Tal Badehi, Dipl. Ac Shiatsu therapist ISA
In this article I will present a summary of three years of work treating low-functioning autistic people with Shiatsu. Shiatsu therapy has the ability to positively affect autistic people: it strengthens their ability to communicate, has a calming effect, and helps to improve various other health problems. This article details some challenges for treatment, suggests methods for dealing with those challenges, and presents some conclusions.
Over the last three years I have worked intensively with autistic people, all of whom were classified as low-functioning. I met with all the patients once a week. This was for me a new, educational, and very challenging experience, and I would like to share the insights that resulted from this work.The reality of life for the patients with whom I met is not easy; out of 21 patients, 6 can make their needs known of their own volition and answer questions, but none can complexly express their emotions. Many of them experience digestive issues, violent tantrums, insomnia, and intense emotional distress. The most common response to this is pharmaceutical and psychiatric treatment. Many of them are predisposed to self-injury, including biting and beating.
The complexity of how autism is expressed fascinated me, so I decided to deepen my knowledge of this field and explore the possibility of treating autistic people with alternative methods. Meeting the patients required me to open my heart, find original ways of communicating with them, learn how to make the treatment accessible for them, and give them a sense of security in it.Shiatsu therapy is based on communication between the therapist and the patient. The therapist listens to the patient’s body, which communicates in a gentle and unconscious language. By moving the body and pressing with fingers, the therapist responds to the patient’s signals and creates a “conversation”, stimulating emotional and physical movement and providing the patient with a feeling of relief and a deep sense of calm. This movement and deep calm allow natural emotional and physical healing processes to work on the patient.
Shiatsu therapy is very valuable for autistic people, mainly thanks to its ability to create a connection with the patient, and its calming influence. However, there are many difficulties in giving Shiatsu therapy to low-functioning autistic patients. Working with low-functioning autistic people is fundamentally different from working with non-autistic patients, and fraught with difficulties and obstacles. Low-functioning autistic patients have difficulties communicating, understanding directions, and in experiencing changes to their schedule. They also experience various sensory difficulties.Among the twenty-one patients I treated, only five agreed to take part in treatment at the first meeting. During the period in which I worked with the patients I learnt various methods of dealing with their difficulties and bring them all to a point where they were comfortable to take part in Shiatsu therapy and fully cooperate in a session that lasted from 15 to 40 minutes.This article is aimed at those treating patients through Shiatsu or other methods and are interested in treating autistic people, and to anyone who works or comes into contact with this community. In the article I will detail the challenges I faced and the methods I found most effective in dealing with them that were the best for the patients.
AutismThe most recent psychiatric definition (2013) defines a disorder on the autistic spectrum as an impairment in two areas of life:
● An impairment to social communication or interaction, expressed as a lack of emotional-social reciprocity, a disability in non-verbal communication used for social interaction, and an impairment in the development, retention, and understanding of relationships.
● Patterns of behaviour, limited repetitive interests and activities including at least two of the following:○ Repeated stereotypical movements, use of objects or words.○ Insistence on routines and ritualised actions.○ Unreasonable focus on narrow and restricted interests.○ Lack of sensory regulation or unusual interest in sensory aspects of the environment.The impairments above must be present from a young age and significantly impact the educational, social, occupational, and functional aspects of the individual’s life. The impairments cannot be explained as an intellectual deficiency or general developmental retardation.Communication and dealing with emotionsLow-functioning autistics suffer from an impairment to their verbal communication that can present in a number of ways, such as: understanding spoken language without expressing themselves verbally, a wide vocabulary without normal sentence structure, repetition of phrases, an inability to form an original sentence, pragmatic and unimaginative language, etc.In addition to difficulties using verbal communication, autistic people sometimes also experience difficulties with nonverbal communication, such as deciphering facial expressions, physical gestures, tone of voice, etc.Both verbal and nonverbal communication constitutes ways of creating interpersonal relationships, personal expression, and emotional release. Because autistic people have difficulty using these complex means of communication, their ability to deal with their emotions is affected.Low-functioning autistic people can be taught how to express their desires with words, gestures, and images. For example, in the hostels I worked at, they used pictures of the different meals available, and they expressed their choice to the nurses by pointing at the pictures.RoutinePart of the autistic disorder is a difficulty dealing with change, expressed in a rigid devotion to routine. Autistic people often develop stereotypical behaviours (repetitive gestures), the repetition of certain phrases, and restricted fields of interest. Any deviation from the routine can cause distress or even a violent reaction.For example, one of the patients would have a violent tantrum if dinner was not on the table immediately after he finished bathing. Another patient would repeat certain phrases every time he saw me and even taught me how I should reply.I believe there is a connection between the ability to communicate and the ability to deal with changes to routine. We use our social networks as security blankets to deal with the unexpected.
ShiatsuShiatsu is a form of touch therapy that was developed in Japan through the integration of Chinese medicine with traditional Japanese massage therapy. Shiatsu can be used to treat a variety of health problems such as orthopaedic pain, headaches, digestive issues, reproductive problems, alleviating stress, and many other problems.Shiatsu therapy includes precise finger pressure in different areas of the body, at special points that encourage the body’s natural healing and affect the internal organs. Pressure is also applied with the thumbs, elbows, and knees. The patient is treated fully clothed while lying on a special treatment mat. The treatment sessions commonly last an hour.The benefits of Shiatsu as therapy for low-functioning autisticsShiatsu therapy is an opportunity for autistic patients to experience a soft and intimate touch that transmits warmth and empathy. For many of the patients this is a rare opportunity to experience physical intimacy with another person. As a Shiatsu therapist I am trained to know how to vary the touch to the individual patient so that they can relax and experience the therapy’s benefits.Lying on a treatment mat is effective in itself. Some of the patients (3 out of 21) had problems with their posture, such as a hunched back, a reverse inclined pelvis (posterior pelvic tilt), foot drop, a twisted spine, or a shortening of the chest and arm muscles. The treatments were an important opportunity for these patients to straighten out their bodies, relaxing and stretching the muscles.Shiatsu therapy helps to activate the digestive system, alleviating symptoms such as gas and constipation, which many autistic patients suffer from. Stomach therapy works on a deeply emotional level. Shiatsu therapy on the stomach can bring hidden emotions to the surface and help the patient to deal with them rather than repressing them. This can be an unsettling experience, but it allows the patients to be freed forever from unresolved emotions and strengthen their ability to make their own decisions. Autistic patients may experience very intense emotions, but—as mentioned—they lack the ability to communicate them, which would allow them to discharge emotional stress. For this reason, Shiatsu therapy—and particularly stomach therapy—is valuable for autistic people.
Research has shown that massage stimulates the release of oxytocin, the hormone secreted by the central nervous system which counteracts the effect of stress hormones and improves mood
.1 It was further found that the release of oxytocin improves the ability to understand nonverbal communication, identify emotions in others, and react appropriately.2 Another study shows that massage therapy on autistic children increases the incidence of eye contact, improves their ability to complete assigned tasks, improves sleep, and lowers the incidence of stereotypical behaviours (such as repeated movements, rocking, etc.).3Defining treatment aimsUsually it can be expected that the patient will be able to lie on the treatment mat without difficulty, for an extended period of time, without interruptions or breaks, and will permit touchon most parts of the body. When treating low-functioning autistic patients, such expectations cannot be taken for granted.
1 V. Morhenn et al. (2012); S. Tsuji et al. (2015).2 T. Watanabe et al. (2014).3 A. Escalona et al. (2001); A. G. Guastela et al. (2010).
In my work I encountered a number of challenging behaviours: patients that have difficulty understanding instructions, patients that are unable to lie on the treatment mat for more than a few minutes, patients that move and speak unceasingly, patients predisposed to self-injury, etc.I also had to deal with a lack of cooperation on the patients’ behalf, who were not always able to understand the therapy situation or had difficulty participating for other reasons, which required me to use various techniques in order to gain their trust, encourage them to cooperate with the therapy, and even look forward to it.
Through considering the patients’ difficulties and abilities, I set myself several basic goals:
● The patients will come to the therapy room of their own accord.
● The patients will lie down on the treatment mat.
● The patients will permit touch on most parts of their body.
● Reduction of self-injury, including the alleviation of stress and learning strategies to avoid states of confusion or panic.
● The therapy will last at least 20 uninterrupted minutes.
● The patients will experience deep relaxation during the therapy.
Challenges and solutionsImpairment of sensory regulationInadequate sensory regulation often goes hand in hand with autism. In a healthy state, the nervous system is able to sort the abundance of sensory information received by the sensory organs and match the force of the stimuli so that the nervous system’s functioning will be optimal. Healthy sensory regulation allows the nervous system to receive information from its environment and react to it through the activation of bodily systems with appropriate coordination and timing. When sensory regulation is impaired, the nervous system can be “overloaded”, or “blocked”, by stimuli, which can stun the person affected. Their reaction to stimuli may be uncoordinated, inappropriate, or poorly timed, and they may feel “attacked” by the rush of stimuli.Sensory impairments may be expressed in various sensory systems: sight, hearing, touch, taste, smell, proprioception (the ability to sense the location of parts of the body), the vestibular system (responsible for balance and eye movement). These impairments may cause the sufferer to require stronger stimuli or to avoid them altogether.4When treating autistic patients, characteristic sensory impairments must be taken into account, and often they impede cooperation. Consideration of these impairments allows us to easily overcome these difficulties through a little creativity.
Examples and conclusions:4 L. M. Anderson and P. G. Emmons (2005).There was a patient who refused to cooperate, sitting stubbornly and refusing to respond to my requests for her to get up off the sofa and come to the therapy room. When I understood how sharp her hearing was, I started talking to her very softly and gently, and I also began to listen to the building’s background noises and reference them aloud. The patient responded immediately and cooperated.I recommend trying to examine the stimuli in the environment, and the patient’s reactions to them. Once the factor that is troubling the patients is identified, we can adapt ourselves to them, calming them and allowing them to cooperate.Sometimes the same patient would sit waiting on the mat, and would not agree to lie down despite my requests. In one session I summoned all my patience and waited in silence for several minutes. To my surprise, after several minutes the patient lay down as requested and fully cooperated with the treatment.I understood, and saw again in later sessions, that sometimes the patients were not able to respond at a speed we are used to, and much patience is required.Another patient hesitated to lie on the mat, but when I suggested we remove the blanket I had used to cover it, he agreed to lie down, smiling. A routine was established whereby he learnt to ask me to move the blanket, and sometimes he asked me to cover the mat with a blanket. It is unclear whether the texture and touch of the blanket was the irritating factor, or if it was the colour, but it is clear that the blanket particularly annoyed him.It is important to consider the texture and colour of the objects with which the patient comes into contact in the therapy environment, in order to make it accessible to them.Another patient agreed willingly to lie down on the treatment mat, but he tended to rock and move about, which made it difficult for me to treat him. When I decided to try and treat him very quickly, uncharacteristic of Shiatsu, he responded by calming down and ceasing to move. To the best of my understanding, it stems from an impairment in the proprioceptive and vestibular systems, and he feels calmer when his body is moving about quickly.This is an interesting example because I and other therapists tend to calm the patients with slow and gentle movements.It is important to examine our basic assumptions and habits as therapists, and match our speed of treatment to the patient.Self-injurySelf-injury is a common phenomenon with low-functioning autistics. Out of the 21 patients I worked with, around 12 would frequently hit or bite themselves. This behaviour seems to help the patients deal with stress, confusion, and panic. It appears that the ability to create and manage a strong stimulus (pain) gives them a sense of control, or the pain overrides the sense of stress and confusion.There is a link between sensory impairment and self-injury. It must be taken into account the possibility that the sense of touch is not regulated, and the self-injury may take place unconsciously. In addition, the injury may regulate and calm the nervous system.For example, there was a patient that would hit her head hard around the temples, several times throughout the day. This caused damage to her eyes and she is losing her sight, so is now wearing a safety helmet to protect her head.I noticed that sometimes she attempts to halt the movements and successfully avoids hitting herself. I wondered if the movement could be impulsive and not under her control, and what might be the cause. I discovered that when I gently placed my hands on her temples, she does not hit herself at all and responds with smiles, sighs, and sometimes even laughter. It appears that the need to hit herself stems from a lack of sensory regulation and a requirement for touch around her temples. I decided to start every treatment touching liberally around the face and placing my hands over her temples. This allowed the patient to receive treatment over an extended period of time (over 30 minutes), without a protective helmet, with a significant reduction in self-injury.Self-injury and repeated compulsive behaviours must be examined in order to understand their source and ascertain whether the patient is controlling their actions, depending on the force of the movement, and whether the patient is trying to achieve a result they could get another way that does not affect their health.Prior knowledge of forthcoming eventsRoutine: autistic people are normally attached to a strict schedule and require foreknowledge of what is going to happen. Often tantrums occur as a result of changes to the schedule, and the caring team dedicates a lot of attention to preparing the patients for any change to the daily and weekly timetable.
It is important to insist on this schedule also for Shiatsu therapy; organising sessions on fixed days, at fixed times, and in a fixed location. The treatment schedule should be fixed as well. It is possible to change the routine, but it is necessary to prepare the patient beforehand.Limited temporal perception: low-functioning patients normally do not understand abstract conceptions of time, such as “minute”, and “hour”. It is best to relate to time through events that the patient knows such as “after lunch”, or “after your shower”. You can create for the patient a perception of the passage of time and expectation of the end of each stage of the therapy by counting. With many of the patients I count aloud “up to twenty” or another number and that helps them wait patiently as it allows them to expect the end as it approaches.
Scheduled breaks: as part of the work, I also schedule breaks. Some of the patients need breaks during therapy and without scheduled breaks they will stop the treatment and refuse to continue. These breaks are factored in to the timetable, and measured by counting aloud.For example, there was a patient that would participate in therapy of his own volition and lie down on the mat, but only for short periods (half a minute to a minute), and would stop the treatment after 5-7 minutes. I spent a long time searching for ways to improve the session’s length and continuity. In one session, I decided to explain to him the exact sequence of stages of treatment, exactly when the breaks would be and how long I would work on each section of the body, while counting aloud. To my delight, the reaction was immediate and in that session the patient lay on the mat for 15 consecutive minutes. After various experiments I arrived at an appropriate formula that allowed me to lengthen the patient’s sessions to 20 consecutive minutes, including scheduled breaks.It is advised to explain to the patients the sequence of events in treatment, and delineate specific time periods by counting aloud. The counting allows the patients to wait patiently for a defined period of time in the clear knowledge of when it will end. The rhythm of the counting is under the therapist’s control, who should display empathy with the patient’s condition and patience. I mainly counted to 10 or 20 for a period of around 40-60 seconds.
PerseveranceWorking with autistic patients requires patience and restraint. For example, one of the patients did not agree to get up off the sofa in the common room, despite all my attempts, for two years and nine months. During this period therapy consisted of massaging the shoulder blades, upper back, arms, and neck. This was not effective Shiatsu therapy.After this long period, a sudden change occurred, and the patient agreed to get up off the sofa and come with me to his room. For the three subsequent weeks the treatments took place in a similar fashion while he lay on his bed. After these three weeks there was further progress when the patient agreed to lie on his bed and allow me to treat him for almost 15 consecutive minutes.It goes without saying that throughout this long period without progress I attempted many methods and I was almost ready to give up on any success with this patient. When I finally succeeded in convincing the patient to accept proper Shiatsu therapy, I was overjoyed.Creativity in treatmentCreativity is an important tool when working with autistic people. You have to thoroughly observe each patient, learning their needs and habits, and use them creatively in order to help them to cooperate.For example, one of the patients would come to the therapy room of his own accord, but was not prepared to lie down on the mat at all, and essentially would wait for me to touch him and try to lay him down gently on the mat. Then he would twist and hang on me, refusing to cooperate. After several sessions it occurred to me that the patient was attempting to play and amuse himself. I started to play a childish tickling game with the patient, pulling and pushing him. He would react with laughter and expressions of happiness. After playing for a few minutes, the patient was relaxed enough to lie down willingly on the mat and agreed to treatment that lasted around 10 consecutive minutes.
Habits in communicationSimilar to non-autistic people, those with autism develop certain habits when communicating. It is important to understand these habits and use them.For example, there was a patient who willingly cooperated with therapy on the condition that I negotiated its sequence, duration, and her reward for cooperating with her beforehand. The patient allowed me to draw out the length of the treatment, so long as this was presented as a “negotiation”.Another patient would often refuse treatment, and only cooperate when I addressed her in commanding and assertive language. This is despite her appearing to enjoy the treatment and sometimes was unwilling to stop.Habits of communication are known to many of the treatment staff and it is important to listen to their advice.
Positive reinforcementSometimes a breakthrough in cooperation can be achieved through positive reinforcement like a cup of tea or coffee, or the chance to read a certain magazine. This is a very effective means when no other method can be found. Positive reinforcement needs to be routine and expected, and needs to be given immediately after the treatment has finished. It should be a reward for cooperating, and this must be clearly explained to the patients.When first working with positive reinforcement, the challenge faced by the patient needs to be minor — very short treatment and touch on very limited parts of the body. After having success with this approach, the defined boundaries can be extended. This process can take several months, and it is important to build the patient’s trust in the therapist.For example, a patient that stubbornly resisted any attempt to treat her, screaming and violently shaking her head. It was decided to attempt using positive reinforcement—a cup of coffee. The first time the patient prepared the cup of coffee in my presence and I used it to get her to follow me to her room. I allowed the patient to receive the coffee without treatment. On subsequent occasions I raised my requirements of the patient: sitting on the treatment mat, allowing me to treat her legs, back, and neck, and so on. I gradually stretched the boundaries and now the patient comes to the treatment room willingly, lies down on the mat, and receives treatment lasting over 20 consecutive minutes on her back, neck, arms, legs, and stomach. She still gets a cup of coffee when the treatment is over.
Using cardsWhen the patient has difficulty understanding spoken language and does not comprehend the therapist’s directions, picture cards are recommended. A board can be made showing the sequence of stages of the treatment, and cards can be used to allow the patient to choose. For example, a picture of treatment on the stomach, or another of back treatment will allow the patient with difficulty speaking to express their needs.Referring to daily routineFor each patient it should be decided whether it is best for them to be treated before or after meals. Sometimes, the desire to eat will distract the patient from cooperating with the treatment, while other patients who eat a large amount of food will not be able to lie down on the mat and be treated with deep and powerful finger pressure after a meal.Summary of three years of treatmentThe success of achieving targets with patients was significant, as can be seen in the table of conclusions below. Five patients cooperated with extended and consecutive treatment from the very beginning, while the other patients showed significant progress.
Before the therapyAfter the therapyNine patients refused therapy.All patients agreed to be treated without resistance apart from one who cooperated on and off.Six patients had difficulty accepting therapy for more than 10 minutes. Six others could only last 15 minutes. Nine could cooperate for up to 20 minutes.All patients could cooperate with therapy for more than 10 consecutive minutes, eighteen of them could do so for up to 20 minutes.Six patients had difficulties being treated for consecutive periods and a several sessions were interrupted.All patients could cooperate with uninterrupted therapy except two who were assisted by scheduled breaks.Seven patients would frequently self-injure in the context of Shiatsu therapy. Of these three patients would self-injure violently and often.The behaviour ceased in all cases almost entirely in the context of Shiatsu.Eleven of the patients refused to come to the therapy room.Three patients continued to refuse to come to the patient room, for some sessions. All the others came to the therapy room willingly for every session.Four patients had difficulty being touched on their stomach, thighs, and lower back.All the patients agreed to being touched in various areas of their body.Two patients could experience deep relaxation through therapy.Eleven patients experienced deep relaxation in most sessions.
ConclusionThe work presented here is a summary of three years of work in which I learnt a great deal about treating autistic patients. I have no doubt that this is the start of a long process that will accompany me throughout my professional career. I believe that this period produced remarkable achievements in the treatment, as presented in this article. I hope that the ideas and tools presented in the article will be of help to other therapists interested in working with autistic patients.It is my feeling that there is a lack of knowledge about touch therapy for autistic patients that is manifested, for example, in the widespread opinion that autistic people are sensitive to touchand touch therapy cannot benefit them. In my estimation, this opinion is mistaken and stems from a lack of knowledge or expertise.For the three years I worked with the patients I made significant achievements in my ability to render the therapy accessible to them. I imagine that if the frequency of sessions were greater (twice a week or more), and if it were possible to dedicate more time to each patient (around an hour), I could, over time, achieve significant improvements in their ability to communicate, their social skills, stereotypical behaviours, dealing with change, reduction of violent episodes, improved sleep, less self-injury, and better posture.Dealing with the various challenges of working with autistic patients sometimes left me with a sense of being behind, lacking advice, and not knowing how I should act. This prompted me to read, take advice, and deepen my knowledge of the field of treating autistic patients. I suggest further reading material in the bibliography.I would like to thank the caring teams of the hostels I worked in. Their deep knowledge of the patients and their personal experience contributed to the project’s success and greatly inspired me. I owe a measure of my success to their assistance and advice.I am glad for this opportunity to share my experience with other therapists and I invite them to share and write about their own experience in order to create a wide body of knowledge based on observation to serve various therapists but mainly those treating autistic patients.I am grateful for the opportunity I was given to work with the autistic patients and learn from them. I hope this article will help both therapists and patients.I am happy to answer questions and receive comments.
Tal BadehiDipl. Ac ITCMACertified Qi & Body Shiatsu Therapist ISATalbadihi@gmail.com
BibliographyEmmons, P. G.; and Anderson, L. M. (2005). Understanding Sensory Dysfunction. London: Jessica Kingsley Publishers.Escalona, A. et al. (2001). “Brief Report: Improvements in the Behavior of Children with Autism Following Massage Therapy”. Journal of Autism and Developmental Disorders 31:5, 513-516.Guastela, A. G. et al. (2010). “Intranasal oxytocin improves emotion recognition for youth with autism spectrum disorders”. Biol Psychiatry 1;67:7, 692-694.Morhenn, V. ; Beavin, L. E.; Zak, P. J. (2012). “Massage increases oxytocin and reduces adrenocorticotropin hormone in humans”. Alternative Therapies. Health Med. 18:6, 11-8.Tsuji, S. et al. (2015). “Salivary oxytocin concentrations in seven boys with autism spectrum disorder received massage from their mothers: a pilot study”. Front Psychiatry 21:6, 58.Watanabe, T. et al. (2014). “Mitigation of sociocommunicational deficits of autism through oxytocin-induced recovery of medial prefrontal activity: a randomized trial”. JAMA Psychiatry 71:2, 166-75.
Further reading:Janek Dubowski and Kathy Evans, Art Therapy with Children on the Autistic Spectrum (London: Jessica Kingsley Pub, 2001).This book describes the origins of language, as the product of capability for symbolic thought. The book explains the link between the ability for symbolic thought and the use of language, games of imagination, and art.Ryokyu Endo, Tao Shiatsu: Life Medicine for the 21st Century (2013).This book details and explains how Shiatsu therapy works.Patrick Casement, On Learning from the Patient (London: Routledge, 2013).Patrick Casement, Further Learning from the Patient: The Analytic Space and Process (London: Routledge, 2013).This book describes the unconscious processes and communication that is created between the therapist and the patient and explains how to learn from them and harness them for the success of the therapy.