In the U.S., patients’ use of hospice care is growing. According to a 2014 report from the U.S. Centers for Medicare & Medicaid Services, the number of people receiving benefits for hospice grew 58 percent from 2000 to 2012; also, Medicare’s expenditures on hospice care increased from $2.9 billion to $15.1 billion, or by 80 percent.
By 2013, the most recent year for which statistics are available, the number of hospice providers in this country had grown to almost 6,000. In 2014, between 1.6 and 1.7 million Americans received hospice care at end of life, according to the National Hospice and Palliative Care Organization.
Gentle massage therapy is oftentimes offered to hospice patients. Here, hospice massage pioneer Irene Smith discusses therapeutic presence and how that can assist massage therapists when providing healthy touch to hospice patients.
Depth of Vulnerability
Dying persons are vulnerable. They have lost physical defenses due to the loss of muscle mass and physical stamina. They have relinquished social defenses in the need to receive intimate care, and many will give up emotional defenses as they let go of their image in the world, their family, their bodily functions and finally the ability to breathe.
This depth of vulnerability requires the practitioner to create a safe environment or container in which the dying person feels that his or her vulnerability is witnessed, validated and honored.
The foundation for this practice of witnessing is therapeutic presence, a term first used by Carl Rogers, Ph.D., an American psychologist who is known as the father of person-centered therapy.
Therapeutic presence is the quality of self, or the way of being that therapists bring to the therapeutic relationship. It is a state of being, rather than a state of doing.
This state of being involves the practitioner’s ability to be personally grounded and available as a nonjudgmental witness for the dying person’s expression of his or her illness.
Presence & Protocols
American psychologist James F.T. Bugental, Ph.D., described three components of therapeutic presence:
- Being open and present to all parts of the client experience;
- Being open to all of one’s own experience as one is with the client; and
- Being able to respond from the immediacy of 1 and 2, noted above, combined.
The practice of therapeutic presence involves the practitioner in the following protocols:
- The practitioner holds the intention of witnessing, validating and honoring the dying person’s experience, rather than trying to fix, change, cure or correct any specific symptom or condition.
- The practitioner is quiet, observes the dying person and takes several breaths. This is a time of introduction on a deeper level than conversation. Each person has the opportunity to sense the rhythm and vibration of the other person’s energy and their energy together. This time of silent interaction provides a space for trust building and gives the relationship a center from which to deepen.
- The practitioner allows the dying person’s symptoms full expression. For example, in the case of Parkinson’s disease, the practitioner would not try or intend to restrict the movement to provide a touch session. The practitioner would observe the patient’s tremors and assess how he or she might interact with touch as a partner in movement.
- The dying person is allowed a greater sense of acceptance, which raises the self-esteem and deepens the trust in the touch relationship. He or she knows that they can bring themselves fully into the relationship without fear of rejection.
Cultivated from Within
No academic discipline has developed a systematic approach for teaching therapeutic presence as a skill or ability. It is cultivated from personal growth outside the training environment.
The Buddhist meditation practice of mindfulness, however, offers a training ground for the development of therapeutic presence through openness and compassion to one’s own thoughts and feelings, and a nonjudgmental witnessing of oneself.
Being at the bedside with a dying person and possibly caregivers and family members—all of whom may be in various states of grief, not knowing what to do—the cultivated skill of therapeutic presence becomes an oasis of wise non-action.
Irene Smith began her journey as a massage therapist in 1974. She founded and directs Everflowing, an educational outreach program dedicated to teaching mindful touching as an integral component to end-of-life care. Smith is a member of the National Association of Massage Therapists, Hospice Volunteer Association and the San Francisco Bay Area End of Life Coalition. She wrote “Advocate for Yourself in the Health Care Environment” for massagemag.com (June 21, 2016).
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