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Aromatherapy and Massage for people with a learning disability

by Shirley Durell(more info)

listed in aromatherapy, originally published in issue 30 - July 1998

During my nurse training, I was able to observe Aromatherapists apply aromatherapy and massage to people with a learning disability. I also studied in depth the relevant literature. This increased my awareness of the potential of these therapies and instilled in me the need to consider the senses of smell and touch within this client group. This article by reviewing such literature, will discuss how the combined application of these therapies can contribute holistically to the lives of people with a learning disability.

Learning disability is a less stigmatising term used today by health care professionals. It provides hope for development by identifying the nature of the disability, reducing it's effects and increasing the learning potential. "It is a generic term given to a variety of 'conditions' which result in intellectual impairment, embracing all possible causes and outcomes in a sensitive and acceptable way."[1](p362)

Aromatherapy is the use of plants' essential oils to enhance health and fight infection. The oils can be extracted from different parts of the plant and have been identified to work in three ways:

pharmacologically: oils enter the bloodstream and interact with hormones, enzymes, etc.
physiologically: oils cause an effect on the body for example, a stimulatory effect
psychologically: the fragrance of the oil when inhaled cause an effect on the Olfactory system, ultimately affecting the Limbic system.[2] [3]

The latter requires further examination, bearing in mind the number of people with multiple disabilities. For example, 48% of people with a learning disability also have a sensory impairment, of which, 18% have a dual sensory impairment.[4]

The Limbic System is a ring of structures on the inner border of the Cerebrum and floor of the Diencephalon, which encircles the brain stem. It is not only associated with the sense of smell but also plays an important role in emotions. This is why it is sometimes referred to as the "emotional" brain.[5] Therefore by affecting the Limbic system, the oils are causing changes at a psychological level, for example a relaxing effect. This suggests that via the sense of smell, emotions can be manipulated.[6]

Massage has been clearly defined as "a mechanical manipulation of body tissues with rhythmical pressure and stroking for the purpose of promoting health and well-being."[7](p16) There are various massage techniques available but for the purpose of this article simple massage strokes, such as effleurage, will be discussed. It is one of the oldest and commonest way through which the essential oils can be applied and used. The merger of the senses of smell and touch, and the acknowledgement of the physical, psychological and spiritual dimensions of the self, identifies the combined application of aromatherapy and massage as a truly holistic experience.[8] So how can the combined application of these therapies, contribute holistically to the lives of people with a learning disability?

Harrison & Ruddle have highlighted how the senses of smell and touch are not often considered when working with people with a learning disability. In particular people with additional disabilities, such as sensory impairments. These senses can compensate for the loss of other senses and allow them to be able to discover other channels by which they can communicate to the outside world.

The authors recognise the popular belief that the strength of aromatherapy lies in the combination of three core elements - the essential oils, massage and the therapistclient relationship. Bearing in mind all these factors, the authors identify five different ways of introducing aromatherapy to people with a learning disability. These are: "to invigorate and promote activity and alertness, to facilitate relaxation and reduce stress, to stimulate sensory awareness, to facilitate and encourage interaction and communication and to treat medical problems using natural substances."[9](p38)

The diversity of the needs of people with a learning disability is beyond the scope of this article. However, in order to develop some understanding on how aromatherapy and massage can be introduced, this article will examine the application of these therapies to stimulate sensory awareness in people with a learning disability and a sensory impairment, who exhibit stereotypical behaviour.

Stereotypical behaviour can be displayed in many different ways. These may include pressing or poking eyes and rocking the body forward and back whilst seated. They are repetitive actions, with no apparent purpose and could be regarded as harmless. But sometimes a person can become engrossed with these behaviours, cutting themselves off from their immediate environment. At the same time, some stereotypical behaviour, such as eye poking, can be dangerous and can be termed self injurious.[10]

Stereotypical behaviour can be identified as a characteristic of a particular syndrome. However, the Royal National Institute for the Blind believe these mannerisms in people with a visual and learning disability, are caused by the aggregation of physiological factors with environmental and staffing issues. High noise levels, poor lighting and building design can cause anxiety and confusion. Carers need to find out what rewards the person with a multiple disability derives from these behaviours and how to offer opportunities for learning and development. Unfortunately, this situation allows the person to create their own sensory stimulation and retreat to a world that is consistent, safe and rewarding. But how aromatherapy and massage empower the person to no longer seek self stimulation?

Multisensory Massage

Longhorn proposes that the aims for a Tactile Curriculum should include: "..increasing awareness of tactile experiences,..an increased tolerance of touch and an improved awareness of an individual's own body."[11](p85) Multisensory Massage fulfils the requirements of a successful Tactile Curriculum and can offer the person an opportunity to explore and be aware of different sensory experiences. This is achieved with the combined application of essential oils and different massage tools during the activity, which can be easily adapted and developed to meet individual needs.[12]

Morbey[13] recognises how the gradual introduction to different textures and scents can help people with a learning disability and a dual sensory impairment become less "tactilely defensive". By gradually increasing tolerance of touch, Multisensory Massage can help the person feel more comfortable with certain events, such as having their nails cut. At the same time, it can encourage the person to learn new skills and become more independent. Initially the person may resist this but will slowly increase their tolerance of touch as they develop through recognisable stages, encouraging the evolvement of Interactive Massage. This experience identified by Sanderson et al is based on the premise of gentle teaching which concentrates on the importance of developing and strengthening relationships. In addition, these therapists apply McInnes and Treffry's work[14], which is the result of years of involvement with children who have a dual sensory impairment. They believed that only through a trusting relationship will these children be encouraged to explore the environment. This relationship will most probably be established by physical contact. The authors propose an eight stage sequence (resists, tolerates, co-operates passively, enjoys, responds co-operatively, leads, imitates and initiates), which the person may progress through during the introduction of a new activity and the development of this relationship. Sanderson et al have termed this the Interactive Sequence, and apply it as a framework for assessing the progress made by people with severe learning disabilities during Interactive Massage.[15]

It could be argued that Interactive Massage can be an invasion of a person's privacy. Even if the stereotypical behaviour may not serve any apparent purpose to the observer, it is important to the person. However, by allowing the person to develop and strengthen relationships on their terms, Interactive Massage becomes an empowering experience.[16] With time the person will start enjoying these interactions and will no longer seek self stimulation. They will be encouraged to explore their environment within the safe boundaries of a trusting relationship, which they could rely on for support when needed, in future growth and development. In addition, Multisensory Massage can improve the awareness of a person's own body by including the beginnings of a positive body image, which can boost a person's sense of self-worth. It is much more than a practical touch, through dressing or feeding and can help to show a person that their body is well worth caring for.[17]

Further examination of the literature reveals several research studies which have investigated further the effectiveness of Sensory Integrative Techniques and included massage as a tactile stimulation, to reduce stereotypical self injurious behaviour in people with a learning disability. These recorded a significant reduction in the behaviours displayed.[18] [19] [20] Although only Dossetor's et al study used a combined application of aromatherapy and massage and not all of the subjects involved in these studies had additional sensory impairments, they are still worth mentioning as they all fit the conceptual hypothesis consistently suggested in the literature reviewed, ".. a number of workers have speculated that the stereotyped, repetitive actions - rocking, rubbing and self - injury - found in many of those with learning disabilities are a form of self-stimulation which might be reduced if stimulation was provided by others."[21](p123)

In 1986, O'Brien offered a valuable tool by which to evaluate the services provided to people with a learning disability.[22] The author identified five key areas or accomplishments which affect the quality of a person's life. These are: choice, respect, competence, community presence and participation. By applying this tool as a framework in the application of aromatherapy and massage, controversial issues such as consent, consultation and collaboration can be addressed. To illustrate this further, the following case study may assist.

Case Study

M has a profound learning disability and cannot communicate verbally. He is unable to guard himself against common dangers and is totally dependent on others to fulfil his needs. He exhibits severe self injurious behaviours which include punching his face, as a form of communicating his requests for food and drink and banging his head on hard surfaces, to gain staff's attention. He is intolerant of delay to obtain his requests and the frequency of these behaviours increase during the summer months and with unfamiliar people and environments. M's physical disabilities and self entanglement in clothing for comfort, make him unsteady on his feet and it is not clear whether his long history of multiple falls and accidents have caused him additional sensory impairments. As a result, M spends most of his days lying alone on a sofa. He participates in aromatherapy sessions, of which I attended several. The following text summarises my observations.

M would sit up on his bed and allow the Aromatherapist to massage his back. Initially his arms would be entangled in his clothing and he would punch his face. As the session progressed, he would free his arms from his clothing and would no longer punch himself. Instead he would smile and vocalise to the Aromatherapist as she applied the oils and complemented him with a soft voice on how well he was doing. M would guide her strokes by offering his arms, legs or chest. He would gradually deem the session over by lying on his side and falling asleep.

It is clear from my observations that M's consent, consultation and collaboration were addressed at all times. His sessions took place within the privacy of his bedroom, a place of choice for M as he found it warm and safe. By directing and guiding the Aromatherapist throughout the sessions he was allowed individuality and respect. M's display of self injurious behaviours would decrease as the sessions progressed. He was starting to enjoy these interactions and was no longer seeking self stimulation. This was developing his competence by encouraging him to explore his environment within the safe boundaries of a trusting relationship. This was of vital importance as it was envisaged that M would move to a community home in the near future. By enhancing his skills and with the support of his carers, M would become a valued member of his community, avoiding segregation and allowing him community presence and participation.

My academic and practical experiences have led me to the conclusion that aromatherapy and massage can contribute holistically to the lives of people with a learning disability. The application of O'Brien's framework to evaluate the use of these therapies, clearly demonstrates how they fulfil the requirements of the values which underpin philosophies of client centred service provision. I hope this article will instigate others.


The Interactive Sequence
Stage1 Description of Response Example: Hand Massage
Resists Initially resists the activity. Do not insist, but switch to a related activity which you know the person enjoys. Return to the new activity once the tension has disappeared. Person initially tries to resist and hides her hands. Switch to touch which you know she enjoys, eg. stroke her hair, arms. Try again.
Tolerance Is able to tolerate activity for a period of time because of the rewarding one-to-one contact rather than the activity itself. Gradually tolerates activity for longer periods. Will allow support worker to touch her hands fleetingly. This is extended until the support worker can touch and stroke her hands for five minutes without the person withdrawing her hands.
Co-operates passively Support worker will notice a subtle change in response as the person becomes less resistant. Person allows her hands to be massaged for longer periods; different strokes can be introduced.
Enjoys Person becomes more relaxed and familiar with the activity. Remains passive but demonstrates signs of enjoyment.

Person may smile when she is touched or stroked.

 

Responds
co-operatively

Person will follow the support worker’s lead with little direction or need for encouragement. Person will begin to smile and show signs of enjoyment when the bottle of cream or oil is given to her, and will proffer her hands for the massage to begin.
Leads Person will begin to anticipate the sequence and direction of the activity. Person will show that she is aware that you have finished massaging one hand and will offer the other.
Imitates Person will go through the sequence of activity independently, given appropriate communication. Person may begin to imitate the support worker’s strokes on the back of her own hands.
Imitates independently

Person will imitate activity without prompting.

 

Person takes bottle of oil to the support worker at the time when the massage usually begins. Reciprocal massage can be introduced where person rubs cream into support worker’s hands after massage.
1    Stages 1 - 4 - Passive Massage                 Stages 5 - 8 - Interactive Massage

 

References

1 Thompson T & Snowley G,People with mental handicap In Kenworthy et al (eds) Common Foundation Studies in Nursing(Edinburgh: Churchill Livingstone,1992),361-78.
2 Trevelyan J & Booth B,Complementary Medicine For Nurses, Midwives And Health Visitors(London: Macmillan Press Ltd,1994),17-42,69-87,227-41.
3 Hildebrand S,Therapeutic Massage and Aromatherapy In Wells R and Tschudin V (eds.)Wells' Supportive Therapies in Health Care(W.B. Saunders Co. UK,1994),103-28.
4 Harris D, Agenda for change: Services for People with Learning Disabilities and Sensory Impairments (London: Change Publishers,1991) Cited In Harrison J & Ruddle J "An Introduction to Aromatherapy for People with Learning Disabilities," British Journal of Learning Disabilities 23 (1995):38.
5 Tortora G J & Reynolds Grabowski S, Principles Of Anatomy And Physiology, Seventh ed. (New York: Harper Collins College,1993),405-42.
6 Toller S V, Introduction To The Sense Of Smell In Vickers A, Massage And Aromatherapy A guide for health professionals (London: Chapman & Hall,1996),32-6.
7 Harris B & Lewis R, "Physiological effects of massage," International Journal of Alternative & Complementary Medicine 12 2 (February,1994):16.
8 Tisserand R, Aromatherapy For Everyone (London: Penguin Books,1990).
9 Harrison J & Ruddle J, "An Introduction to Aromatherapy for People with Learning Disabilities," British Journal of Learning Disabilities 23 (1995):37-40.
10 Royal National Institute for the Blind, Stereotypical behaviour in people with visual and learning disabilities Focus factsheet (London: RNIB,1995).
11 Longhorn F, A Sensory Curriculum for Very Special People (London: Souvenir Press 1988) Cited In Sanderson H et al, Aromatherapy And Massage For People With Learning Difficulties (Birmingham: Hands On Publishing,1995).
12 Ruddle J, "Aromatherapy," RNIB Focus Newsletter 9 (April 1993):28-37.
13 Morbey G, Helping with sensory impairments In Shanley E & Starrs T A (eds) Learning Disabilities A Handbook Of Care, Second ed.(Edinburgh: Churchill Livingstone, 1993),135-47.
14 McInnes J & Treffry J Deaf-Blind Infants and Children - A Developmental Guide (Milton Keynes: Open University Press,1982)Cited In Sanderson et al, Aromatherapy And Massage For People With Learning Difficulties (Birmingham: Hands On Publishing, 1995),77.
15 Sanderson et al, Aromatherapy And Massage For People With Learning Difficulties (Birmingham: Hands On Publishing, 1995),83.
16 Sanderson H & Carter A,"Healing Hands,"Nursing Times 90 11 (March,1994):46-8.
17 Sanderson et al, Aromatherapy And Massage For People With Learning Difficulties (Birmingham: Hands On Publishing, 1995),85.
18 Bright T et al, "Reduction of Self-Injurious Behaviour Using Sensory Integrative Techniques,"The American Journal of Occupational Therapy 35 3(March, 1981):167-72.
19 Dossetor D R et al, "Massage for Very Severe Self-Injurious Behaviour in a Girl with Cornelia de Lange Syndrome," Developmental Medicine and Child Neurology 33 7 (1991):636-40.
20 Wells M E & Smith D W, "Reduction of Self-Injurious Behaviour of Mentally Retarded Persons Using Sensory-Integrative Techniques," American Journal of Mental Deficiency 87 6 (1983):664-6.
21 Vickers A, Massage And Aromatherapy A guide for health professionals (London: Chapman & Hall, 1996).
22 O'Brien J, A Comprehensive Guide to the Activities Catalogue: An Alternative Curriculum for Youths and Adults with Severe Learning Difficulties. In: Bellamy J T & Wilcox B (eds) (Baltimore: PH Brooks,1986) Cited In Sanderson et al, Aromatherapy And Massage For People With Learning Difficulties (Birmingham: Hands On Publishing, 1995),21-25.

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About Shirley Durell

Shirley Durell is a Registered Mental Handicap Nurse, who will be undertaking professional training in Aromatherapy later on this year.

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