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Physical Hypnotherapy for the Critically Ill

By Jane Buckle, RN, MA, Cert. Ed.

Originally published in Massage Bodywork magazine, February/March 2002.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.




Communicating Through Touch
While working in critical care I realized that communication with my patients was a major problem. Most of them could not express their needs to me because they were intubated (a breathing tube placed down their throat) and therefore could not speak. Almost all of these patients were attached to heart monitors and had many intravenous lines. Sometimes there were so many machines monitoring essential body function it was hard to remember that underneath it all was a person -- someone's loved one.

I wanted to be able to communicate with my patients; I wanted them to know I cared. As I had young children myself, I was well aware of the power of touch, instinctively hugging a fear away or rubbing a "hurtee." I realized I could communicate through touch and I was sure touch would be a valuable tool, but it was not one I had learned to use in nursing school. I attended a massage course that taught me valuable techniques and gave me more confidence in touching. However, when I tried to use massage in a critical care setting, I found that many of the strokes I had learned were inappropriate for such fragile people. They needed something more akin to stroking -- something very gentle, very slow and very reassuring.

During the following years, I worked on creating a structured system of touch that would be suitable for the critically ill, the very fragile or the dying. This method of touch became the 'M' technique.(R) The 'M' stands for manual, but could equally stand for my husband's name, Michael, as many of the strokes were "tested" on him first.


The Power of Touch
Touch has been described as "the first and most fundamental means of communication."1 Slow stroking or gentle massage has been consistently shown to improve a person's ability to relax.2 Other studies have shown that touch can make pain more bearable.3 Simon writes about people feeling "skin hunger" for touch.4 He explains this by saying "every human being comes into the world needing to be touched, and the need for skin contact persists until death." Barnett reports that the more critically ill the patient, the less they were touched,5 meaning the sicker patient, the more they may feel (and may be) literally starved of the comfort of physical touch.6

The acceptance of touch depends on culture, education and experience.7 If a person has also experienced physical abuse, even gentle touch can be perceived as a potential threat. Cultures which encourage skin-on-skin touch are likely to be more comfortable with therapies using touch than cultures such as the Japanese where touch is highly ritualized, and the national method of massage -- shiatsu -- is performed on a clothed body.


The 'M' Technique
The 'M' technique is a series of stroking movements performed in a set sequence. Each movement, identified with a mnemonic name, (a name which acts as a "hook" for remembering) is repeated a set number of times. Because the technique is structured in terms of strokes, sequence, number and pressure, the technique is completely reproducible and therefore useful in research. The 'M' technique is so gentle and soothing it has been called "physical hypnotherapy."

I first started teaching the 'M' technique in America in 1994. It has been taught at universities, nursing colleges and massage schools across America. Students have even created a new verb and talk about 'M'ing their clients.

As a direct result of students' comments, I realized that today's nurses are still seldom taught how to touch, even though research shows that touch is an important part of care. I remember carrying out research 10 years ago in the critical care unit at The Bristol Royal Infirmary, a hospital in England. One of my patients said to me, "You are the first person who didn't hurt me." That stunned me. I did not go into nursing to hurt people, yet much of what I did as a nurse was embarrassing, invasive and yes, sometimes painful. It is not often that nurses can focus on giving pleasure.

The 'M' technique can provide a simple method of touching for nurses to help put the care back into health care, or for massage therapists looking for a different way to touch the very fragile client. The 'M' technique is empowering because it is quick to learn and quick to do.


Different from Massage
It must be emphasized that the 'M' technique is quite different from massage. The 'M' technique is so different that many massage therapists are learning it to use in their practice alongside conventional massage therapy. New Jersey massage therapist Sharon Gibson says that normally 65 percent of her clients go to sleep on the table during a massage. With the 'M' technique, however, 100 percent go to sleep within the first 10 minutes. Lori Mitchell, a critical care nurse in Kalispell, Mont., uses the 'M' technique in critical care and says it brings rapid and prolonged relaxation to her patients, some of whom have not responded to orthodox sedation.

The first fundamental difference between massage and the 'M' technique is that the latter follows a set structure. Each movement and sequence is done in a distinctive pattern which is never modified. Each stroke, within each movement, is repeated three times. If you were to watch a group of practitioners carrying out the technique, they would all be doing exactly the same stroke at exactly the same time.

The rationale for this set form of repetition is simple -- to build up confidence and remove anxiety in the receiver. The first time you do a stroke, the receiver will pay attention to what you are doing. The second time you do it, the receiver will recognize that stroke. The third time the receiver knows what is going to happen and begins to relax. By sticking to the magic number of three, the receiver is lulled into a deep state of relaxation in a very short period of time.

The second fundamental difference between massage and the 'M' technique is that the 'M' technique uses a set pressure. If you were to measure that pressure on a scale of 1 to 10 -- when 1 is no pressure and 10 is crushing pressure -- the 'M' technique's pressure should always be a three. Conventional massage alters the pressure depending on the situation.


Even a Tool for the Very Young
Having taught this method of touch to hundreds of people, it's not necessary for the student to be either a massage therapist or a licensed health professional to learn it. It is also a good method of touch to teach to caregivers who may be looking after a sick relative or friend. The method is so simple to learn, I have taught it to a 4-year-old. I remember teaching it to a little girl of that age who was visiting her grandfather in an intensive care unit. She was angry and upset to be there, worried by all the strange noises and equipment, bothered by hospital smells and the nearness of illness. Her father did not know what to do with her. He could not leave her outside on her own, but he showed his intense worry that the child would trip over something and cause a disaster.

I asked her if she would like to touch her grandfather. She shook her head. I asked her if I could. She nodded with solemn eyes. I began to do the 'M' technique on her grandfather's hand, quietly explaining what I was doing, not only for her grandfather's benefit (and even patients in a seemingly deep coma do take note of what is said to them and how they are touched), but as much for the child.

She edged toward me, fascinated. "Would you like to try?" I asked. She shook her head sadly. "It's really easy," I encouraged. "Look." She watched as I repeated the movements. Then she held out her hands.

Within a few moments she had grasped the essentials -- slow speed, gentleness and rhythm. She became quite engrossed in her task, communicating her love for her grandfather through the ''M' technique -- no longer a distressed visitor, but a little therapist empowered and wanting to give comfort. I shall never forget the change in her, nor the change in the whole intensive care unit as she began to quietly sing a nursery rhyme as she worked.

Another impromptu student was the hospital chaplain of a hospice I was visiting. The nun stood beside me watching as I applied the 'M' technique to a very agitated patient nearing the end of life. As the touch worked its power, the patient began to visibly relax and stopped fighting the dying process.

After a few minutes the chaplain asked, "Could I learn to do that, do you think?" I replied, "I know you could, and quickly. Would you like to?" Her eyes shone at the thought of being able to give physical comfort so simply. I demonstrated the 'M' technique on one of the patient's feet and she repeated my strokes on the other foot. Within five minutes we were working in tandem, both using identical strokes at the same time -- totally synchronized. It was like a small, healing ballet. Before she went on her way, she confided that she would be adding the 'M' technique to her spiritual ministry, to "give physical comfort at a soul level."


'M' Technique Aromatherapy
The 'M' technique can also be used in aromatherapy to bring together the power of touch and smell. Both smell and touch can have rapid, therapeutic effects which can be used to lower stress levels,8 enhance parasympathetic response9 and improve comfort.10 Aromatherapy is often used with topical applications, either in the form of compresses or in various kinds of therapeutic baths, such as foot, hand, sitz or full baths, or in a gentle massage.11 When aromatherapy is used topically, gentle friction encourages the essential oils to be absorbed through the skin into the blood stream.12 This kind of massage is actually more akin to a gentle stroking touch13 and the 'M' technique is an excellent way of using diluted essential oils topically. Aromatherapy, using this kind of touch, has been shown to reduce the symptoms of severe depression14 and help multi-handicapped children interact socially, sometimes for the first time.15

This method also helps solve another problem faced by all caregivers -- time constraint. In a busy, clinical setting, there is sadly often little time to devote to each patient. However, the 'M' technique takes as little as five minutes for a patient's hand, or 15 minutes for both feet.


'M' Technique in Hospice Care
In Western society we find it hard just "to be." Hospice brings us face to face with our own mortality and asks us to confront the need just to be. I think the greatest gift you can give to someone who is in the last chapter of their life is to truly "be" with them. But that is hard for many of us. What to say? What to do? We want to touch, but we just don't know how.

The 'M' technique can bridge that awkwardness, allowing touch to communicate in a way words cannot. Touch is the first sense to develop in the unborn child and it is the last sense to leave us before we pass on. It seems obvious then that touch is an important part of life, death and bereavement.

In our society, there is little ritual left to help us celebrate or mark the different stages of life. Death is perhaps just that -- a rite of passage, leaving one room for another. Touch can help that transition, opening a door to relaxation at the level of the soul. And it is to the soul that we turn at the end of physical life. Whatever one's spiritual belief, death is hard to accept. Touching through death by using the 'M' technique can help.

One of the greatest shocks a family can have is to learn one of them has a terminal illness. This sets off an internal process of mourning. Anger and anxiety can get in the way of acceptance. The 'M' technique, because it reduces anger and anxiety, can lead the way to mutual acceptance.

You can involve the whole family with the 'M' technique and give feelings of comfort, empowerment and pleasure. Its use is also a wonderful way to say goodbye. Even though the loved one's hands may be cold and pale, you will be able to give and receive love through touch, and share in the moment when they move on into eternity. Favorite aromas, candies and music can help enhance the ritual and enrich the memory.

In the death process, the 'M' technique allows communication at a spiritual level and a little glimpse of the God that lives within us all. It can help in the transition between life and death by creating a supportive ritual which helps the giver focus on the now.

This technique is being used in hospices across the country by nurses, hospital chaplains, volunteers and relatives. I have found teaching the 'M' technique to be one of the most satisfying aspects of my career.

Jane Buckle trained in critical care nursing in England in the 1960s. She has a MA in clinical aromatherapy and a BA in complementary medicine, and until recently, was senior lecturer at Oxford Brookes University, Oxford, UK. Now living in the United States, Buckle is adjunct faculty at Bastyr University and The College of Nursing, New Rochelle, N.Y. She has created two CEU certification trainings in clinical aromatherapy Foundations in Clinical Aromatherapy (home-study course) and Aromatherapy for Health Professionals (endorsed by the American Holistic Nurses Association. Author of Clinical Aromather-apy in Nursing, she is director of R.J. Buckle Associates LLC, an educational consultancy in complementary therapies. A teaching video, $95, with explanatory brochure (NCBTMB CEUs) can be purchased from R. J. Buckle Associates LLC. For more information, visit her Web site at www.rjbuckle.com.


References
1. Barr, J. S. and Taslitz, N., "The influence of back massage on autonomic functions," Physical Therapy 50,12 (1970): 1679-1691.
2. Porter, S. J., "The use of massage for neonates requiring special care," Complementary Therapies in Nursing and Midwifery 2,4 (1996): 93-97.
3. Degner, L. and Barkwell, D., "Non-analgesic approaches to pain control," Cancer Nursing 14,2 (1991): 105-111.
4. Simon, S. B., Caring, feeling, touching (London: Argus Communications, 1976).
5. Barnett, K., "A survey of the current utilization of touch by health team personnel with hospitalized patients," International Journal of Nursing Studies 9 (1972): 195-208.
6. Buckle, J., Clinical Aromatherapy in Nursing (San Diego: Arnold, London and Singular, 1997).
7. Tiran, D., Aromatherapy in Midwifery and Nursing (London: Balliere Tindall, 1996).
8. Knasko, S. C., "Ambient odor's effect on creativity, mood and perceived health," Chemical Senses 17,1 (1992): 27-35.
9. Stevenson, C., "The psychophysiological effects of aromatherapy following cardiac surgery," Complementary Therapies in Medicine 2,1 (1994): 36-41
10. Betts, T., "The Fragrant Breeze: the role of aromatherapy in treating epilepsy," Aromatherapy Quarterly 51 (Winter 1996): 25-27.
11. Franchomme, P. and Penoel, D., Aromatherapy Exactement (Limoger, France: Roger Jallois, 1991).
12. Styles, J. L., "The use of aromatherapy in hospitalized children with HIV disease," Complementary Therapies in Nursing and Midwifery 3,1 (1997): 16-21.
13. Weiss, S. J., "The Language of Touch," Nursing Research 28,2 (1979): 76-80.
14. Moate, S., "Anxiety and depression," International Journal of Aromatherapy 7,1 (1995): 18-21. 15. Shipton, H., "Stroking away the pain," International Journal of Aromatherapy 7,1 (1995): 4-5.




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