Validation

Personality disorder integrated care pathway
NHS Highland

Validation is a key strategy in treating personality disorder and can be defined as acknowledgement of the legitimacy of a person’s behaviour and experience. Invalidation is a related concept, considered to be of significant importance in developing and maintaining personality disorder. Invalidation occurs when a person’s behaviour and internal experiences are discounted or not regarded as legitimate. Invalidation occurs on a continuum, ranging from having one’s opinion dismissed as “stupid” to severe neglect and physical or sexual abuse.

Invalidation, in transaction with an emotionally sensitive temperament, may play a particular role in the development of borderline personality disorder. The establishment of a validating treatment process strengthens the working relationship, provides new and validating experiences to help counter previous invalidating experiences, promoting self-validation and encouraging development of a more adaptive sense of self.

Validation can and should occur in almost every interaction with patients. It is important to recognise that validation does not necessarily imply approval. Validation involves active listening and observation, accurate reflection of the patient’s emotions, thoughts and behaviours, and direct validation (the explicit acknowledgement of a thought, emotion or behaviour as valid and legitimate for that person, both understandable in the current context and in the context of previous experiences). It is useful to help a patient distinguish between their experience, reasons given for the experience, conclusions drawn from the experience, and actions based upon the experience. While beliefs and emotions should be accepted and acknowledged, their origin and implications should be questioned and explored.

It is important to recognise unhelpful behaviours, for example self-harm or substance misuse, may be the only way the person has had to cope with their experiences and that there is always some validity to any behaviour in its own context. Relentless self-invalidation is often present in people with personality disorder and usually serves to maintain the disorder. Therefore, negative self-judgements should be identified and
highlighted and areas of competence should be recognised and acknowledged. This promotes self-observation and reflection and can help to reduce self-invalidation over time.

Therapists should make every effort to avoid invalidating the patient. However, mistakes are inevitable and therapists should openly acknowledge errors they have made as soon as possible. Minimising problems, prematurely focusing on the positive, providing inappropriate reassurance, interpreting normal experiences as pathological and interpreting all problems as stemming from personality disorder are frequently experienced as particularly invalidating by patients. If a rupture does occur in the therapeutic relationship, it is important to identify this quickly, to explore possible reasons, and to explore and validate the patient’s reaction to the rupture.

Case example: validation - accordion option

Bill felt let down and angry when his friend did not telephone as promised. He decided that his friend no longer liked him and that the only way that he could reduce his intense anger was to cut himself, a behaviour which he had been trying to reduce.

In this situation, it was valid that Bill felt rejected and angry in light of his assumption that his friend had rejected him (even though that assumption may have been incorrect). In the past, people failing to telephone as arranged had signalled the rupture of friendships. Bill’s judgement that only self-harm could reduce the intensity of his anger was also valid (also probably incorrect), given that this had been the only strategy that had worked to reduce his anger in the past. The act of self-harm was valid as the only solution Bill could
see to change an intolerable emotional state.

The therapist, after actively listening to Bill explain the situation, reflected her understanding of the situation and Bill’s associated emotions, thoughts and behaviours back to him and checked out that she had understood correctly without missing any important information.

She then directly validated Bill’s experience while helping him explore and question the antecedents and consequences:

Therapist: So, Bill, if I have understood you correctly, your friend didn’t phone you as agreed, and you took this to mean that he no longer liked you. You felt let down and angry and cut yourself to reduce your anger to a tolerable level. You then thought you were a failure and felt ashamed. Is that about right? [accurate reflection following active listening]

Bill: Yes, that’s about right.

Therapist: I can see why you felt angry and let down, anyone would if they thought their friend had snubbed them and didn’t like them any more [direct validation]. . . but how did you know for sure that your friend had deliberately let you down [exploring antecedent]?

Bill: Well, he didn’t phone, what else could it mean?

Therapist: What other alternative explanations might there be? [exploring antecedent]

Bill: I don’t know. . . well, I suppose he may have run out of credit or lost his phone.

Therapist: Possibly—I suppose we don’t know for sure until we have more information, but I remember you said that a lot of people have let you down in the past, so I can see why you made that judgement [direct validation; distinguishing judgement from fact]. I can also see why you cut yourself—your anger was intolerable and you needed to do whatever it took to feel differently, cutting yourself was the only thing you knew had worked in the past [direct validation].

Bill: Yes, I had no other option.

Therapist: I recognise that’s how it seemed for you at the time, and I get that something had to be done [direct validation] but you’ve identified before that cutting yourself causes you to feel very ashamed and you’re left with a scar. Do you think it may have been worth trying out any of the emotion regulation skills you have learned over the past few weeks first? [exploring alternatives]