|Year : 2018 | Volume
| Issue : 2 | Page : 64-69
The role of human touch in psychiatry (Manasa Oration IPS-AP State conference Kakinada)
M Vijaya Gopal
Professor, HOD, Department of Psychiatry, G. S. L. Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India
|Date of Web Publication||31-Dec-2018|
Prof. M Vijaya Gopal
Department of Psychiatry, G. S. L. Medical College and General Hospital, Rajahmundry, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gopal M V. The role of human touch in psychiatry (Manasa Oration IPS-AP State conference Kakinada). Arch Ment Health 2018;19:64-9
TOUCH ME DOCTOR
Please come and touch me Care me and comfort me
Look at me while talking Smile to rejuvenate me
I come with a hope to you Hoping to get my lost heart
Tears flow down my cheek
Wipe them with your loving motherly touch Your
Relax me and reassure me Yours fatherly pat on my shoulder
Gives me a meaning to my life I can judge your touch
Even with my closed eyes Anger and disgust in your
touch Will deteriorate me o' doctor Love and concern
Will elevate me to life from death!
Please touch me, doctor Don't leave me
Touch me with your heart Give me life again
Respected chairpersons, my professional colleagues, and dear friends,
At the outset, let me pay my gratitude to the IPS-AP chapter for giving me this opportunity and specially I thank the members of the award committee for selecting me this year for the oration.
I stand before you with humility to give today's oration which was given by Stalwarts in psychiatry from all over India in the past.
The first oration in 1985 was given by none other than Prof. Venkoba Rao. Many leaders of psychiatry like Sharadha Menon, V. K. Varma, N. N. Wig, Kuruvilla, M. A. M. Khan, Mohandas, and Ajith Avasthi.
Although I am not as tall as all these leaders, I want to fulfill this responsibility given to me by the society. It is gratifying to me my teachers at All India Institute of Medical Sciences Prof. N. M Wig and Prof. D. Mohan are also delivered this Manasa Hospital Oration in the past.
It is coincidental and it is my fortune to deliver the oration in Kakinada in the town to which I had lot of emotional attachment. I worked as assistant professor of psychiatry in RMC during 1986–1991 along with Prof. Mallikarjuna Rao Garu.
Currently, after my retirement as superintendent of GHMC Visakhapatnam, I was brought to Rajahmundry by none other than the famous multifaceted renowned psychiatrist Dr. Karri Rama Reddy Garu who is actually the founder of Manasa Hospital Rajahmundry Oration. In this occasion, I would like to remember Dr. Manasa first M.D. psychiatry student from G. S. L Medical College probably on whose name the Manasa Hospital in Rajahmundry as well as this oration stands.
Coming to my topic today, the Role of Human Touch in Psychiatry is a broad and important area not only for psychiatry but also for any branch of medicine which deals with patients. Basically, we know that we are not dealing with the diseases but dealing with human beings who are having diseases. If a clinician only focuses all his attention and effort on the disease and forgets the human being, the results may not be favorable. Hence, our approach slowly has changed from diseased centered to client centered. Psychiatry as a branch of medicine we all know deals with the psych of the patient. For that matter, a psychiatrist or a physician, who deals with the patients who are the sufferers, cannot be a machine like or mechanical in dealing with the patients day-in and day-out. They should deal with the clients humanly which benefit both the parties involved in the healing. Behaving in a neutral or inhuman way is considered generally a heartless job.
Although it is great to deal the things in a divine way, it may not be possible for us because we are all just human beings with no extra divine powers. However, if we can show our humanness in whatever we do, especially dealing with the patients day-in and day-out, it will yield magnificent results and we may be called by these patients as Gods.
Basically, what we are doing, i.e., treating psychiatry patients is a service though of course for fees and it should look like almost a selfless service.
We all know that our patients are called as mad persons by the society and are considered dangerous as wild animals not only centuries back but also today in the 21st century. We read in history that these individuals are isolated and kept in madhouses, i.e., asylums in European countries in the 18th century. They were beaten, whipped, and were tied not only with ropes but also with iron chains and handcuffs like prisoners. Bloodletting was considered as one of the treatment methods, and many patients lost their lives in the hands of these healers. These patients were rescued by a great French physician who was a great soul and as the asylum-in charge he released these mad patients from the shackles of the mad treatment and gave them life and called his method as TREATMENT MORALE (1745–1826).
We all read about the behavior of the psychiatrists in Russia who have admitted the individuals of different political opinions into mental asylums considering treating them as psychiatric patients during the dictatorial rule the country.
After the doctors started recognizing that the psychiatric patients are also human beings, the humanistic way of dealing with them has started. John Locke said that there is degree of madness in most people, and we hear often an expression that every human being will have an amount of madness maybe it is in a small quantity like a cherry. William Battle called for a psychological approach in dealing with these patients rather than something doing with the body.
Nearer home, we all have witnessed Erwadi fire incident on August 06, 2001 in Ramanathapuram district of Tamil Nadu. A madhouse owner Moideen Badusha used to treat psychiatric patients who flock from far and near to Durgah of Quthub Sultan in Erwadi village. The treatments are physically restraining the patients, i.e., tying them to the cots during nights and trees during daytime. Patients had to stay for longer times probably many months till they get a dream or a message from Allah stating that they became well. On one such horrible night, there was a fire accident where the patients could not escape and 28 patients were charred to death beyond recognition. This incident has attracted the attention of the society and the supreme court to start moving in a humanistic way of dealing with the patients. Although we have today lot of psychiatric hospitals in government and private sectors, we know that such inhuman things are going on at many places. People, in general, have many fears to approach psychiatric service centers with an idea that they may be treated badly.
Our Indian society and culture which is the oldest in the whole world teaches us through scriptures how to deal many things in this life in a proper way. One such sloka from Brihadaranyaka Upanishad tells us that all humans should live without sorrow and illness.
We are all basically human beings and we have learned the skills of treating these mental patients. The common quality in all of us is humanness and also the psychiatry skills. When we talk of human, it is something different or superior from an animal. Although the evolution says that we all came from animals, we are superior to them in the special quality called humanness. Hunger, sleep, fear, and cohabitation are equal to both humans and animals. Then, what is that superior quality as human beings we have. Our Rishis said that it is Dharma, i.e., righteous way of thinking and doing and dealing the things.
It is a common understanding and observation that there will be a better outcome if we deal with the patients in a humanistic way rather than in inhuman way, which may worsen the situation. Hence, the teachings as well as our efforts are in that direction.
A good person or a human being can only be a good psychiatrist. A good human being means a nonselfish loving person like a mother. Here, I would like to quote the expression of Raja Rantideva of Mahabharata.
Raja Rantideva was a great king who is a devotee of Lord Vishnu. Once Brahma, Indra, and other Devatas went to Vishnu and asked him who among them is a real devotee of Lord Vishnu. Then, Lord Vishnu said a king called Rantideva in Bhooloka is his real devotee. Then, they became envious and wanted to test this human being with permission of Lord Vishnu. King Rantideva was about to end his 40 days fast and sat for eating food. Then, one hungry person came and asked Raja for food as he has not eaten anything for many days and the king has given half of his food to him. Moreover, when again king started to eat, another person approached asking for food saying he was about to die if he will not eat anything. Hence, the king has given the remaining food. Later, when he thought of quenching his hunger by taking water from kettle, another person approached requesting the king as he was thirsty and not taken water from many weeks, then the king handed over the pot of water to that weak person. That person expressed his inability to touch the pot saying that he is an untouchable and if he touches the pot, everything will become impure. Then, the king went near him and held his hand saying that everything in this world is pure because Lord Vishnu is there in every human being and made him drink the water. Then, the Devatas showed their real appearances along with Lord Vishnu. Lord Vishnu congratulated Rantideva for his ability to stand the test by the Devatas and offered him Moksha, i.e., liberation. Then, Rantideva told the below lines. “He does not need any kingdom, heaven, or escape from birth. His only wish and desire are to remove pain and suffering of the living beings.” A doctor who is noble because he is in a noble profession should not wish anything except the relief of suffering of his patients.
Then only, he is considered as human.
A patient thinks that doctor is a God, who saves his life from death. He thinks his body is like a dead body because of these diseases and wants a medicine which is as pure as Ganga water. This meaning is embedded in the following sloka.
Our humanness is only manifested when a patient is sitting near us. Are we able to feel his suffering, are we able to relate to him, are we able to connect to him? These are the questions. In clinical psychiatry, we talk about empathy and sympathy. A good clinician should be able to place himself in patient's position and have an ability to understand and also should have feelings of concern and desire to help. We all have this type of empathy most of the times, but occasionally, we lose it or appear we are not having this type of human feelings toward the patients. The challenge is how to be a human 24/7.
HELP EVER-HURT NEVER is a moto given by a saint of our times. Successful psychiatry treatments or psychotherapy has four components as follows:
- Patient as well as the therapist should have common ideas or thinking about the disorder or the suffering. Many times a patient goes from place to place in search of a diagnosis. Many doctors say that he is not having real suffering. However, when a doctor says that the patient is suffering from an illness or a disorder whose nature he is able to explain and the patient accepts it then the outcome of the therapy will be better. As in the story of Rumpelstiltskin
- The most important component is the quality of the therapist – A good successful therapist will have three important human qualities. If they are present, the outcome of the treatment will be better. They are genuineness, empathy, and warmth. Hence, all of us should examine ourselves and try to increase or improve these qualities
- The outcome of the treatment also depends on patient's expectations about the doctor, hospital, and about the services. If he really thinks that he will be getting benefitted by this therapist or by this treatment, he will definitely improve. We call this sometimes as a Placebo effect and it is also known as the edifice complex. Every successful therapist of the hospital tries to influence patients or clients about the effectiveness or greatness of his services by different means
- The outcome also depends on the techniques that are used for treatment. For various types of procedures, many types of medicines, all are important to deal with a particular problem.
Carl Rogers studied about the components of the therapeutic personality. He called it humanistic approach, and those therapists who have unconditional acceptance of the patients will be more effective.
Beta and Whithorn had described characteristics of successful and unsuccessful therapists. Successful therapists will have three critical qualities such as accurate empathy, nonpossessive warmth, and genuineness. Therapists who were deficient in these three qualities are not successful.
Some studies conducted on schizophrenic and neurotic and institutionalize male juvenile delinquents. Those patients who had received high levels of these three things improved by 90% and low-level receivers improved only by 50%.
Similarly, studies on 40 institutional female juvenile delinquents and 24 college underachievers showed similar results. Students who received good empathy and warmth from their teachers scored high grades.
During the 18th century, after the industrial revolution in the West, there is a humanitarian movement in psychiatry. Between 1833 and 1846, 70% of psychiatric patients got improved and discharged from Worcester State Hospital, Massachusetts. At that time, the therapists or health personnel showed more interest and kindness toward the inpatients. They looked after well, the inpatients of that asylum by interacting with them genuinely, feeding them properly, sitting with them and listening, and also giving some gifts to the patients. We should be aware that there are no modern treatments such as antipsychotics, antidepressants, electroconvulsive therapies, and modern method of psychotherapies during that time.
These findings can be compared to the discharge rates of the patients in the present times.
This shows the importance of the qualities of the therapist and what type of individuals we are taking to train as psychiatrists or mental health professionals. Today, the modern method of selection into the medical profession or getting a seat in psychiatry is only an academic achievement. Academically high-grade individuals, can they be good therapists? This is the question! Hence, we understand the present process of selection is not proper. We are following the Western methods of selecting.
When compared to this in many Asiatic countries from times immemorial, those people who are genuinely interested in helping people are picked up by the ayurvedic physicians or those who are having these qualities naturally entered into these professions. Some of the modern studies showed that the effectiveness of treatments to mental health issues by the so-called indigenous psychic healers and the modern Western training therapists are comparable.
Vidura in Mahabharata says that the utmost duty or dharma is not to do bad things to others which one himself do not like to receive. If we are the patient, we want to be treated in a proper humanistic way and we dislike some doctor or psychiatrist behaving or treating in a rude way or improper method. We want doctor to be genuine and honest and interested in us. Hence, we should also behave in similar way toward our patients.
One sloka describes how one should behave when one meets an interested person, with a smiling face, pleasant gaze, interested in conversation, sweet speech, and lot of affection. Whenever we meet a patient, we should be genuinely interested and show all these pleasant qualities. If a patient sees us in an angry mood with a frowning face, the outcome will be unfavorable.
Some of the developments and facilities in delivering the mental health services over a period of time are made keeping in view of the human angle. Establishment of the family wards by allowing the family of the patient to stay and participate in the treatment process and to make the patient feel that he is not abandoned by the family. Establishment of the mother–baby units, going into the community, and treating the patients at their doorstep are also made with such ideas in mind.
The laws made from time to time in dealing with the psychiatric patients keeping in view of the patient rights and also to protect them from the inhuman behavior of the system. In modern cyber age, many patients want to contact and interact with the doctor out of the clinical settings by way of modern gadgets, making telephone calls or asking something by WhatsApp or giving e-mails. Hence, unless you are warm and human and genuinely interested, you cannot allow all these things and have these particular hybrid relationships. Hence, things such as telemedicine and telepsychiatry came into vogue in modern times.
Till now, we talked about dealing with a patient in a humanistic way, mostly psychologically. There is another angle in this human touch, i.e., really, physically touching the patient.
Touch is a powerful medium through which healing can take place and emotions can be communicated. It is a nonverbal communication. Emotions such as joy, love, gratitude, and sympathy can be conveyed. One feels more connected to someone with their touch.
The language of touch develops before birth while still one is in the womb feeling the mother's heartbeat. The role of touch in parent–child relationship is to be understood. Mother's touch enhances the attachment of the child to the mother, which conveys the mother is there always for the child and it is safe.
Touch makes one closure and one feels connected and liked. Touch increases cooperation and touch lowers the stress hormones. Studies have shown warm touch stimulates release of oxytocin. There are some touch research institutes which are doing lot of research and bringing the role of human touch in healing.
A handshake with a patient conveys warmth.
A squeeze on the arm could be a sign of sympathy.
A pat on the shoulder of a patient gives him encouragement and energy. We all need to touch and be touched. The body speaks when we do not have words. Florence Nightingale when she went from bed to bed to treat and serve the patients during the Second World War had a lot of influence on the patients' recovery when she used to touch them with love and warmth. Some people say the touch has the healing power.
Benefits of massage therapy in mental health are well documented. Neurochemical benefits and changes are seen in anxiety and depressed patients. Massage increases serotonin by 28% and dopamine by 31%, thus decreasing the negative and depressed mental state of the patient. Body massage decreases the stress hormone cortisol by 53% and also boosts the immune system.
We all know about the Harlow's monkey experiments. In the experiment, Infant Rhesus Macaques approached and attached to the cloth mother and avoided the wire mother. Infants need contact comfort for their survival.
We all want to establish therapeutic alliance with our patients without which the treatment cannot proceed further. Sometimes, touch enhances this alliance. Client feels more closeness and cared if you make shake-hand or pat him on the shoulder. A doctor's congruent, appropriate, and nonerotic touch increases empathy, sympathy, and comfort.
The Western thinking is a dualistic thinking, where they see body and mind as separate and in psychiatric treatments we have nothing to do with body. The Eastern or the oriental way of thinking is body and mind cannot be separated, they are one only and disease in the body effects the mind and vice versa. In this concept, psychiatry treatments in healing can also be brought by touching the body, doing massages, etc., so body-centered therapies came into existence with ideas such as body psychotherapy, somatic energizers, Reichian, bioenergetics, and Gestalt therapy. If we see body as a healing tool and biochemical changes can be brought out in the brain by manipulating the energy levels of the body.
The energy which is present in the body is called with different names in different cultures:
Chiropracters ------ Innate intelligence
Hindus ------ Prana
Chinese ------ Chi
Freud ------ Libido
Reich ------ Orgone energy
The energy levels in the body are enhanced by various bodily massages sometimes with some oils, etc., work through Limbic system, and bring out the restoration of mental and emotional health.
An appropriate ethical touch by a therapist will lead to better outcome and enhances the improvement and the reverse will worsen the clinical outcome and also may land in troubles to both. We should also remember these things are called boundary issues. Because of the mind–body split, the Western method of dealing encourages independence. America, in general, is a low-touch culture. Today, in a technology-focused society, people are touching much less than before and are more in touch with the cellphones, laptops, and tablets rather with human beings which are causing psychological problems more often. As psychiatrist, we know that solitary confinement, sensory deprivation, and lack of touch for longer periods lead the brain to rewire itself precipitating the psychological problems. The elderly who are deprived of physical touch die early. In the West, there are movements such as free hugs movement to increase the human touch to feel one connected and be healthy. Getting touched and touching makes one healthier happier and less anxious.
Various types of therapeutic touch as an adjuvant to verbal therapy are frequently used by clinicians for better outcomes:
- Ritualistic for greeting and departure
- Conversational touch
- Consolation touch
- Reassuring touch
- Playful touch
- Grounding or reorienting touch
- Task-oriented touch
- Corrective experience
- Instructional or modeling touch
- Celebratory or congratulatory touch
- Experimental touch
- Referential touch
- Inadvertent touch
- Touch intended to prevent self-harm
- Touch intended to hurting another
- Therapeutic intervention-Body psychotherapies
- Hostile – violent
- Punishing touch.
We all know about John Bowlby attachment theory and touch from sensitive caregivers allow infant to feel safe and secure. From this, the Kangaroo mother care was given in obstetric wards regularly. The advantages of hugs, pats, and intimacy are, they inspire positive thinking and expand trust, reduce social anxiety and stress and it also boosts immune system and lowers the blood pressure.
Surveys on touching therapy revealed that the most therapists touch their clients genuinely and warmly, and they feel it is an adjuvant to verbal psychotherapy. Inexperienced and male therapists use this form of touch less frequently than experienced and female therapists.
The role of human touch in dealing with our clients has to be appreciated by all clinicians. Should be able to touch the mind and body of the sufferers and should not keep ourselves at a distance.
To wipe the tears your hand must touch To care and cure
your heart must stretch To heal a weeping mind
you should warmly touch the body O ‘ mind doctor
never mind to extend the hand!!
Thank You Very Much for Your Attention
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Conflicts of interest
There are no conflicts of interest.