The Gineste-Marescotti methodology of care.

 

All rights reserved in France and abroad.

Registered trademarks : "Toucher Tendresse", "Gineste-Marescotti", "Philosophie de l'humanitude", "Capture sensorielle", "Manutention relationnelle", "Mourir debout".

 

International Copyright č 1999 to 2008. These articles are published subject to the condition that they shall not be reproduced without the written consent of Yves Gineste and Rosette Marescotti, and with the mention : Production Yves Gineste and Rosette Marescotti, CEC.87220 France, http://www.cec-formation.net

 

In Quebec, IGM-Canada teaches the Gineste-Marescotti Care Methodology

 

The ASSTSAS organize training sessions derived from the methodology, in a programme called "Relational Care".

 

 

 

 

 

 

 

 

Sensory capture and feedback in the management of behavioural disturbances in demented old patients during basic care.

 

 

 

 

 

Yves Gineste, Rosette Marescotti

 

 

 

 

 

Reminder of definition : Dementia is characterized by memory disorders associated with another disorder of the superior functions.

 

 

Introdution :

 

Healthcare workers are well acquainted with those problems they have to face frequently : patients screaming during bath, refusing all care, drawing back when toileted or dressed , which renders care very difficult, if not impossible.

 

Such patients may sometimes behave aggressively, trying to hit the healthcare staff in charge, biting them, scratching them or insulting them.

 

Twenty nine years of practice and experimentation have made it possible to us to conceptualize another approach to dealing with such disorders. It is based on a philosophy of care, on verbal and non-verbal communication techniques, on care sequencing techniques during bath, as well as on particular nursing techniques.

 

This new approach, presented here for the first time, has now moved into a stage of evaluation and neuro-psychological conceptualization. The first results show an alleviation of behavioural disturbances in over 90 % of the cases.

 

 

Philosophical approach :

 

Developed as early as 1996, we have called this approach "Philosophy of  humanitude" (humanitude being a neologism coined by Professor Jacquart). It tries to answer the question : "What is a healthcare worker ?

Everyone will probably agree to define healthcare staff as professional workers who take care of persons to improve or preserve their health or  simply to accompagny them on their way to death. But this definition does not answer the question : what do we call a person ?

 

Man is an animal. But the person in charge of animal care is an veterinary surgeon.

 

You cannot claim to be a heathcare worker before you are in  charge of what makes man specific.

 

What  we have called humanitude represents these distinctive features.

 

Humanitude is the whole of the features that allow persons to recognize their association with mankind.

 

As is the case for all species, it is a vital necessity for man to be recognized as belonging to his species.

 

We take it as axiomatie that regressive behaviours (immobility syndrome in old patients) as well as "aggresive" behaviours in demented patients appear  when the conditions of belonging, of recognition by the species, are no longer sufficient.

 

When a dog sees another dog, even a very different one, it knows that it meets an animal of its own species.

 

The signals of belongings to the species, whether innate or acquired, are essential for immediate survival as well as for development. They are present at birth and grow during education. It is reasonable to think that a lack of such signals might lead to regression and that aggressiveness in old patients is often but a desperate attempt to resist and survive.

 

Let us first try to determine the essential points of the distinctive features of humanitude.

 

When a lamb is born, its mother licks it, which the lamb recognizes as a first sign that it belongs to a species. If the mother does not lick the lamb, it most often dies.

 

In the first months of its life, a baby will in the same manner receive signals of humanitude :

 

  1. Sight is a first essential sign. In its relationship with its parents, the child develops under a fond look, full of love and tenderness. It is a prolonged look, an intensive one into each other's eyes, and it is at all times on the parents' faces.
  2. Speech : It is also continual, it is more often just a gentle flow of music, a lullaby, but the meaning of lyries does not matter in the beggining. The only essential point is the regular presence of the tune. It radiates joy during the baby's bath or care and favours reciprocated affection. The baby is fascinated, as if hypnotised by those sounds which it recognizes better and better, giving it an opportunity to feel different from the surrounding people or environment. Progressively, the words acquire a meaning, and each word pronounced by the infant is greeted by the parents'look, reinforced by the expressions of joy of the family circle. When the baby cries, it makes you understand it feels left alone, abandoned, frightened, suffering. The words and the look of the parents can comfort a baby, but a third essential point must be added : the sense of touch.
  3. Touch : The human touch also lies within a specific framework of tenderness, affection, pursuit of a better quality of life, pleasure. Here, we are dealing with a loving touch.

This particular touch can be described as follows.

-       It is generally very soft, affectionate, full of tenderness.

-       Most often, it follows the other two signals, sight and speech.

-       It is associated with other positive stimuli, such as the taste of milk, the end of hunger, the end of the unpleasant sensation of being wet, the feeling of well-being in the bath.

 

These three points, sight, speech and touch are bound to evolve together, throughout the first years of childhood.

 

At neuro-psychological level, touch is part of the sensitive construction of an emotional memory in the limbic lobe. Each moment of care plays a role in the construction of the "emotional atmosphere" memory, from wich all human beings are going to draw all their life to identify the good moments spent together.

 

Spitz has studied the hospitalism crisis syndrome in infants living in orphanages. In those centres in which the professional approach prohibited affectionate exchanges with the babies, in which singing a lullaby was disregarded by the hierarchy, the babies could not develop affectionate behaviours. The results ar nearly as disastrous as they were in the study on lambs : death, anorexia nervosa, severe retardation, autism, severe behavioural disturbances ( See Table I).

 

Other major points playing a role in the access to humanitude are upright position, development of conceptual intelligence, laughing, smiling, humour, dressing, social habits (food, clothes, social life, etc.)

 

It is not the purpose of this study to go further into all these points, though essential to "good healthcare".

 

In order to develop management strategies to tackle "aggressive" behaviours, it is necessary to remember some neuropsycho-geriatric features :

 

* Sight : Demented old patients most generally suffer from a more and more reduced field o view as their dementia develops. Moreover, lower acuteness of vision is often a geriatric handicap.

 

* Speech : The mean verbal communication time with a bedridden old patient in an institution is inferior to 120 seconds per 24 hours (Recorder study by Gineste-Marescotti, 1983-1985), without forgetting that hearing is often defective.

 

* Touch : The "aggressive" or bedridden old patient is, as a rule, not touched by the healthcare staff except when absolutely required : during care, when the patient is changed, during toileting or dressing. It is very rare to touch the  patient affectionatelly, as a source of comfort.

 

* Progressive destructuration of the bodily scheme is quite common.

 

* At motory level, the loss of strength and illness inevitably compel the patient to stay in bed, with the consequent loss of the sense of upright position.

 

 

Sensory capture and feedback in the management of the so-called "agressive behaviours".

 

All demented old patients suffer from symptons such as reduced efficiency of the senses, loss of memory, that lead to some kind of aggressive anxiety that expresses their inability to "decipher" the world around them, as well as to interfret their lives in terms of "humanitude".

 

As is easy to understand, the patient runs the risk of  losing the four fundamental signals required for the construction of humanitude : affectionate look, loving touch, speech and upright position.

 

The reduced cognitive capacities increase the patient's anxiety, in particular the loss of semantic memory (what are you talling about ?), as well as damage to autobiographic memory (what on earth am I doing here ?).

 

Very often – if not always – the loss of immediate (recent) memory gives the patient the impression that he is constantly taken care of by a newcomer.

 

The perception of this whole set of serious disorders has led us to test a new patient approach : sensory capture.

 

 

Principles of sensory capture :

 

The preliminaries : each care must be preceded by 1 to 3 minutes of "preliminaries", compresing the following steps :

 

 

a)     Visual approach :

 

This approach must compulsorily be made in a communication channel, in which the healthcare worker presents himself face – and alone - , trying to catch the eyes of the patient. He avoids direct intrusion into the intimate bubble and, for a start, stays some 50 centimetres from the patient's face.

 

b)    Touch :

 

      He lays his hand with tenderness, following the principes of the tender touch which we       have explained, on some neutral part of the body : calf, forearm.

                              The hand must be laid starting gently with the fingertips, until the palm is in full contact with the skin. From that moment on and during the whole phase of sensory capture, one hand must always be in contact with the patient and never leade him, on no account (see Table II at the end).

 

 

c)     Speech :

 

It must be part of the act as soon as the heathcare worker enters the field of view of the patient : the voice is audible, soft, quiet ; it opens with a word of greeting, followed by a pause to wait for a reaction. The heathcare worker introduces himself each and every time : Hello, I am  John. (See Table III at the end).

 

The sentences that follow are always assistance/help – related : How are you ?, I'm here to help you, I'm a friend, my name is John, I'm coming to look after you, to help you.

 

The purpose of these repetitions is to try and find back an emotional memory of quiet, serene moments. If the words chosen create mnesic links, they must find back nothing but sensations associated with situations of well-being.

 

Words likely to remind fo antagonistic situations must not be used (I'm coming to give you a bath, e-g., when the patient has a horror of it).

 

This phase of capture lasts as long as cries, agitation or whimpering continue.

 

All gestures are annouced and described.

 

 

This takes us to sensory feedback.

 

At brain level, the patient thus "recognizes" a forgotten approach. As speech, touch and sight operate in a loop, in harmony, they appease the patient. The muscle tone is reduced significantly and the handling of stiff patients become easier. The sensory feedbak is then attained, the patient is globally calmed down and the procedure of care is made easy.

 

The patient seems to be in direct contact with his memory of emotional atmosphere – well described by North American neuro-psychologists – which is the last one to survive.

 

This practice leaves a trace in the secondary memory. In a demented patient, the links between short term memory and secondary memory are generally impossible, which explains why the patient is virtually unable to recall recent events. This is where a second circuit takes over, a "feeling" circuit, which stores in the second memory – that of  emotional atmosphere – the quality of the moment and its feeling of appeasement. The next day, the patient does not recognize you, but he "feels" that you are going to do him good.

 

Filmed sequences have revealed the impregnation of this priming or impression. Very often, after one single bath with sensory capture, the next ones are already much more relaxed without any further particular precautions. This priming takes a few days before fading.

 

One the other hand, if care with capture and feedback continues, "aggressive" and disturbing behaviours completely disappear in less than two weeks.

 

 

 

Conclusions :

 

At this point in time, when the complaints of healthcare worker suffering from the aggressiveness of demented patients increase in worrying proportions, the benefits of this new approach of care appeat to be essential.

Estimates based on long-term patients highlight that more tan 30% of them display disturbing behaviours, and 10% of them behave in a direct aggressive manner towards these professionals.

 

.

 

 

 

The authors :

 

Yves Gineste and Rosette Marescotti are training managers. Their association, the CEC (Communication Etudes Corporelles), and IGM France (Institut Gineste-Marescotti) has been a partner in hospital care training for over 29 years.

Internet : www.cec-formation.net

 

 

 

Table III

 

Speech

 

May we remind the reader of the results of a study made on long-term patients (CEC 1983 – 1985), leaving voice-release tape-recorders in the patients' rooms. An average of 120 seconds per day of verbal communication between the healthcare workers and the patient, some tapes remaining absolutely blank, in the case of patients exteriorizing nothing or apparently understanding nothing ! (Study made in full compliance with the code of professional ethics and confidentiality).

 

Such a situation is normal, since human communication obeys a number of rules. The speaker (the healthcare worker in this case) sends a verbal message (good morning, for example) to a receiver (the patient). But at the same time, the speaker expects an answer, in real time, before he continues his conversation. This answer is called "feedback". The very essence of the speaker's communication comes from the receiver.

 

Before a conversation can continue, it is normal, natural to wait for an answer. Most of the time, the answer is non-verbal, it is just a facial experssion, a mere sign of understanding. Such non-verbal communications represent over 80% of all communications. If the patient is not able to return some feedback, i.e. a verbal or non-verbal answer, or if the feedback does not carry any meaning, without any explicit relation with the spoken message, the verbal communication of the speaker is bound to stop.

 

If silence is natural, speech is professional. It can thus be learned, improved, trained.

 

That is the reason why we have designed a new method of conversation.

 

In a song, the tune and the lyrics are combined. If you whistle the tune, the lyrics come to your mind. If you say the lyrics, you will remember the tune.

 

 

In heathcare, the tune is symbolized by the gestures of the heathcare worker.

 

With those non-communicative patients, we have opted for a solution where we coach our trainees and ourselves in describing all our gestures. This methodology leads to conversations of this type : Madam, I am going to wash your arm (predictive). I am now lifting your arm, it is your left arm, I am soaping the top or your hand, your palm, I am cleaning your forearm, I am lifting it, etc. (descriptive).

 

However simple the system may appear to be, it requires considerable training. The predictive is often met, but the descriptive is never attained in a natural manner. When the treatment sequence is described, speech may become automatic. When the healthcare worker associates his words with the perceptions of the patient, he initiates a real restructuration of the bodily functions.

 

This approach makes it possible to multiply by 7 or 8 the time of direct verbal communication. This time is generally sufficient to prevent the patient from sinking into a motionlessness syndrome of iatrogenic origin, i.e. caused by the stay in institution. (Let us remember that this syndrome renders the patient fully bed-ridden, with blokage of the joints and continual complaints or mutism. This is as a matter of  fact a kind of suicide by inches as a result of utter distress).

 

Obviously, as soon as the patient recovers his ability to respond, the above-described approach becomes obsolete.

 

With old patients, it is also necessary to have some training in a  somewhat special kind of communication. For example, you give an order : "sir, raise your arm, please". If there is no response, wait 2 or 3 seconds, and repeat the order exactly in the same way. In case there is no response either, change the words : "sir, put your hand in the air", etc … It is often surprising to see how patients respond, even if the medical file describes them as advanced Alzheimer cases.

 

 

 

Table II

 

Touch

 

Non-verbal communication and, more precisely, touch  : this is probably the most important means of communication. Safe mobilization and gentle manipulations are essential for both the patient and the healthcare worker.

 

Now, strict adherence to these two priorities poses two problems :

 

1° According to Laborit, gestures are 98% unconscious. How can one control such unconscious gestures ;

 

2° The more "difficult", -aggressive, suffering, heavy- the patient is, the more gestures become inadequate, violent, in total contradiction with what we want to be, i.e. healthcare workers. All this is indeed unintentional, though in concordance with the laws of physics : force equals half mass multiplied by the square of speed, which amounts to saying that  speed is increased – mass being invariable – in order to increase force. Now, speed is not compatible with gentleness. The way the patient is toileted and the techniques required to do this must be chosen with a view to fostering the richest and sweetest possible non-verbal communication. It is now an absolute necessity to train healthcare workers in the use of the tender touch, or even the loving touch.

Gentleness is the key-word of this most particular touch. This is the reason why we ban lifting patients by the wrists, wich is painful, may cause bruises on the forearms of old patients, if not wounds, but can also be psychologically very aggressive. Have you ever seen lovers holding each other's wrists when they walk around ? Never. But each and every time someone caught you by the wrist, as if by a pincer, it was to punish you.

 

The memory of these punishments by wrist lifting is very deeply engraved in your limbic brain, seat of all our emotions, of all our memories associated with bodily states.

 

In the case of severely declining patients - Alzheimer, or a demented alcoholic patient or other dress him, the only "real" language is that of touch. Should you unfortunately lift his arm by the wrist, the risk is high that he will feel assaulted.

 

Once again, it will be necessary to fight against our typically human wrist lifting gesture. To get rid of these instinctive reflexes in favour of support lifting, at least one year of daily corrective training is required. But the game is worth the candle, and the healthcare workers who succed become the most gentle and the most wanted by the patients and their families.

 

The touch of the healthcare worker must also solicit the patient's "bodily agreement". Under normal circunstances, our conscience informs us each time someone touches us. But just imagine how you would leap up if a stranger in the street put his hand on you without a warning. As we want to avoid this kind of "surprise", we recommend the case of the fingertips alone to start with, after wich the palms are laid on the body, and the reverse when the hands leave the body. This particularly tender touch in itself expresses the kind of tenderness that improves the quality of exchange between the partners involved.

 

In order to lower the overall level of non-compliance tonus, it is also highly advisable not to leave the patient alone a single moment, without direct contact with his skin, throughout the whole duration of the care. Just as in climbing, you must never let go of the two hands at the same time. One hand in constant contact with the skin is an absolute necessity in non-verbal communication, which means that two persons are required to do the job. Should this be impossible, the healthcare worker on his own must always carefully inform the patient that his hand will again be in contact with the skin, starting with the fingertips.

 

To increase the feeling of gentleness, the fingers are not active on the skin, we just follow the palm, which is the active part of the hand. In order to increase the contact surface, thus to reduce the intensity of exteroceptive sensitive information during manipulations, more particularly when turning over the patient, it is also essential to counter the "claw" reflex due to the information of the sensitive receptors at the fingertips, which reflex causes the finger flexors to contract.

 

There again, long training is required in order for the touch of the healthcare worker to be recognized as a fully professional gesture of its own, just the same as that of the sculptor, painter or joiner.

 

We must not forget that we are manual workers and, like all of them, we must practice the proper handling of our tools.

 

Our specific tool is our hand. It is true taht so far, heathcare workers have learning a number of techniques such as toileting, dressing and others, but few of them have been trained specifically to use their hands as care and relation tools for the patient. Logically, after a few years of experience, we shoud be able to assess the pain of a patient only by running our hands over his body, blindfolded. Just the same as a joiner who recognizes a wood species just by touching it.

 

It is all right to be a manual worker, but a bit of brain helps so much …

 

 

 

 

Table I

 

Hospitalism syndrome (Source : Encyclopedie Universalis)

 

R. Spitz has coined the word hospitalism to describe the deterioration of the body in the course of long-term stays in hospital or due to the deleterious effects of premature stays of infants in an institution. The latter situation is characterized by an interruption in the already active relation between mother and child, by an insufficiency in new emotional exchanges and stimulations (maternal substitution is not very satisfactory or multiple substitutes), and by a difficult identification of the patient to a stable image. This, according to Spitz, is a source of emotional deprivation (whatever the quality of psychological, physical or medical care), that appears in two degrees. The partial deprivation of affects, when it appears after six months of good relations with the mother, leads to an overall clinical picture of "anaclitic depression", from reactions of distress to a stoppage of growth, and then to a lethargic state after three months.              J. Bowlby compares these reactions to symptoms of depression (with inhibition, inertio, loneliness, lack of interest for the outside world). These disorders disappear rapidly if the child is reunited with the mother between the third and fifth month after they have been parted. In the case of total lack of affects, if the child and mother were parted earlier and if they are not reunited, the stages of the partial syndrome develop into a serious motory delay, a state of cachexia that reminds of the overall clinical picture of encephalopathy or retardation, a state wich is irreversible and may even lead to death.

 

The term "hospitalism" has been used -even in a wider sense- by a good number of authors (among whom J. Aubry), to refer to the harmful consequences -physiological and psychological- of partial or total deficiencies in affects linked with a stay in hospital or retirement home.

 

 

 

 

 

 

The Gineste-Marescotti methodology of care.

 

All rights reserved in France and abroad.

Registered trademarks : "Toucher Tendresse", "Gineste-Marescotti", "Philosophie de l'humanitude", "Capture sensorielle", "Manutention relationnelle", "Mourir debout".

 

International Copyright 1999 to 2008. These articles are published subject to the condition that they shall not be reproduced without the written consent of Yves Gineste and Rosette Marescotti, and with the mention : Production Yves Gineste and Rosette Marescotti, CEC.87220 France, http://www.cec-formation.net

 

In Quebec, IGM-Canada teaches the Gineste-Marescotti Care Methodology

 

The ASSTSAS organize training sessions derived from the methodology, in a programme called "Relational Care".