For those therapists who practice touch therapies such as massage, aromatherapy and reflexology, our world has been turned upside down by the presence of a virus; an invisible life form which we cannot see, hear, touch, smell or taste. To reduce the spread of the virus COVID-19, in line with government guidelines, professional bodies, including the FHT, have given guidance that precludes the continuing of hands-on therapeutic work with clients. To date, we are not aware of medical permission being granted for touch interventions during this time of lockdown in the UK. Ethically, we are in a difficult place where compassionate intention and the need for touch is in conflict with infection risk to ourselves and others in our care.
To survive and thrive, we have to become more creative and find alternative approaches to offer our skills and abilities. Due to the possibility of spreading infection, our main means of communication - the therapeutic use of touch - is no longer available. So, how do we adapt in the short-term and then in the longer-term find our way back to providing touch therapies? First, we need to remember our purpose in offering a therapy session; it is likely to be to promote relaxation, feelings of calm or wellbeing. So, let’s explore the potential for the resourceful use of the voice as a therapeutic and flexible approach.
One major advantage is that we always have our voices with us, and providing an individual can hear us, our voice can be used at any time and in any situation. Our voices can be used in a variety of situations where patients are not able to receive touch through a physical therapy, for example, where the client and therapist are not present in the same room. The client may be at home or having a clinical treatment or s/he has an infection which is contagious and is being isolated. Here you can use telecommunication/ social media to engage and deliver a spoken relaxation session or demonstration and guidance on a self- help or self-soothing technique. For, example progressive muscle relaxation (PMR), involving the tightening and releasing of muscle groups from head to foot (or the other way around) combined with breathwork is well evidenced in research to promote relaxation and reduce anxiety.(1) Both of us have worked with patients undergoing radiotherapy, providing relaxation techniques, such as a mini PMR over an intercom system – no one can enter a room when the radiotherapy treatment is in progress. These situations require prior planning, engagement and practice with the patient to create a suitable PMR and /or guided imagery session that works for the individual. Importantly, being comfortable with using your voice is in itself an art and skill.
Complementary therapy without the use of touch
We have always advocated integrating the use of the human voice either alongside the therapeutic use of a touch therapy, and perhaps guided imagery may offer a useful framework for this situation. Sessions can be between 5 to 15 minutes in length; recordings of the sessions can be made for home use; the session can be carried out via the telephone (or a telecom) or the client can be involved through a digital network.
Suggestions for person generated guided imagery
The combination of a person’s own resourceful memory and the sound of the human voice can be an engaging and powerful way of working. Using an individual’s own experiences creates what we call ‘person generated guided imagery’ (PGGI), in which our experience can be recalled more easily than a generalised script. Working in a person-centred way is an engaging process and focuses on including words and content that resonate with an individual, such as a journey or event that triggers a smile and/or warm feeling. Kelly King, in reviewing the research evidence for guided imagery, suggests that clients be enabled to create their own place or image of relaxation and calm.(2) It is important to recognise that general guided imagery scripts, often easy to locate on an internet search, are not suitable for every client - we need to be sensitive and mindful of an individual’s history, culture and beliefs. For example, a beach may not be appropriate image for someone who discovered a skin lesion while sitting on a beach or even witnessed a distressing incident.
In the early stages of learning to construct and deliver a guided imagery, therapists may use a simple script, incorporating some suggestions from the client, for example, a journey, mode of transport and a destination. We would also suggest moistening your mouth with sips of water prior to starting - it can make all the difference to a dry voice. Below is a
‘5 Senses’ framework which will support you in working with another individual to develop a more personalised guided imagery – a PGGI, whatever the situation…
Incorporating sensory language
When an image is formed in our thoughts it utilises five physical senses: visual (sight), auditory (sound), kinaesthetic (touch, feelings and sensations), olfactory (smell) and gustatory (taste). The inner experience is communicated to others through language, with individuals usually having a preferred sense through which they visualise and communicate. When constructing an image, it is likely most of the other senses will inform parts of the image, although some senses will be less dominant.
Examples of sensory words
Visual: see, bright, clear, sparkle, light, glisten.
Auditory: ring, loud, soft, quiet, crashing, squeaky.
Kinaesthetic: warm, cool, feel, smooth, rough, velvety, pressure.
Olfactory: scented, aromatic, smell, musky, earthy.
Taste: sweet, salty, sharp, bitter, citrus, spicy.
It is essential to explain the process to the client before obtaining consent to participate. Paper and a pen/pencil will be needed for making notes - jotting down as much as you can as the client talks. Key phrases and words will help you form a brief script. Do ask the client to repeat words or phrases; once s/he starts to tell you about the memory the words usually flow.
Engaging the client in the process
Ask, ‘Do you have a memory, place or event that is comforting for you and makes you smile?’ Once the person nods or says, ‘Yes’, then you can invite them to, ‘think of your senses (aromas, colours, sounds, etc), let them take you to the place/event chosen.’ When s/he has ‘arrived’ you can begin to gather information in terms of sensory language. Ask open questions such as, ‘What can you see?’, ‘What can you hear?’ and ‘How do you feel?’. You may want to help the individual develop his/her responses by asking more questions, for example, ‘What colours are you aware of?’, ‘How warm is it?’, ‘Tell me about the weather’, or ‘What other sensations do you experience?’ Ask about the sense of taste where the scenario features food, for example, a picnic, baking, or a celebration. To bring the information gathering to a close you can ask him/her to be aware of the positive/warm feelings experience when accessing their chosen event/scene.
Recounting the PGGI
Once you have the client’s ‘story’ and some notes, you can use it as a stand-alone intervention or during a touch-based session at his/her chosen time during the treatment (when we are once again in a position to provide hands-on treatments). We suggest three stages in recounting the ‘story’:
1. Ensure that the client is comfortable and suggest that s/he thinks of an event/scenario which made him/her smile (or other suitable words).
2. Once you have written the key phrases and words, retell the story, using their own words wherever possible, as though you were telling it to a friend.
3. When you arrive at the conclusion of the narrative, let the client know that s/he can return to this pleasant memory by thinking of the aromas/colours/sounds etc. S/he can use the memory for relaxation or promoting sleep, or for creating a feeling of wellbeing as an interlude during the day.
An important factor of working in a client-centred way is that you need to work with what s/he suggests, however strange it may seem to you (providing it is appropriate, of course). Usually the information shared is important to the client and will be linked to deep feelings of comfort and calm. The following scenarios, linked to a memory, have been typically suggested:
- A celebration, event or achievement
- A favourite location, walk or holiday moment
- Being with friends, family members or pets involved in an enjoyable activity.
A way forward
With some preparation, a PGGI session is not intended to be lengthy or involved but serves to engage the client in a pleasant mind activity during a short session. Where a client decides to use the technique in future situations, recall of the experience may help to promote calm, or a means to self-soothe prior to, or during, a medical procedure or investigation. As therapists, if you are also wanting to use PGGI to support healthcare staff and carers at this time, it can be used to access resourceful memories and hopes in the future, so giving them a tool which can help to promote resilience.
We hope by proposing this approach it can be part of your toolbox when we can eventually return to hands-on care for clients and their family members. In addition, this approach can be combined with a prepared aromastick (if qualified in aromatherapy), so the individual has it available ready for the guided imagery.
Want to learn more?
For more information on ‘Relaxation and Creative Imagery’ and ‘The HEARTS Process’ courses, contact the Integrative Therapies Training Unit at the Christie NHS Foundation Trust, Manchester on email at: ITTU@christie.nhs.uk You can also read an article on the role of fabrics and textures in therapy treatments by Ann and Peter, published in Issue 128 of International Therapist, at: www.fht.org.uk/material-therapist
About Peter and Ann
Dr Peter Mackereth was the clinical lead of the complementary therapy and wellbeing service at The Christie, a specialist cancer centre in Manchester, for over 15 years and is currently an honorary lecturer/researcher. Peter is now working temporarily as a nurse and awaiting return to his role as a hospice therapist. He has authored numerous papers, chapters and books, and received an FHT Award in 2016 in recognition of his outstanding contribution to integrated healthcare and the complementary therapy industry.
Ann Carter has a background in training and health promotion and has worked as a complementary therapist and teacher since 1989, in both hospices and the acute sector. For more than 10 years she was the co-lead for The Christie complementary therapies training programme and also developed The HEARTS Process; a multisensory approach to facilitate relaxation in cancer care, incorporating the use of touch techniques over textures accompanied by the human voice (3).
- Mackereth P Tomlinson L (2010) Progressive muscle relaxation: a remarkable tool for therapist and patients. In: A. Cawthorn and P.A. Mackereth (eds) Integrative Hypnotherapy: Complementary approaches in clinical care. Elsevier Science. London
- King K (2010) A review of the effects of guided imagery on cancer clients with pain, Complementary Health Practice Review 15(2): 98-107.
- Carter A Mackereth P (2019) Combining Touch and Relaxation Skills for Cancer Care: the HEARTS process. Jessica Kingsley Publications. London.
© 2020 Dr Peter Mackereth and Ann Carter. No part of this article may be reproduced or disseminated without the express permission of the authors. Please note that the FHT does not necessarily associate itself with any views expressed in this article, which has been submitted by the authors, as a general interest piece for FHT members. As such, the FHT shall not be liable for any loss or damage whatsoever arising from any information contained in this document.