Providing Indian head message to inpatients in an acute mental health unit had physical and psychological effects, and also improved the atmosphere on the ward
Creating an environment that focuses on individual recovery within an acute inpatient environment can be challenging. To add to the therapeutic nature of a mental health assessment and treatment ward for women, we conducted a pilot of six Indian head massage taster treatments for patients. Feedback was obtained from patients and staff through the questionnaires, observation and verbal feedback. The feedback showed individual positive experiences and that the treatment enhanced experiences of care. These outcomes are being used to explore the benefits of the use of IHM in ward environments. The feedback indicates IHM training for multidisciplinary ward staff would be beneficial. This article reports on the use of a complementary therapy as a component of a ward recovery ethos and an intervention to help with promoting a therapeutic and caring ward environment.
Citation: Howard V, Halldorsson R (2013) Using Indian head massage to aid recovery. Nursing Times; 109: 25, 14-16.
Authors: Vickie Howard was a modern matron for adult mental health services and service manager for perinatal services; Rachel Halldorsson was an inpatient occupational therapist within adult mental health services; both at Nottinghamshire Healthcare Trust.
- This article has been double-blind peer reviewed
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Receiving care and treatment within an acute inpatient environment can be distressing.
People tend to be admitted for inpatient mental health treatment when home treatment is deemed unsafe or unhelpful. Wherever possible, people requiring inpatient care are supported to be admitted on a voluntary basis, but there are situations when it is necessary to detain individuals under the Mental Health Act 1983 (Department of Health, 2008). Inpatients may therefore be experiencing an array of emotions around their personal circumstances and at times could disagree with staff about their needs.
Although staff aim to provide patient-centred care, there is a need to maintain a safe and therapeutic environment, and achieving one that is both can require a fine balancing act. The role of ward staff is to support the patient in regaining a state of wellbeing and balance over distressing and severe symptoms such as psychosis (commonly described as a detachment from reality), extreme mood experiences, severe depression and feelings of hopelessness.
Acute wards have in the past been criticised for their lack of therapeutic value and reports have described patients “not feeling safe”, with specific criticisms directed at a lack of prioritising the individual care needs of patients (The Sainsbury Centre for Mental Health, 2001).
Why Indian head massage?
Complementary and alternative therapies are being used in a range of health settings to both complement mainstream treatment and to extend patient choice. In the UK, there are a number of topical issues and developments regarding the use of complementary therapies, including the safe regulation of practitioners, professionally organising complementary and alternative approaches, and the need for advisory information for health professionals and patients.
We conducted a literature review in May 2012 that showed a lack of evidence and policy guidance in complementary therapy use in acute mental health inpatient settings. Much of the available literature focused on research on physical healthcare, in particular cancer treatment and palliative care. Where research had been carried out in mental health settings, we found this focused only on specific conditions such as anxiety and depression. However, we found three articles that focused on the use of massage in mental health inpatient settings.
One paper described the practical issues involved in setting up a massage clinic in a mental health hospital and highlighted that patients frequently reported they found the massage helpful and that it brought about therapeutic communication between patients and staff (Fire, 1995). The second paper reviewed supporting literature around the use of massage to mental health patients and showed there were positive clinical effects, including the reduction of anxiety and depression (Brownsword and Baker, 2008). The third paper was a pilot study evaluating the effect of massage on stress levels and anxiety and aggression in a young adult psychiatric unit. This study revealed a reduction in anxiety of patients and highlighted improvements in the ward environment and therapeutic atmosphere (Garner et al, 2008). This last paper reflected similar massage techniques to those used in IHM, which focus on the back, shoulders and head.
IHM can be administered over clothing, which we consider makes it appropriate because it is not invasive. As some patients may be experiencing disinhibition, vulnerability or unusual thoughts, we felt we needed to be especially aware of this when formulating an approach to the use of IHM. We felt it was important to be mindful of how touch may be interpreted by individuals considering these factors and possible past experiences involving touch, such as physical or sexual abuse.
Implementing the pilot
To deliver IHM, we undertook a certificated course along with eight other members of staff, which included using the therapy with people experiencing mental health problems.
The next step involved exploring how to deliver the therapy in practice and as part of our existing roles. We consulted with patients we already worked with to explore what current patients thought of IHM as part of their care package and what they may find useful. We also discussed possibilities with ward staff members, advocates and managerial colleagues. We found that most patients had some experience of accessing complementary therapies including massage, but not specifically IHM. Much of the patient feedback showed that patients favoured the provision of IHM and felt it would help with relaxation.
When we considered the feasibility of including IHM in our existing roles and of introducing a new intervention in to the ward routine, we decided taster sessions would be a helpful starting point. We conducted a full risk assessment (key risks in Box 1). We produced a management plan in collaboration with other trained IHM practitioners, ward staff and clinical managers and followed the principles and guidance of our healthcare trust complementary therapies policy. We chose a female admissions ward to begin delivering IHM. Information was given to patients verbally and by providing a leaflet on the potential benefits and contraindications of having IHM. Information was displayed on patient information TV monitors on the ward.
We evaluated the taster sessions through the use of a questionnaire and by gaining verbal feedback from patients and staff involved in the sessions. We informed all participating patients that we were evaluating the sessions in this way and gained their consent for their feedback to be used to evaluate the service and to make improvements for future sessions.
Box 1. Key Risks
- Contagious infection/diseases
- Injury/illness due to existing or past health issues, for example high blood pressure or a previous upper torso, neck and head injury
- Falls due to low blood pressure, medication effects or following deep relaxation
- Mental distress of patient during treatment and/or unexpected patient response to physical contact
- Possible chaotic and disruptive ward environment
- Obtaining informed consent
- Unsafe practice and lack of effective facilitation for taster sessions
In total, 18 taster treatments were delivered over six sessions. Ten patients received the treatment and all completed the feedback questionnaire, which included seven brief questions on the experiences and views of patients following their first session of IHM.
Most patients said they had not had IHM before and had enjoyed it. All patients said they would have IHM again and most reported feeling either “a lot” or “quite a lot” more relaxed after receiving the treatment.
The most highly reported beneficial experience of the massage was “muscles feeling more relaxed” followed equally by “mind feeling more relaxed” and “feeling the staff care”.
When asked what would make the massage better, most commented it could not be better but some suggestions were put forward including: increasing the length of time; using a separate room with relaxing background music; and to have the therapy as an established part of the ward routine.
Verbal feedback was taken from each patient during and after their taster session (Box 2).
Themes drawn from the feedback included physical improvements, such as the relief of muscle tension and associated pain, and IHM helping with negative psychological experiences to reduce anxiety and give a break from worry. Other themes included increased experiences of feeling cared for and more positive feelings towards the ward environment and provision of therapeutic interventions.
Box 2. Patient comments
Patients made the following comments about Indian head massage
“Some people are admitted to the ward carrying a lot of guilt… it’s healing to have something done for them.”
“The ward can be a harsh environment at times, the touch feels caring and helps with feeling connected again.”
“It’s the first time I’ve been physically touched since I was sectioned and it made me feel cared for.”
“I had severe muscle tension and pain in my shoulder and following the Indian head massage it is so much better.”
“It’s my personal time for me.”
As IHM practitioners, we made a number of unexpected and unpredicted observations.
We observed how IHM reduced muscle tension, especially in the faces of patients. One patient said to us “I can open my eyes now!”, explaining that before the treatment her muscles had been so tight and energy so low she did not have the strength to open her eyes. We observed that some patients who had repeated IHM taster treatments became more self-aware and were more proactive with their appearance. Some patients seemed energised after the treatment and looked as though they had made a psychological shift.
Patients commented on how just watching another person receive a treatment helped them feel more relaxed themselves. We saw that patients gave each other positive feedback following a treatment and it appeared to help develop supportive communication between patients and with ward staff who spoke to patients about the treatment.
Other members of the multidisciplinary team reported their observations to us. It was felt that some patients may be leading isolated lives and using IHM as a means of therapeutic touch is an effective way of sending a message of welcome and inclusion. One staff member referred to this as promoting being part of the “great human jigsaw”.
Staff on the ward reported they felt a change in the atmosphere of the ward when we were conducting the treatments and this was referred to as “a noticeable calm descending”. It was also noted that ward staff and occupational therapists discussing the therapy with patients just before IHM was due to be offered on the ward greatly supported patients to engage in the taster sessions.
We found that delivering IHM gave us another way to develop therapeutic relationships with patients. This added a more fulfilling experience to our professional roles and clinical work, improving our morale and role satisfaction. Using IHM with patients helped to develop trust and helped staff to get to know patients we may otherwise have had little contact with. Patients were also much more likely to discuss other issues associated with their care and support needs.
The patients who took part in the sessions were all women and between the ages of 18 and 65, from diverse economic backgrounds and ethnicities. All were experiencing distressing mental health problems that warranted inpatient care.
The results of the questionnaires and verbal feedback showed an overwhelming positive view from patients about the therapeutic effectiveness of the therapy. Key factors were highlighted such as how IHM has affected patients’ physical health and feelings of wellbeing; how patient perception of the environment and staff support was changed and how it has influenced self-awareness and self-esteem.
The methods used in this project were restricted as only minimal resources were available. Practitioners’ time was fitted around current clinical workloads, which was at the discretion of managers, and sessions were delivered at the same time each week, so possible differences in the experience of the therapy at different times of day/evening would not be picked up. This project has provided a starting point for further research to investigate the use of complementary therapies.
Implications for practice
We are interested in further exploring how IHM may affect a person’s recovery, their experience of the therapeutic nature of the ward and their interactions with staff members and other patients. We would like to explore using IHM at different times of the day and investigate impact on untoward incident rates, the use of PRN (as required) medication and sleep quality.
The better perception of the therapeutic nature of the ward and increased positive perceptions of feeling cared for indicate the potential benefit of training more ward staff to deliver IHM. The outcomes of this project have been used to submit a successful funding bid to train further multidisciplinary ward staff in the use of the therapy. We are hoping this significant support will improve the chances of obtaining further funding to support research that is being developed by members of staff across adult mental health inpatient services.
This project has provided valuable insight into the experiences of patients and staff members during and after the introduction of IHM taster sessions to inpatients on a mental health ward.
Following an initial taster session, 100% of participants would seek a further IHM treatment. In carrying out this project, we hope to influence further investment and future research projects designed in this area.
- Complementary and alternative therapies are used in a range of health settings
- Much of the literature on these therapies focuses on physical rather than mental health
- Massage can improve therapeutic relationships between staff and patients
- Indian head massage focuses on the back, shoulders and head and can be done over clothing
- Reported therapeutic effects of Indian head massage are: feelings of balance and calm; relief of discomfort and pain; less stress/anxiety; and better muscle tone and circulation
Brownsword A, Baker E (2008) Can massage and aromatherapy benefit the users of forensic services? The British Journal of Forensic Practice; 10: 1.
Department of Health (2008) Code of Practice: Mental Health Act 1983. London: Stationery Office.
Fire M (1995) The problems of providing massage in a psychiatric hospital. International Journal of Alternative and Complementary Medicine; 10, 28-29.
Garner B et al (2008) Pilot study evaluating the effect of massage therapy on stress, anxiety and aggression in a young adult psychiatric inpatient unit. Australian and New Zealand Journal of Psychiatry; 42, 414-422.
The Sainsbury Centre for Mental Health (2001) Acute Problems - a Survey of the Quality of Care in Acute Psychiatric Wards: Briefing 4. London: The Sainsbury Centre for Mental Health.