When Your Massage Client Has Dementia  https://medium.com/@everflowing"


Providing massage for dying persons presents multi level challenges to me as a practitioner. One of these special challenges is working with persons experiencing dementia. One of the blog posts that has been archived earlier is titled The Lost Pause. https://medium.com/@everflowing" Please read that post as well, as it is the preparation for the following guidelines for working with clients with varying degrees of dementia.

The following guidelines will assist you in remaining sensitive in your communications:

*Always approach the person with dementia from the front and tell the person who you are. Communicate at eye level. This may indicate that you sit to say hello.

*Use short simple words and sentences.

*Speak slowly and clearly. Breathe between thoughts.

*Give one step directions. (Ex) “Hold my hand” rather than, “Reach over and take my hand.”

*Patiently wait for a response. Verbal response may be faster than body response. Allow time.

*If the body does not respond, repeat the request again exactly the same way as the first time. If there is no body response, add a touch cue. If action does not follow then say, “That’s ok” and state what you are going to do next. “I am going to hold your hand.”

*Be willing to repeat information or questions. Use the same words each time.

*Your client may forget who you are and what you are doing several times during a session. Be willing to repeat these very basic details as often as needed. This will require you to acquire permission over and over again in regards to touching your client. Permission and trust building are ongoing with the client experiencing dementia.

*The client may also suggest that you attend to an area of the body to which you have already attended. Be willing to touch the area again before moving on or simply repeat the actions.

*Clearly define what you are saying. (Ex) “I am using lotion,” instead of “I am using this.”

Cueing

*Cueing is talking the client through a request in specific terms. (Ex) Instead of asking a client to lift this leg, You will touch the area of the body affected, to guide the client through the action while giving the verbal instruction. You would say, “can you lift the leg that I am touching.” Once again you will touch the areas of the body affected by the request.

*Turn questions into answers. (Ex) “I am going to touch your shoulder” instead of, “Do you want me to start with your shoulder.”

Communicating with Family

Family members of those suffering with dementia are in a deep state of loss. They are watching their loved one lose every aspect of their identity in the world. They are in constant fear that their loved one will one day no longer know who they are. Family are many times relating to what they have lost rather than what is present. I learned this the hard way when I took a photo of one of my clients that I thought was radiant. He was beaming and so comfortable. I showed this photo to the family. It brought immediate pain to the mother who explained to me that the person in that photo was a mere shadow of who had been her son and never to do that to her again.

As a member of a health care team I have the opportunity to meet the person in the bed. I have no past experience to grieve. I only know who I see and feel in that moment. The full experience is much broader than that. I must stay gentle and aware of the larger picture. I have learned to hold my excitement and awe of my touch experiences and share them with the larger picture in mind and heart.

Don’t Take It Personally

*With short term memory loss there may be a sudden change in the relationship. You may be asked to leave or the client may simply say, “That’s enough.” Try and make each touch as complete as possible as the session may end at any time.

*Feedback and gratitude at the end of a session may not be possible with more advanced symptoms of dementia because the session is not retained consciously. Be alert to the feedback expressed through the body and in facial animation as you facilitate the session.

Over Stimulating

Stimulation is needed; however, overstimulation can be frustrating. Remember your client is integrating in slow motion. Perform bodywork for short periods of time. Work slowly so you can observe the body’s response. After the initial trust building and set up for your touch session, ten minutes of touching physically may be enough.

Remember that you will be returning the room to its previous arrangement. Rearranging the room is more stimulation and is still part of your touch session.

Reporting

Grandiose ideas such as having lunch in Paris or having intimate relations with the body worker may be a symptom of dementia. Always report any out of the ordinary behavior to a staff member on-site. Make written reports on your sessions and note any irregular behavior or accusations.

Always Remember Your Client’s Safety

Short-term memory loss and loss of motor control may indicate that your client can forget their physical limitations, such as not being able to walk. They may also not be able to clearly assess the edge of the bed. Stay alert to your client’s limitations, the equipment you are using, your surroundings, and the directions you are giving. Be alert, as well as compassionate.

Irene Smith www,everflowing.org

https://medium.com/@everflowing/beyond-massage-b27a3a73fc12

Check out my new blog page https://medium.com/@everflowing/touch-awareness-beatrice-2c8d46d375c2

Listening is our bridge to the deeper wisdom in a massage session with a hospice client. Entering into a hospice client’s space requires the practitioner to integrate into the existing experience. This requires the practitioner to pause, listen and observe the activity already in motion. This pause involves observing the environment and noting any obvious changes to the clients comfort care such as bed positioning or client positioning, Is there any new equipment by the bedside? What is the clients overall demeanor, skin tone, body animation? Are there sounds; labored breathing or moans? After a verbal intake from caregivers, this visual assessment, even before  entering the client’s immediate space, gives the practitioner current information about what is happening in that moment.

There may also be other support team members in the space. This is a common occurrence in hospice massage. The hospice massage practitioner is not the primary support as in other massage practice environments. In hospice massage the practitioner is a part of a greater support team. Although I may have an appointment I must take a seat at the larger table and integrate my piece of support with the wider care plan. The pause allows me to sense and feel the dynamics already present in the client’s space and assess how I might enter into the current dynamic without a sense of intrusion This might include speaking softer than usual moving slower or saying hello to a number of other visitors or team members before saying hello to my client or introducing myself to a new client. I may also need to sit while conversations or activities are completed or need to simply wait outside the room. There may be several layers of activity happening besides my appointment.

The pause also allows the practitioner a moment to adjust his/her level of receptivity to the physical pain and emotional stress that may be present in a dying person’s space. There are many layers of pain involved with the dying process. The client may be experiencing physical pain as well as depression and unimaginable grief in regards to leaving loved ones, the loss of one’s personal identity, regrets and all that one might process in reflection of one’s life journey. Others in the room, including the professional caregivers, will all be in various stages of grief and grieving in their own unique ways. Everyone experiences grief differently. Feelings may vary from anger, fear, and resentment to deep sadness and withdrawal. Attitudes such as mistrust, defensiveness, aloofness, chaotic humor, or the inability to process any new information, including my name and why I am there, may be exhibited as byproducts of grief.  The room is already full. There may be no receptivity to input. To walk gently and slowly and speak softly is in honor of the unknown and / or the unseen and unspoken. This is the silent dialogue we must pause and listen to.

The second level to this silent dialogue is that of the practitioner observing his/her responses to these dialogues and listening to one’s own dialogues that are triggered within oneself.

Both the physical and emotional dynamics of the client, the environment and those in the clients space require the practitioner to pause, observe and listen. To deeply listen requires a commitment to be fully present and available to the space in between the breaths; the silence. We listen with our eyes, we listen with our heart, and we listen with our hands.

The following protocol gives practical physical steps as a guide for entering into a hospice clients space.

• Begin entry with a pause. Be still.
• Feel your feet on the earth.
• Observe the moment and breathe.
• Observe your client’s environment; your client’s body. What’s happening? What experience are you entering into? What is your experience? Observe yourself.
• Breathe
• Integrate the experience you are witnessing.[ intellectually and through the senses ]
• Ask permission to enter into your client’s space.[ This may be a hello to other team members in the room and being asked to enter or with a lone client who is non verbal , stating what you are going to do and observing the body language as to comfort or discomfort to your entry.]
• Integrate into the experience you are witnessing[ Listen, sense, observe]
• Breathe with exhale included.
• Listen deeply, listen with your head, your heart and your body
• Ask permission to step to the bedside or chair.[ In case of a non-verbal client, state what you are going to do and evaluate permission or lack of, through your client’s body animation. This requires a pause for observation and a quiet mind.]
• Breathe with exhale included.
• At the bedside, ask permission to touch or state exactly where you are going to touch if the client is non-verbal.
• Observe your client’s body animation.
• Approach the body slowly, honoring the space around the body.[ The energy fields surrounding the physical body are scientifically the most sensitive of the bodies Move slowly and gently, so as not to create anxiety.]
• Offer the hands as a point of regard for whatever your client’s body is expressing.[ This is the practice of witnessing, rather than the intention to fix or change.]
• Always feel your feet grounded with the earth.
• Breathe with exhale included; rest and touch.
• Observe your client’s body responses and facial animation.
• Integrate the experience.[ intellectually and through the senses ]
• Listen to the silence, this requires a pause. Listen with your head, your hands, your whole body and with your heart.
• Observe your responses and breathe with exhale included.
• Continue to touch or massage with this pause [ the breath ] for observation and integration as your guide.
• Always feeingl your feet grounded with the earth.
• Always breathing. Always resting.
• There is nothing to fix; nothing to change; nothing to heal. Your experience is already perfect.

This is an excerpt from Massage in Hospice Care, an interactive iBook by Irene Smith

Today august 24^th marks the 12th anniversary of the passing of my dear friend and teacher the late pioneering thanatolgist.  Dr. Elisabeth Kubler-Ross Every year on this day I post this precious story.

 We met in 1979 in Escondido California when I attended my first Life Death Transition workshop. Several workshops later Elisabeth wrote a reference letter in my behalf and told me to take it to hospice. So began my work with the dying and a 25 year friendship with a dear colleague.

Elisabeth was a person of passionate spirit and I learned from her to open my heart to the spiritual nature of life.  

Sunday August 24,2004 I came out of my shower and went into my bedroom and laid on top of the bed to relax and look out to the tops of the trees that give me so much grounded ness in my 3^rd floor attic apartment.

As I gazed towards the trees I saw a pair of wings rising from the stairs below my deck. I raised my head in curious awe when an eagle appeared and perched on my deck looking into my room." Oh my God! "I exclaimed." what is this?" It was a small Golden Eagle. It did not fly over. It came up to intentionally perch on the railing of my 3^rd story deck.

 I sat in utter amazement and wondered what it meant. After about two minutes it flew away. I immediately got my animal spirits book and looked up eagle, hawk. It said, A Native American omen of healing, rebirth, and a sign that I should be alert to what is coming ahead. The eagle is the messenger to God who takes our prayers to Heaven. I knew I was being given a very important message but I wasn't clear what it was. I emailed a good friend in Arizona and related the event.

Tuesday morning I received an email telling me of the death of my dear friend Elisabeth' Kubler Ross, I took a shower and went into my room to lay on top of the bed and look out to the trees. As I looked out I came to clarity:

Elisabeth's totem animal was the Golden Eagle. I wept in deepest gratitude for this gift and for the wisdom to recognize it.

At Elisabeth’s memorial service a Native American woman performed one of many rituals. As she spoke of the Golden Eagle being at the top of Elisabeth’s totem she asked us all to look up and imagine Elisabeth as a Golden Eagle. I smiled.

Many Blessings Irene Smith

As I sat and massaged my client’s hands at the dining table I felt a pull behind me. The pull became very strong. Holding one of my client’s hands I slowly turned around. Gayle, the Chinese speaking resident sitting at the head of the table, was leaning forward and moaning and calling  to me with her eyes. She wanted a witness for her pain.

Her eyes were intensely focused on me and now she was reaching out her hand. I responded and reached out one hand to her. She took my hand and leaned even more forward. I knew I was crossing professional boundaries.

I told my client I needed to be present for Gayle for just a moment. I let my client’s hand go and turned my body fully towards Gayle. Gayle moaned, looked deep into my eyes and continued to hold my out stretched hand. “I’m so sorry for your pain.” I said. Gayle responded with head nods. There was the passing of a moment .The touch seemed grounding and Gayle began to rest more comfortably in her chair.

In the next moment a staff member stepped up to the table and looked at me and said.” That’s not needed. She has had her morphine.” I looked up, said nothing and continued to hold Gayle’s hand. A nursing assistant at the other end of the table said, she’s right Gayle has had her medication she’ll be fine.”

I experience this concept over and over again. There seems to be a blanket belief that when one is on pain medication comforting isn’t necessary because the patient doesn’t feel discomfort.

After thirty five years at the bedside I can honestly say that there is always consciousness. My teaching to others is to always honor the consciousness. Honor the core being under the medication. Validate the person’s experience and hold that experience with the utmost compassion.

Touch is our original language. It is our birthright to bond; to connect. From my experience medication does not counteract the need to bond. In fact with the sometimes floaty out of body experience from some drugs, touch grounds and settles the body. Touch may be the anchor in a world that is turning round and round.

Many times medication interferes with the body’s ability to express discomfort but may not eliminate the discomfort.

In listening to many bodies with my fingertips I have the opportunity to hear the conversations that the body can no longer express through animation. I am the silent witness to these conversations.

This is an extremely compassionate and valuable offering at the bedside.

Always speak to the consciousness.  There is pure consciousness in every cell in the body deserving dignity, respect and validation. We deserve to feel connected through all stages of our lives.

Blessings, Irene Smith

w ww.everflowing.org

As a hospice massage practitioner for over three decadesI find that full-body sessions are rare with hospice clients due to physical, emotional and environmental restrictions and limitations. Many sessions will involve one or two areas of the client’s body. Sessions that usually present themselves in a hospice setting are:
(1) legs and feet, (2) feet, (3) head and neck, (4) face, (5) back, (6) arms and hands or (7) hands.

I call this piece work. Gentle stroking, holding as in acupressure or Reiki and sometimes rocking these areas of the body for short periods of time, prove to be comfortable hospice sessions.

As your client approaches the end of his or her life, your touch sessions may become shorter and return to basic forms of family touch such as stroking the forehead or holding a hand.
For me this is the most difficult form of touch to provide. It requires me to put technique aside and to simply, without fanfare, be present with another human being in touch. It is as if all the previous massage practice was to build my confidence for this one moment of just being.

This is truly the advanced practice; an advanced practice in the ability to be intimate without attachment. For me this is the healing, the big reveal in hospice work.

Please paste the link below into your browser to view a short video snippet of providing a head massage to a hospice client, CB. The intimate contact in this short piece speaks volumes. This video appears in my new interactive book ‘Massage In Hospice Care” now available in your iBooks store on your iMac computer or iPad .The video snippet includes a short introduction to the book before the head massage. I welcome and treasure comments.

https://www.youtube.com/watch?v=vlOZBYwoa0w



Blessings and Gratitude,
Irene Smith www.everflowing.org

As I walked into Sara’s room I was halted by the vision of large pink organdy butterflies dancing over Sara’s bed. Long pale pink ribbons trailed down about six inches moving ever so delicately in the slight breeze coming through the open window. Against the wall two three foot wide hot pink organdy butterflies with sequined tipped wings lay flat, ready to be witnessed and loved. Behind Sara’s bed hung two plaks. One  read Laugh and the other, Dream. I paused as tears rolled down my cheeks. Sara lay looking into the butterflies overhead touching the ribbons with awesome joy. She then looked at  me and broke into laughter.

How did I cultivate the opportunity to share in this depth of a daughter’s love and her devotion in keeping the end of her mother’s life filled with beauty? How did I ever create a professional life that looks like this. It is truly a blessing.

The blessing, however doesn’t come without challenges. The skill base required to go into private homes and health care facilities to provide massage for dying persons and communicate with the families and health care professionals  is multifaceted. It requires specialized in person training.

Currently I have nine clients. All clients are in the final stages of their lives. Five clients are in hospice care. Two clients are in private homes and seven clients are in health care facilities. Three of my clients can speak, and two of the three are able to carry on a conversation. Six of my clients are non verbal.

*I am challenged to assess the outcomes of my sessions kinesthetically, by listening to the client’s body, observing the body’s animation and by being quiet and centered enough to hear my intuition.

*I am also challenged by having clients who can not move. I have to be creative and find positions that allow me to touch my client without hurting myself. The challenge of attending to my physical body onsite requires a deep level of commitment to honor my own comfort. Having compassion for myself has been a difficult kindness to learn.

*Adapting massage techniques to work in varied positions, with a client who can not move  requires constant modification, patience and letting go of concepts of what massage is supposed to look like.

The session with one of my clients includes her neck, and the arm ,shoulder, leg and foot on my side of the bed. Her bed is against the wall and her body is rigid. The opposite leg can not be moved over without great stress. It frightens her. My challenge is to let the other side of the body go. I have had to learn that the greatest outcomes from touch are deeper than the sum of body parts I can reach.

*Gathering information on my clients as a private practitioner can be challenging because health care facilities are bound by confidentiality guidelines. I have to make sure I take the time to gather all the information I need from my contracting agent before I arrive onsite. That might be a family member, care organization, conservator, a nurse, or all four contacts. Each contact will have a different level of information. Gathering sufficient information takes time, patience and skill.

*Working as a private practitioner rather than for any specific organization  allows me to set my preferred fees, adjust session length and gives me scheduling flexibility. My greatest challenge is reporting to my contracting agents who serve in a wide range of roles. Dialogues are different with family members than with nurses and conservators.

I send written reports once a month to my contractors which include touch techniques utilized, the clients receptivity, outcomes , including physical and emotional response and an assessment of any props or care strategies that might support the comfort of my client. Family members will often want me to call after sessions to report verbally as well, especially at the beginning of the relationship and at the end. I have to keep in mind that the family is grieving. Time, compassion and skill are  required.

Family members will often want to be involved in sessions. Guiding a son or a daughter in gently touching or holding their mother at the end of her life are moments that I treasure. The challenge is being comfortable with this depth of intimacy. The questions I ask myself are,“Am I soft enough? Am I vulnerable enough? Am I honest enough?”

Blessings and Gratitude,
Irene Smith www.everflowing.org

Recently I was asked to give a presentation on touch as a viable service to the dying. In my reflection of this topic, I realized that a primary outcome that keeps me at the bedside is I get to assist those I touch in remembering their loveliness. I have the opportunity to remind those in pain and suffering of their beauty. In turn, I am reminded of mine.

“M” was on of my clients in the nursing home many years ago. Her story however, is still vivid.

Our communication was primarily non verbal and M’s eyes spoke loud and clear. M enjoyed having her feet massaged while in the day room in her geri chair. The only comfortable way for me to do this was to sit on the floor and put a pillow in my lap and place M’s feet on the pillow. A very conservative woman, M often found a curious humor in my sitting this way.

One day while massaging M’s feet, she began to lean forward. Her eyes had taken the expression of awe and her mouth was beginning to open slightly. I remember distinctly that I was massaging the big toe. Her expression became more exaggerated and I became excited for her. She was loving this session. She really looked to be involved with the beauty of the hand motions.

I wanted to enter into her excitement. “Oh yes” I said, “Massage is so beautiful.”

With great pleasure and realization M spoke. “No!” she said, looking at her foot “ my toe!”

What greater gift can I deliver than the gift of remembering one’s loveliness?

I believe it is said very well in one of my favorite pieces of poetry:
 Saint Frances and The Sow by Galway Kimmel

 for everything flowers from within of self blessing
though sometimes it is necessary to reteach a thing it’s loveliness
to put a hand on it’s brow
and retell it in words and in touch it is lovely
until once again it flowers from within of self blessing.”

I look forward to you sharing your stories and comments.

Blessings,
Irene Smith
www.everflowing.org 

Recently I had the opportunity of facilitating an inservice for Maitri Aids Residential Care nurses. The inservice was on Comforting and each nurse brought their own special way of comforting into the room. Witnessing them sharing their personal comforting strategies and comforting each other with touch, triggered a deep conversation within me on the topic of comforting.

I realize that my mission in life is to comfort. It seems no matter where I am I am seeking comfort, whether it is to comfort another or to receive comfort. I also realize that comforting another gives me a sense of comfort.

Today my first client in the nursing home had a difficult time integrating my presence and it was more difficult than usual for him to sit up and get into the chair. He wanted to focus on me but his eyes couldn’t. Turning off the TV is usually the first thing he does, however today he didn’t turn it off.

As he was struggling to focus on me, the TV caught his attention and he started to watch it. I was going to suggest we turn it off however, I noticed that he was using it as a focusing tool. I then noticed his anxiety start to calm. The TV was bringing him a sense of comfort.

As the session progressed I couldn’t help but hear the very dramatic dialogue on the soap opera. Every few minutes my client and I would have non verbal communication with eye contact and facial animation in regards to what had just been said. The communication between us became easy, and intimate, and a different level of bonding took place. I noticed that the family like intimacy was very comforting to both of us.

What I usually viewed as a limitation had become a tool for comforting for both my client and myself. I left feeling easy and nurtured.

As I got to the elevator I heard loud vocalizing coming from another floor in the community and  recognized it as one of my clients in seeming distress.

I wasn’t scheduled to see this client and got on the elevator to go to the lobby and leave. I heard the vocalizing in the elevator as I went to the lobby and continued to hear it as I was signing out. My thoughts were strong. I was on my way home. It wasn’t my day to see her. I paused. I made a choice, not as a massage therapist but as a human being, wanting to comfort a person in distress.

As I arrived upstairs, I saw my client in her wheel chair facing the window . She was expressing herself through loud tones, which is her only way of communicating.

As she continued to express herself, I sat down beside her, said a few words, reached out, and laid my hand on her shoulder looking at her, although her eyes  were closed. Each time she was going to vocalize her forehead became a bit flushed. I continued to touch her.

Then I cupped the back of her head with my hand and  cradled it like you would a baby’s head.
 A passer by might have thought I was a family member. We sat this way a few minutes.

Continuing to look at her and just breathe, I laid my hand on her forearm and shoulder. We sat quietly for about 15 minutes  before she seemed to drift into sleep. I left.

I realize I was not with my client as a massage therapist. I had answered a call of the heart to comfort a being in distress. This is how it used to be for me. This is the place that brought me into this field. This is the connection to humanity that I want to check in with in my practice. This is where the comfort lies for me.
 
In both of these sessions I reached past the massage session boundaries into a deeper sense of connectedness. I chose to be a comforter.

How do we as practitioners integrate this deeper human need into our practice. How do we stay connected to our humanity. No right, no wrong; just something to notice.

I would love to hear your comforting experiences and your strategies for integrating your deeper needs  into your practice.

Blessings
Irene Smith www.everflowing.org

 Being With Family

Margaret was in the final days of her life and each visit was a gift for both of us. Although Margaret was wide eyed and interested in my presence, I felt like this would be our last visit. Her breathing was calm and even and she kept her eyes open throughout the session.

When I left I thanked her for her receptivity and for the opportunity to express such tenderness. I stroked her forehead and held the side of her face for a moment. It felt complete when I left.

Two days later on my regular scheduled day to see Margaret I called the nursing home. The wellness co ordinator told me Margaret was actively dying and her daughter had asked if I would come. I said yes.

When I arrived Lauren and her husband were in the room with Margaret. Margaret’s breathing was fast as if she were going up hill. Lauren explained that the hospice nurse had come by and told her Margaret would probably die that evening and gave Margaret pain medication to ease the difficult breathing.

Lauren expressed gratitude for my presence and said she trusted me to do whatever I thought was appropriate.

Although Margaret’s breathing was fast it wasn’t labored or anxious. Margaret seemed peaceful; no anxiety. Her face was open and unfurled. I didn’t want to interfere. I sat by the bed, spoke softly and gently and touched Margaret’s arms, hands and legs. It felt perfect to just gently touch.

Lauren sat by the head of the bed and I sat at the foot. She observed and commented on the tenderness and closeness of the relationship. Lauren also touched her mother and spoke to how peaceful her mother seemed.

After a few minutes I offered Lauren a neck and shoulder massage and she accepted. Lauren sat by the bed touching her mom while I gave her a massage.  I talked with Lauren’s husband throughout the session. The room began to settle.

Lauren asked about the process of dying ; what to expect, and about the breathing. I was glad to be able to respond with basic information that she had not been told.

Before leaving the room I made the suggestion that Lauren stay the night; to just relax as much as possible and stay by her mother’s side. I also showed her how to swab her mother’s mouth and dab her lips with water.

This practical bit of information gave Lauren some insight of how to care for her mom on that last night; how to stay connected. It seemed grounding for both of us.

As I left the room I expressed my gratitude for the years of experience with hospice that allowed me to share in this sacred time with a daughter supporting her mother through the dying process. 

Greetings,

The attached link is to an Everflowing you tube trailer showing a touch exercise during a Touch Awareness in Caregiving day long workshop . The participants are hospice caregivers . The person being touched is a piece of clay. The sculptor[ the person touching] was creating the upper torso ,face and head. The voice is me, Irene Smith, in a dialogue that has been added. What you hear is not the instruction to the participants.

I would love to hear your comments

https://www.youtube.com/watch?v=jc6DKfXXyZE

Last week while preparing for a presentation on listening, I leaned back in my chair at the computer wondering what story I could tell about listening deeply. Not just involuntary hearing but truly listening to the meaning of the words. Listening with my heart as well as my ears.

My heart burst open and I started to cry. I heard my mother say "I made soup."

My mother had severe crippling arthritis, scoliosis and heart disease. Her physician was an osteopath and she combined acupuncture, herbs, supplements and homeopathic medicine in her health care. She never went to the hospital .She would simply stay in bed for days at a time.

Cooking was very painful for mother so friends would bring food or take her out to eat most of the time. This was her program for the last 20 years of her life.

I*n her last few months every time Mother called me she would say "honey, I made vegetable soup. It’s so good!"

My response was always , "Great Mom." I actually remember being somewhat bored by these conversations and not really interested in her soup.

I harbored a well of anger with my mother and didn’t work through that before she died. It clouded all our communication.

Last week, 16 years later I got it. "I Made Soup"meant, honey I’m out of bed today; Im feeling strong and I was able to cut vegetables. It’s a glorious day!"

" I Made Soup" was a statement of mother’s courage and independence and her ability to push through her suffering .

Deep Listening is a practice and a philosophy developed by Pauline Oliveros. It is said in this practice that listening deeply requires the temporary suspension of judgment and a willingness to receive new information. It is a process of learning.

Truly listening allows us to not only hear what someone says and, what they think, but allows us the understanding of what it means to them and why it matters. There is perhaps no greater way to show our respect than to truly listen to someone.

Many blessings and please share your listening stories . Your stories mean so much to the community.

Irene smith

www.everflowing.org

Reading the Massage Magazine special issue on pain relief I am reflected into how working with pain differs in my hospice massage practice from more traditional modalities.

A couple of months ago I was working with an intern at an inpatient hospice. We went into see a woman with cerebral palsy who was not on our list of referrals.

Sabrina had spent most of her life in hospital wards. Her body was a roadmap of surgeries and called out loudly for tenderness.

Sabrina spoke of her legs and back being in great pain. She continued to speak of her discomfort as I positioned myself sitting comfortably at the foot of her bed. As I slowly lifted the sheet to assess her right leg my heart shed a tear for the dwarfed limb that was exposed.

I cupped my hand around the thigh and softly spoke," I am honored to offer this limb some tenderness....I feel your leg loves the attention.... I’m so glad we’re here."

While gently holding and tenderly petting this leg Sabrina replied, "If someone had done that years ago I might still be at home."

I covered the leg as Sabrina asked me to touch her back. Although she was in a lot of pain she requested that a nurse position her onto her side so I could touch the exact spot.

After positioning was completed I sat comfortably behind Sabrina on her bed, uncovered her back and with Sabrina’s permission I came very close. With one hand slipped under her head pillow as to hold her, I simply laid my other hand on her back and said, "Oh I know you have been in pain for a long time. I'm so glad we’re here."

As I became comfortable, slowly exhaling, I felt Sabrina going to sleep. Her pain had been validated. She expressed her gratitude before the silence..

After a couple of minutes I slowly removed my hand from underneath her pillow and changed places with my intern.

The Everflowing intention is never to remove pain from someone’s body. The intention is to validate and honor the symptom ology that is being experienced, and to create an environment where the client’s anxiety about having pain can be eased.

We are in a culture that insists that pain is something we have to get rid of. We essentially make pain wrong therefore when pain appears we are afraid of it getting worse; we defend ourselves, hold ourselves tightly. We want the pain to go away. This directs a profound degree of energy to the pain, and creates anxiety.

As an Everflowing practitioner, I want to create a resting place as I walk into a room or up to someone’s bed; a place of stillness first, and then a place of very gentle movement like a breeze or a soft wave of water as the tactile relationship begins. A place where there is no resistance; a vulnerable place.

This is achieved through slow body movement, slow speech, slow audible breathing; and my willingness to find my own place of physical comfort; just being comfortable and breathing as I slowly speak to my client. I am just a witness.

This resting place, this alternative rhythm, eases a lot of tension in the room. There appears to be more empty space and the client might begin to find comfort as well.

If I can stay grounded and comfortable in body and mind then the static and resistance has been broken. The cycle has to reestablish itself.

This change in the pain cycle can cause a decrease in the pressure being experienced by the client and give the client an alternative strategy for coping with the pain.

Pain is multidimensional when someone is dying and may be my client’s most familiar response to his or her condition. I cannot assume that alleviating it is the kindest strategy. I feel I must validate the existing relationship and give models for reestablishing a more compassionate communication with ones self and one’s environment.

This is the Everflowing approach to pain. I look forward to your sharing your approaches and stories.

Blessings

Irene Smith www.everflowing.org

I have been concerned for a long time about the way the field of hospice massage is growing. As with any therapeutic intervention that becomes mainstream ,the integrity of the field is suffering.

Practitioners with the desire to serve ;however without sufficient training to work with dying persons, are being hired by program co ordinators that have no knowledge in what is needed to facilitate a safe massage program.

I am alerted to hospice programs taking on massage practitioners that have no training in adaptations from working with healthy people on a massage table to working with seriously symptomatic persons in beds.

Many hospice co ordinators are corporate administrators who believe that a massage certification is all a practitioner needs to massage hospice clients.

Although some schools have continuing education programs for working with the dying, massage schools do not teach working with dying persons in core training as a general rule. Sometimes the topic will be minimally addressed in a geriatric or oncology course.

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Twenty seven years in hospice massage gives me the experience to outline what have proven to be challenges in this field ,and areas of training needed for safe relationships between clients and practitioners, and organizations

If you are a massage program co ordinator, educational director for a massage school, or hospice massage practitioner these are a few of the areas that require knowledge in this field.
*Hands on precautions as pertains to massage not nursing.

*Modification of standard massage techniques to meet the needs of the physically and emotionally fragile client. This includes; intention, amount of pressure facilitated through the hands, the speed of technique delivery, and the duration of a session.

*How to adapt massage for working with people in beds and chairs; including body mechanics for the practitioner. Practitioners need to know how to comfortably reach the client to prevent injury to themselves.

*How to gather sufficient information for treatment assessment.

*How to work in a home setting. This involves working in a bed; being with family; communicating with other team members; reporting; setting limits ,and what to take as equipment.

*How to cope with the emotional impact of clients dying which includes personal coping strategies as well as support systems.

This is a specialized field of service that requires practitioners to have sufficient information, supervision and support for the safety of the client and the massage practitioner.

If you are an administrator , educational director or practitioner reading this please go to my website www.everflowing.org and check out the educational resources. Resources are available to give you the information you need. You may download articles for free that will serve you well. You may also ask questions on this site.. Go ahead use me!!!

Many times patients are so hungry for touching, and practitioners are so hungry to make a difference that they don"t recognize the difference in a safe and unsafe session. It’s up to the integrity of the schools, co ordinators and teachers in this field to see that wisdom prevails.

Blessings

Irene Smith www.everflowing.org