When using hand under hand? A compassionate guide for caregivers

Research shows person-centered care approaches significantly reduce anxiety and agitation in individuals with dementia. Understanding when using hand under hand is a crucial skill for caregivers aiming to provide compassionate, respectful assistance during everyday activities and interactions.

Quick Summary

The hand-under-hand technique is used for gentle, respectful guidance during daily tasks, transitions, and communication with individuals who have cognitive impairments, maintaining their dignity and promoting a sense of control.

Key Points

• Timing is Key: Use the technique for guiding, not controlling, during daily tasks and transitions to reduce anxiety.

• Promote Independence: Hand-under-hand allows the person to feel involved in the activity, preserving their dignity and sense of control.

• Communication Beyond Words: Especially helpful for those with cognitive decline or sensory impairments, this method uses tactile connection to communicate reassurance and intent.

• Builds Trust and Comfort: The gentle, non-threatening touch fosters trust and reduces agitation by stimulating positive neurological responses.

• Choose 'With' Over 'To': Always aim to be a care partner 'doing with' a person, rather than a task-oriented caregiver 'doing to' them, a key distinction from hand-over-hand.

What is the Hand-Under-Hand Technique?

Developed by dementia expert Teepa Snow, the hand-under-hand technique is a gentle, supportive method of physical prompting used to assist someone living with dementia or other cognitive impairments. Unlike the controlling hand-over-hand approach, where the caregiver places their hand over the person's, this technique involves the caregiver's hand being underneath the person's. This positioning offers guidance and security without taking away their ability to move their hand or feel the object they are interacting with. By providing tactile cues from a less intimidating position, it fosters a sense of partnership and trust, reinforcing that the caregiver is 'doing with' them, not 'doing to' them.

Core Principles for Effective Application

• Respect and Dignity: Prioritizes the individual's dignity by giving them a sense of control and independence, rather than forcing compliance.
• Connection and Trust: Builds rapport through tactile communication, making the person feel more secure and understood, and less anxious.
• Non-Threatening Posture: A supportive, side-by-side stance, often at eye-level, makes the person feel less intimidated and confronted.
• Empowerment: Allows the individual to participate in tasks for as long as possible, which can boost their sense of purpose and self-worth.

Key Scenarios for When Using Hand Under Hand

Assisting with Activities of Daily Living (ADLs)

For individuals with declining fine motor skills due to dementia, hand-under-hand is invaluable for tasks such as:

• Eating: A caregiver can place their hand under the person's hand, holding the utensil, and guide the hand through the motion of scooping food and bringing it to their mouth. The person still feels like they are feeding themselves, preserving their autonomy.
• Grooming: This technique can be used to help guide a person's hand while brushing their hair, brushing their teeth, or washing their face. The constant contact provides reassurance and helps maintain a familiar routine.
• Dressing: The caregiver can use the technique to assist in buttoning a shirt or pulling up a zipper, providing guidance on the motion while allowing the individual to feel involved in the process.

Navigating Transitions and Movement

Transitions, like moving from one room to another or getting in and out of a chair, can be confusing and frightening for a person with dementia. The hand-under-hand method provides steady guidance.

• Getting Up from a Chair: With the person seated, the caregiver can take the person's hand in a hand-under-hand grip, move to their side, and offer a slow, gentle lift. This is less jarring than a forceful pull and feels more collaborative.
• Walking: The caregiver can offer their hand for a steady, supportive grip, providing reassurance and helping maintain balance. This is especially helpful when walking over uneven surfaces or through crowded areas.

Facilitating Non-Verbal Communication

When verbal communication becomes difficult, touch becomes a powerful tool. The hand-under-hand connection can be used to:

• Conveying Intentions: Gently guiding a hand to an object, such as a cup or plate, can signal intent without the need for complex verbal instructions.
• Offering Comfort: Holding the person's hand in this manner can provide a calming, reassuring presence during moments of anxiety or agitation.

Exploring New or Unfamiliar Objects

For individuals with sensory impairments, or those who are hesitant to interact with their environment, hand-under-hand encourages safe exploration.

• Introducing an Object: The caregiver can place their hand underneath the person's and, with both hands together, gently explore a new object. The person can feel the object's texture, weight, and shape, while also feeling the caregiver's reassuring touch.

A Step-by-Step Guide for Caregivers

1. Approach Calmly and Respectfully: Approach from the front, make eye contact, and use a calm voice. Announce your intention and ask for permission before initiating touch. "May I help you with your cereal?"
2. Offer Your Hand: Extend your hand palm-up, as if initiating a handshake. This is a non-threatening and familiar gesture.
3. Establish the Hand-Under-Hand Grip: Once the person's hand is in yours, roll your hand under theirs, creating a supportive grip. Their palm should rest on yours, with your fingers providing gentle support from underneath. Avoid squeezing or gripping tightly.
4. Move to Their Side: Position yourself side-by-side with the person. This eliminates the confrontational aspect of a face-to-face position and promotes a feeling of partnership.
5. Guide, Don't Command: Using the hand-under-hand grip, slowly and deliberately guide the person's movements. Talk them through the steps in a calm, soothing voice. For instance, "Let's take a bite together."
6. Maintain Continuous Contact: When performing a task, maintain continuous, gentle contact. This provides a constant stream of reassurance and sensory input.
7. Watch for Cues: Pay close attention to the person's body language. If they pull away or show signs of resistance, respect their autonomy and back off. You can try again later, or offer a different form of assistance.

Hand-Under-Hand vs. Hand-Over-Hand: A Comparison

Feature	Hand-Under-Hand	Hand-Over-Hand
Physicality	Caregiver's hand is beneath the person's hand, guiding from below.	Caregiver's hand is placed on top of the person's hand, controlling from above.
Effect on Individual	Promotes a sense of security, control, and dignity. Less intrusive.	Can feel invasive, controlling, and disrespectful. May increase anxiety and agitation.
Communication Style	Collaborative, respectful, and reassuring tactile guidance.	Coercive, manipulative, and can be interpreted as a demand.
Primary Goal	Encourage active participation and independence.	Complete a task quickly, often without the person's full participation.
Typical Use Case	Dementia care, deafblindness, sensory impairments.	May be used with a young child learning a new skill, but generally not recommended for adults with cognitive decline.
Ethical Implications	Centers on consent, dignity, and autonomy.	Can lead to feelings of helplessness and infantilization.

The Psychology Behind the Technique

This gentle approach works due to the way dementia affects the brain. Fine motor skills, complex language, and executive functioning diminish, while gross motor skills and the desire for comfort and connection often remain. The constant, supportive contact of hand-under-hand stimulates positive hormone release, such as oxytocin and serotonin, which reduces the stress hormone cortisol. This neurological effect helps to build trust, reduce agitation, and improve overall mood and cooperation.

Conclusion: Fostering Respect and Independence

Knowing when using hand under hand is appropriate is a hallmark of compassionate, person-centered care. By choosing this gentle and respectful approach, caregivers empower individuals with dementia to participate in their own care for as long as possible, preserving their dignity and enhancing their quality of life. It transforms daily tasks from a source of conflict and anxiety into a shared experience of trust and connection. For more information on person-centered care techniques, including the Positive Physical Approach, visit Teepa Snow's Positive Approach to Care website: https://teepasnow.com/. Embracing this method is a powerful step toward a more empathetic and effective caregiving journey.

Frequently Asked Questions

What is the primary difference between hand-under-hand and hand-over-hand?

Hand-under-hand involves guiding someone from beneath their hand, offering support while allowing them to maintain control. Hand-over-hand is more restrictive, with the caregiver's hand placed on top, and can feel coercive and disempowering.

When should I use the hand-under-hand technique with someone with dementia?

Use it when assisting with daily activities like eating, brushing teeth, or getting dressed. It's also effective for guiding movements, navigating transitions, or offering comfort during moments of anxiety.

How can I introduce the hand-under-hand technique without causing distress?

Start with a calm, respectful approach from the front, making eye contact. Offer your hand palm-up and, once they take it, gently transition to the hand-under-hand grip. Always ask for permission and respect if they pull away.

What if the person resists my touch when I try to use hand-under-hand?

If they resist, immediately release the grip and give them space. Never force the interaction. You can try again later, or re-evaluate if the task is truly necessary at that moment. Resistance is a form of communication that needs to be respected.

Can I use the hand-under-hand technique for communication?

Yes. When verbal communication is difficult, the technique serves as a powerful non-verbal tool. It can be used to offer reassurance, signal intentions by guiding their hand to an object, or simply to provide a comforting presence.

Is hand-under-hand only for people with dementia?

While it is widely used in dementia care, the principles of hand-under-hand can also be applied to assist individuals with other cognitive or sensory impairments, such as deafblindness or low vision, to help them explore and interact with their environment.

Does hand-under-hand work for someone who is bedridden?

Yes, the under-hand technique can be adapted for individuals who are bedridden or have limited mobility. It provides a way to guide hand movements for tasks like eating or grooming, maintaining a sense of involvement and dignity.