff and residents; reduced physical and verbal aggressive behavior by the residents; and improved work climate for staff in residential care settings.^6,7

Mindfulness

Mindfulness is a process by which we foster nonjudgmental awareness of the present moment.⁸ Originating from Buddhism, in which mindfulness is often cultivated through meditation, any activity that encourages people to slow down and become more aware of what is happening internally in any given moment can encourage a state of mindful attention. Furthermore, any activity that helps people become more aware of nonvolitional reactivity—whether in thoughts, feelings, or behavior—helps cultivate a more mindful attitude.

Mindfulness has been researched in numerous sectors and is used therapeutically in mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). Although research has shown mindfulness reduces burnout and stress, and improves wellbeing and self-compassion, it is important to remember mindfulness is not a panacea and does not automatically make us more calm or less stressed.^9-11 Mindfulness is a process of paying attention to whatever arises and helps us respond with consideration and intention rather than react involuntarily. Focused equally on both challenging and pleasant experiences, mindfulness not only helps us identify when we might be burned-out (eg, “I am exhausted, feel trapped, and can’t bear to get out of bed, let alone go to work today”) but can also help us notice signs of burnout (eg, “I am feeling irritable at work and at home” or “I am shouting at my kids”). Identify feelings and signs of burnout with mindfulness can provide support for preventing burnout by creating space to respond rather that react, allowing informed choices rather than involuntary reactions to external circumstances and personal impulses. For instance, with mindfulness, a person may notice they tend to ignore their body when they are busy even though there are physical signals to slow down and recognize this is because they care about the work they do, but that not slowing down does not serve them or their work well.

Bringing Mindfulness and Validation Together

As yet there is no research comparing mindfulness and validation approaches which have have similar qualities and processes, but also differ in fundamental ways (Figure 2). We propose that validation and mindfulness begin with a similar approach: cultivating an awareness of the present moment (ie, centering in validation) and an ability to step back to see what is happening in that moment (ie, observation in mindfulness). The point at which mindfulness and validation diverge, is in the actions that each technique informs. At its core validation is a method for communicating with others, whereas mindfulness is often considered, especially in Buddhist practice, as a way of laying the groundwork for actions of the mind and body such as loving-kindness and compassion. This comparison between Validation and Mindfulness is captured in the image below.

Clinician Validate Thyself

As mentioned, there are a number of areas where validation and mindfulness overlap and skills from both can be applied to help clinicians and caregivers prevent burnout. The following examples elucidate these skills and how they might be applied. These techniques can be used in any and all circumstances, not just in stressful interactions. Avoiding burnout is better than dealing with it once it’s taken hold.

Example 1. Centering or Awareness

An elder comes into your office and is filled with sadness about their life, stating, “It’s just not worth it anymore” at a time when you are feeling rather wonderful because your eldest child is graduating from college with honors, and you are looking forward to the ceremony. You could respond by smiling and stating, “It’s going to be okay,” brushing aside their sadness. Alternatively, you could put aside your own happiness and thoughts of the future to be in the present situation with this person, remembering that you can pick up your thoughts and feelings later after you clear out the emotions of the visit with this person.

Mindfulness Techniques. A key focus in mindfulness is on noticing what is arising. You might take a moment to check in with yourself, which might help you notice that you are feeling good right now and looking forward to something, but that this other person is feeling very differently. In slowing down and checking in, you may notice there is an impulse to avoid engaging with the feelings of sadness expressed and say something like, “It’s going to be okay.” Noticing that impulse can bring understanding and intention to the conflict between your own thoughts and feelings and the other individual’s thoughts and feelings and help to prioritize needs in that moment.

Validation Method. The validation method uses “centering” to clear away our thoughts and feelings in order to be open to the thoughts and feelings of the other person. If you are filled with your own present or future emotions or thoughts, you cannot be available to the other person and whatever is coming up for them in that moment.

Example 2. Breaking Through Automatic Reactions

If during a visit with a person who is age 78, they blame you for making them incontinent, you could respond by saying, “No sir, that is just what happens at your age,” or you could recognize that this person is fighting their aging process and is unaccepting of the losses that come with age and so would not respond well to such a response. You could instead take a breath and rephrase, using a tone that matches theirs, stating, “you notice that you’re incontinent!” This can be followed up with open questions that explore their experience and needs.

Mindfulness. Building on the previous example, using mindfulness, you would pause to notice what this interaction brings up in you, which might include a number of different thoughts, feelings, physical sensations, or impulses. By slowing down and noticing this, however, you give yourself an opportunity to choose how you want to respond based on what you’ve noticed about the situation and yourself, allowing a broader understanding of the other person.

Validation Method. Using centering is a way to give yourself time to enter into the world of the other person, using empathy. Instead of responding to others from our own perspective, you respond from their perspective. There is a reason behind the behavior of elders living with cognitive decline, and usually that reason is anchored in a basic human need. With this understanding you may shift your focus to exploring what the other person is expressing.

Example 3. Accept the Other as They Are in the Moment

A patient, age 82, approaches their doctor with their eyes wide with fear, saying, “I have cancer. I’m going to die. I know it.” The physician may think, they are healthy and being overly dramatic, which could lead to dismissing their concerns by saying, “you’re not going to die, everything will be fine.” Alternatively, instead of contradicting this patient, the physicians could pause and consider what is causing this individual to have so much fear, asking questions such as “Where do you feel the cancer?,” “Is it sharp or dull?,” “How long have you had this feeling?” Perhaps the patient might then say, “Oh, it’s been at least 3 months. It started after my spouse died.” If the physician echoes that back, asking, “The pain started after your spouse died?,” the patient might wonder or even ask, “Do you think that there is a connection?,” which again can be echoed with “Do you?” Spending just 1-2 minutes accepting a person as they are and exploring their fear can help them express it and build a trusting connection.

Mindfulnes Techniques. Another key element of mindfulness is being nonjudgmental. This often focuses on not judging ourselves (eg, it is OK if our minds wander) but also expands to not judging others. We do not know what motivates other people. This nonjudgmental stance can affect how we engage with ourselves and others.

Validation. The Validation principle that applies to this example is that elders should be accepted as they are; we should not try to change them. A validator accepts the individual, recognizing that they are trying to fulfill their basic human needs.

Summary

Burnout occurs when mental, emotional, and physical exhaustion take over. It can affect individuals and systems and is often evident amongst health providers caretakers. Validation is a method for connecting and communicating with older adults who have cognitive decline.

Mindfulness is a process by which non-judgmental awareness of the moment is fostered.

Validation and Mindfulness share similarities and differences that are worth exploring for health providers, as elucidated by the case studies presented. The practical tools included are designed to offer health providers and caretakers with valuable skills to promote self-care and reduce the risk of burnout.