How to do hand under hand technique: A comprehensive guide for compassionate care

Individuals with dementia often retain gross motor skills longer than fine motor control, which makes the hand-under-hand technique a powerful tool for guided assistance. This compassionate approach allows caregivers to support and connect with individuals during daily activities, preserving their dignity and reducing anxiety.

Quick Summary

The hand-under-hand technique involves a caregiver placing their hand beneath the care recipient's to gently guide movement, rather than controlling it from above. This respectful method capitalizes on retained muscle memory and fosters a sense of security, promoting cooperation and minimizing agitation during daily tasks like eating or dressing.

Key Points

• Gentle Guidance: Provides physical support from underneath, preserving an individual's sense of control and independence during tasks.

• Brain-Informed Method: Capitalizes on intact gross motor skills and muscle memory, which are retained longer than fine motor skills in people with dementia.

• Reduces Anxiety: Minimizes agitation and defensive reactions often triggered by forceful 'hand-over-hand' techniques.

• Promotes Partnership: The caregiver acts as a supportive partner, working alongside the individual rather than controlling them.

• Requires Observation: Success hinges on watching for non-verbal cues from the individual and adjusting the approach accordingly.

• Multi-Use Application: Effective for various daily activities, including eating, dressing, and guiding a person to move.

Understanding the Philosophy Behind Hand-Under-Hand

The hand-under-hand technique, popularized by dementia expert Teepa Snow, is a person-centered care strategy that re-frames the caregiver's role from a director to a supportive partner. Instead of imposing a movement, this method invites participation and works with the individual's remaining abilities. The principle is based on brain science: for people with cognitive changes, placing pressure on the top of their hand can feel forceful and provoke a defensive reaction. Guiding from underneath, however, is less confrontational and utilizes the person's intact gross motor skills and muscle memory to complete a task. It provides a constant, reassuring tactile cue, which is a powerful form of non-verbal communication.

The Contrast with Hand-Over-Hand

Feature	Hand-Under-Hand Technique	Hand-Over-Hand Technique
Core Principle	Guides and assists, preserving dignity.	Controls and manipulates, often causing agitation.
Caregiver Position	Palm-up, under the person's hand.	Palm-down, over the person's hand.
Feeling for Recipient	Supportive, familiar, and respectful.	Forceful, restrictive, and controlling.
Effectiveness	High, promotes cooperation and participation.	Low, can cause resistance and frustration.
Communication	Non-verbal, tactile reassurance.	Non-verbal, conveys a loss of control.

Step-by-Step Guide: How to do hand under hand technique

For success, the technique should be part of a respectful, phased approach known as the Positive Physical Approach (PPA).

1. Start with the Positive Physical Approach (PPA). Approach the person slowly from the front, in their line of sight, and at eye level. Use a calm voice and a gentle expression to get their attention and make them feel secure before initiating physical contact.
2. Initiate the Connection. Gently extend your hand as if for a handshake, but with your palm up. As they reach for your hand, move your hand slightly under theirs to establish the grip. This creates a secure, palm-to-palm connection.
3. Position Yourself Correctly. Instead of remaining face-to-face, which can be confrontational, move to the side of the person, preferably their dominant side. This shifts the dynamic from a control situation to a partnership. If they are seated, kneel or sit beside them so you are at the same eye level.
4. Gently Guide the Movement. With your hand under theirs, you can now begin to guide the movement needed for the task. Your fingers, thumb, and arm act as supportive instruments. For instance, if you are helping them use a spoon, your hand holds and guides the utensil from beneath their hand, while they feel the motions. You are doing with them, not to them.
5. Observe and Respond. Pay close attention to the individual's non-verbal cues. If they pull away, squeeze harder, or stiffen, it may be a sign of discomfort or a need for a break. Respect their response and adapt your approach. This feedback loop is crucial for building trust.

Applying the Technique for Specific Tasks

Assisting with Self-Feeding

The ability to self-feed is one of the last skills lost for many with dementia. Using hand-under-hand for eating allows individuals to maintain this automatic, lifelong skill. With your hand under theirs, hold the utensil and guide the arm from the plate to their mouth. The person's muscles can follow the familiar pattern of movement, increasing their sense of involvement and purpose. You can also use verbal and visual cues, such as holding the food up to get their attention, but the tactile guidance is the most impactful element.

Helping with Dressing

Assisting with dressing can be a source of frustration, but the hand-under-hand method can make it smoother. When putting on a shirt or jacket, a caregiver can thread their hand through the sleeve, offer the handshake grip, and then gently pull the person's arm through the sleeve. This technique minimizes the awkward and potentially painful contortions that can come from trying to force an arm into a sleeve. For tops that go over the head, guide the arms into the sleeves first, then the head. The key is to allow the person's body to move in a more natural, controlled way.

Crucial Tips for Successful Implementation

• Patience is Paramount. This is a learned technique for both the caregiver and the recipient. It requires patience and a calm, unhurried demeanor.
• Provide Clear Cues. In addition to tactile guidance, use simple, clear verbal prompts. For example, when eating, say “Let’s take another bite” as you guide their hand.
• Position Yourself Correctly. As mentioned, sitting or kneeling beside the person at eye level is key. Working from behind is also an option for certain tasks and can be less intimidating.
• Use Constant, Gentle Contact. Maintaining a constant touch provides reassurance and comfort, communicating that you are a trusted partner in the process.
• Engage Multiple Senses. When introducing an object or activity, use verbal descriptions and allow them to feel and explore the object with your guidance.

Common Pitfalls to Avoid

While hand-under-hand is a powerful tool, it can be misused or misinterpreted. Being aware of these pitfalls is essential:

• Forcing a Movement. Never force the person's hand or arm to complete a motion against their will. If they resist, pause and try again later. Forcing a movement can lead to agitation and fear.
• Gripping a Joint Incorrectly. Avoid gripping or squeezing a person's mid-arm or calf, as this can cause discomfort and bruising. The hand-under-hand grip focuses on the palm and wrist area for gentle guidance.
• Neglecting Feedback. The effectiveness of this technique relies on observing the person's reactions. If you ignore their cues of resistance, you may lose their trust.
• Staying in a Confrontational Position. Continuing to face the person directly can feel like a confrontation. Always move to the side to foster a sense of partnership and shared space.

Conclusion: Fostering a Partnership in Care

The hand-under-hand technique is more than just a physical maneuver; it is a philosophy of care that prioritizes dignity, respect, and communication. By working with an individual rather than on them, caregivers can help maintain independence, reduce anxiety, and strengthen the bond of trust. As memory and communication skills decline, this gentle, tactile guidance becomes a vital way to stay connected and ensure your loved one continues to feel secure, valued, and in control of their actions. For more information on person-centered care, explore the resources available from Positive Approach to Care.

Frequently Asked Questions

What is the primary purpose of the hand under hand technique?

The primary purpose is to provide gentle, non-confrontational physical assistance to an individual with cognitive decline or other disabilities. It helps guide them through tasks while preserving their sense of dignity, control, and independence.

How is hand under hand different from hand over hand?

Hand-under-hand places the caregiver's hand underneath the recipient's, offering support and guidance in a respectful way. Hand-over-hand involves the caregiver's hand being placed on top of the recipient's, which can feel controlling and forceful, often causing resistance and agitation.

Can I use the hand under hand technique for tasks besides eating and dressing?

Yes, the technique is versatile and can be used for many daily activities. These include grooming tasks like brushing hair or teeth, moving from a seated to a standing position, and even holding an object to provide reassurance.

What should I do if the person resists my hand under hand guidance?

If the person resists, pause your action immediately. It may be a sign of discomfort, fear, or a desire for a break. Never force the movement. Disengage, give them some space, and try again a little later when they seem more receptive. You can also re-evaluate if the task is appropriate at that moment.

How does hand under hand preserve dignity?

By guiding rather than controlling, hand-under-hand allows the individual to actively participate in the task, using their own retained abilities. This fosters a sense of competence and involvement, preventing the feeling of being helplessly manipulated, which is a key part of maintaining their dignity.

Is hand under hand only for people with dementia?

No, while widely known in dementia care, the hand-under-hand technique is applicable for anyone who requires gentle guidance and communication via touch. It can be used with children with special needs, individuals with limited mobility, or those who are deafblind.

How do I use hand under hand to help with walking?

For mobility, the caregiver places their hand under the individual's hand, offering stability and direction. The caregiver moves to the side, maintaining the supportive grip. This provides a constant, reassuring tactile connection and helps guide the person's movements without pulling or pushing.