The Foundational Principles of Hand Under Hand™
Developed by renowned dementia care expert Teepa Snow, the hand under hand™ technique is a cornerstone of compassionate caregiving, shifting the dynamic from 'doing to' a person to 'doing with' them. This method places the caregiver's hand underneath the person's hand, offering support and guidance while allowing the individual to feel in control. This non-invasive approach reduces anxiety and agitation, creating a safer, more respectful interaction. The success of this technique hinges not just on the hand placement, but on the crucial preparatory steps to first get the person's attention in a non-threatening way.
Step 1: The Positive Physical Approach
Before initiating any physical contact, the caregiver must first enter the person's 'personal space' respectfully. This is known as the Positive Physical Approach (PPA). Instead of startling the person by approaching from behind, come into their line of sight from the front and slowly approach. Position yourself at their eye level, perhaps by kneeling or sitting, to avoid being intimidating. Maintain a calm, friendly facial expression and a relaxed posture. Use a gentle, welcoming tone of voice and speak slowly and clearly. This series of actions helps establish a sense of safety and trust, inviting the person to connect with you rather than retreat from a perceived threat.
Step 2: Gain Attention with Verbal and Visual Cues
Once you are within their line of sight, use a combination of verbal and visual cues to gain their focus before making physical contact. Start by calling the person's name softly and respectfully. Wait for their gaze or a small sign of acknowledgement before proceeding. If they don't respond, you can gently offer an open hand, palm facing upward, at their eye level. This is a common, non-threatening gesture that signals a desire to connect. Avoid clapping, tapping, or shouting, as these actions can be frightening or agitating for someone with cognitive impairment. The goal is to make a calm, intentional connection that respects their senses and current state.
Step 3: Gentle Tactile Cues to Signal Intent
With permission established through your approach and verbal/visual cues, you can add a gentle tactile signal to solidify attention. A powerful, non-intrusive method is a gentle, rhythmic 'pumping' of the hand you wish to guide. If their hand is resting on a table, you can place your hand under theirs and gently press up, then release, a few times. This provides a clear, physical signal without a firm grasp that might feel controlling. This action can precede the full hand under hand™ grip, which involves moving your guiding hand to a supporting position underneath theirs. This subtle cue gives them time to process the touch and prepare for the next step of the interaction.
Using Hand Under Hand™ for Different Tasks
The hand under hand™ technique is highly versatile and can be adapted for a variety of caregiving tasks. Its effectiveness is rooted in the principle of co-participation, where the person with cognitive impairment remains actively involved in the task to the best of their ability. This approach empowers them and preserves their sense of dignity, even when their functional skills are declining.
Assisting with Eating
When assisting with eating, position yourself at the person's side, preferably their dominant side, to offer support. Place your hand under theirs and guide their hand with the utensil toward their mouth. By keeping your hand underneath, you allow their hand to continue the familiar motion of eating, with your hand providing gentle stability and guidance. This reduces the risk of food spills and helps the person maintain the motor memory of eating independently. This is more dignified than using a spoon to feed them from above.
Assisting with Walking
To guide someone while walking, use the hand under hand™ technique to offer stability and direction. Stand slightly behind and to the side of the person, placing your hand under their arm or hand. This provides a tactile anchor and allows you to gently steer them by rotating their forearm. It's a much more secure and respectful method than pulling them by the arm, which can be disorienting and uncomfortable. Your presence and contact provide a sense of security while they walk.
Common Challenges and Solutions
| Challenge | Hand-Over-Hand Reaction | Hand-Under-Hand Solution |
|---|---|---|
| Resistance to Touch | Can trigger a pull-away reflex or agitation, as it feels controlling and invasive. | Respect personal space initially. Use a verbal invitation or gentle tactile cue, and be prepared to back off if they resist. |
| Lack of Attention | Yelling or tapping can escalate the person's confusion and fear. | Use a calm, slow approach. Get to eye level, call their name gently, and offer an open palm. |
| Loss of Dignity | Forcing assistance can make the person feel helpless and incompetent. | By working "with" their hands, the person retains a sense of control and participation in their own care. |
| Physical Discomfort | Grabbing or pulling can cause pain or injury, especially in frail individuals. | The hand under hand™ grip is gentle and supportive, reducing the risk of injury and physical distress. |
The Role of Body Language and Tone
Beyond the physical technique, your body language and tone of voice are paramount. Individuals with dementia often lose the ability to interpret complex language but remain highly attuned to non-verbal cues. Your posture, facial expressions, and vocal tone can communicate your intentions more clearly than words. Maintaining a calm, reassuring, and patient demeanor is critical. If you appear rushed or frustrated, the person may mirror your stress, making communication more difficult. The entire process, from approach to physical contact, should be a slow, deliberate conversation between bodies.
Building Trust and Connection
Ultimately, hand under hand™ is not just a tool for performing tasks; it is a profound method for building and maintaining connection. It communicates, "I am here to help you, not control you." Over time, this consistent, respectful approach builds a deep level of trust. The person you are caring for will associate your touch with security and kindness, making future interactions smoother. This positive association can significantly reduce distress and anxiety, improving their overall quality of life.
Conclusion: Fostering Respectful Engagement
Getting someone's attention respectfully is the critical first step to using hand under hand™ effectively. By combining the Positive Physical Approach with clear verbal and visual cues before engaging physically, you can create a safe, supportive environment. The technique's power lies in its subtlety and emphasis on dignity, empowering individuals with cognitive impairments to participate in their own care. This process moves beyond a simple task-oriented action to become a genuine, loving connection. For anyone caring for a person with dementia, mastering this initial engagement is the key to unlocking more peaceful and cooperative interactions.
For more information on dementia care strategies and training, including the hand under hand™ technique, you can visit the Positive Approach to Care website.
