Visiting a friend or family member in coma has particular value. What exactly is coma and how can we connect to someone in a coma?
What is coma?
The word comes from the Greek, koma, meaning ‘deep sleep.’ A person in coma is in a deeply withdrawn and extreme state. There are different reasons for coma, which include coma resulting from structural or mechanical damage, metabolic changes that occur near death or from insulin imbalances and psychological or psychogenic factors. The focus here is on coma near death.
There is a common misconception that once the patient is unresponsive and near death nothing is happening. We attend to personal cares and then leave the patient alone to fend for themselves. However, new research shows that those in coma do register what is going on around them but are unable to respond in the usual manner. (Barbato; 2002; Owen, A et al; 2006.)
We also know from individual reports that those in coma and near death have a rich inner life where they are open to opportunities for deep inner experiences, including exploring the meaning of life; finishing off business and making spiritual connections. The amount of time spent in coma is usually related to the amount of disease involved, the psychology of the person and the assistance one has to navigate these inner processes (Mindell, 2004).
Signals from those in an altered state
We often misinterpret signals of patients in an altered consciousness as signs of pain, drug reactions or disease progression, hallucinations, agitation or terminal restlessness, when in fact they may be the way the patient is seeking the solutions to life. The process of dying is not always a matter of peacefully floating off to another world.
When relating with someone in deep coma, even the smallest signs can be doorways into the other’s experience. The minimal signs include sighing coughing, twitching, swallowing, eye movements; changes in heart rate; breathing; facial movements; uncompleted movements; visions; flickers; skin changes; body postures; movements of limbs, muscle tension; vocalisations; sneezes, unidentifiable noises and unintelligible speech. We can use the signals the patient gives to have a very simple form (yes/no) of communication.
Pacing the Breath and Heart Beat
People approaching death function at a slower pace. This is important to remember when you are relating with someone dying and/or in a coma. Whatever their pace, you can pick it up in the rhythm and depth of their breath. You can match it by speaking in that rhythm, by humming a tune, or moving them in that same speed.
The kind of touch we use in coma is very important. Touch can be gentle, loving and open, in which our hands sense the responses in the patients’ muscles, tissues and skin. Touch can also be firm, to match the patient’s experience. The ability to touch in a compassionate way and matching the patient makes it possible to support them in their process.
Being in a coma can be lonely. Hospice workers often report how people in coma need and appreciate the body contact and sensitive touching, especially if they have been in hospital a long time.
What we can bring to the connection
It is important to be aware of our attitudes and beliefs that influence who we are and what we bring to the way we are with the person who is in coma. Attitudes or skills that are helpful include curiosity, openness, patience, playfulness; having the sense of not-knowing and the ability to have a creative mind; compassion for everything that is happening, and taking nothing for granted.
- Coma work takes place within the boundary of the medical system and the family culture
- We introduce ourselves to the patient, ask permission to communicate, and always relate what we are doing, while paying attention to feedback.
- As the patient is always ‘in charge,’ we stay open to varied and potentially creative outcomes.
The following technique may be useful as a way to connect with the patient and support them in their process.
Exercise: Touch and pacing the breath
- Ask the patient if it is okay to touch them on the wrist
- In the absent of any negative indication place your hand on their wrist and bring awareness to your touch there.
- Now pace the rhythm of their breathing, pressing down gently each time they breathe in.
- Notice any tiny reactions that they may have.
- Notice your own reactions and feelings. Are you shy, excited, cautious, loving? etc.
- Watch for feedback
You can also do the above with other parts of the body such as the balls of the feet, the crown of the head, the base of the skull. (From Asian-Pacific Palliative Care Conference, Western Australia, 2010; notes of Kay Ryan.) Process Work facilitator (NZ))
The following is excerpted, with adaptations, from Arnold Mindell’s Coma: The Dream Body Near Death
Until now, mainstream psychologies have focussed primarily on understanding altered states. Now we must develop the tools to enter these states, to communicate with those who are in them, and come out of them again. If comatose and trance states are not helped to complete themselves, they freeze awareness into a kind of void that some clients have described as ‘white out’ or ‘blackout.’
The way you relate nonverbally is as important as what you say since the [patient] understands you with body feeling as well as hearing. Communicating congruently means getting a verbal message across in such a way that it matches your nonverbal message.
The patient’s breathing rate matches the experiences he is having in his trance. Thus, speaking and touching him at the same rate means that you are communicating with him in his language, or on his wavelength, so to speak. Thus he is likely to have the impression that you are wherever he is.
Processing the Trance
1) Connecting Sit near the patient and when he exhales, speak gently and slowly, in the rhythm of his breathing, near his ear. Say something like the following: ‘Hello. I am —. I am really here with you today. I am going to speak with you and, in a moment, I will also gently touch your arm… Now, this is my hand on your arm. You can feel me pressing gently on your arm. This is a way of being with you.’
Now, gently touch his arm as he inhales and relax your touch when he exhales. Continue, following the rate and strength of the breathing.
2) Finding the Way Make a statement about your intentions, for example, ‘I am following the rate of your breathing. I want to follow everything that happens in you. What goes on outside and inside of you is important because it will show us how to proceed; it will show us the way.’
This gives the idea to the patient that what is happening is important; that there is a way to be followed; that he is not alone and that you will provide help on the path. Finally, this message encourages the patient to become aware of himself.
You can gain access to the ‘way’ by helping him follow specific signs and signals. As you exhale you might say, ‘All you have to do is notice what is happening. See whatever you are seeing, if you are seeing. Feel everything you feel. Hear the things you hear, if you are hearing. Take all the time you need and see, hear, or feel.’
3) Pick up Minimal Cues Now give him time to respond, and you make the suggestions above – about seeing and feeling and hearing what is happening – and watch for any minimal cues such as auditory, movement or eye changes.
It may take a while (even as much as twenty minutes) for the patient to respond or for you to notice some of these minimal cues. While you continue to follow his body motions and breathing, do not just be passive but participate by observing what is happening inside and outside of yourself. You may become aware of changes in your own breathing, changes in body temperature, or even the appearance of spontaneous fantasies or plays of imagination.
The kind of response you give him is important as it indicates that you have connected and also helps him become aware of what he is doing and to ‘say’ more. The blank-access response [see above] is the most useful as it encourages further communication without assuming what the content is. Trying to understand him intellectually might inhibit his expression.
We all use blank access all the time. Meditation, staring at the sea or mountains, or listening to music, are all blank accesses – means to open up to whatever needs to arise. We fill in the blanks with our own sounds, imaged and fantasies. All blank-accessing methods are soothing and creative because they help bring up what is inside by giving it space and time.
A verbal blank access would be, ‘Oh yes, that’. An auditory blank access would be to say, ‘Listen to that.’ Or ‘Look inside and see.’
Such encouraging and yet empty statements can be very useful.
It is important to respond with verbal statements that are enthusiastic but whose content is vague. ‘Yes’ and ‘Gosh’ are interpreted by the patient as needed.
If the eyes move from one side to the other without focusing, you might respond with saying ‘Noticing sounds can be important.’ If he closes his eyes, relaxes and looks sleepy, you might say, ‘Feeling things is important.’ If he moves even a little bit, you might say, ‘Ah, it can feel good to move!’
Every time you say something, be certain that you also communicate the same message through your hands by gentle changes in your touch.
Breathing along with the other. Pace the others breathing for 2 or 3 breaths; and then add another kind of breath, your own, with a different sound or tempo to it. Some patients respond strongly to this kind of communication by adding on to their breathing new sounds, rhythms or noises.
Almost everyone responds, although people who are taking painkillers will need longer to respond than those who are not drugged.
If you have not noticed any response, go back and repeat your recommendations that the person see feel or hear whatever he is experiencing. If the eyes open and look at you don’t assume that he wants to relate to you. Just look back. You might want to say, simply, ‘It is lovely to be with you.’ Let him respond the way he wants to; accept whatever he wants to give now.
Do not ask questions that require an answer.
There is something mysterious about this work. Following processes whose content is unknown is an act of faith, the belief that the individual knows and will show us the way. As long as someone is alive, I assume that that person has a purpose in being here that he is she knows and is reacting to. Focussing so intensely on minimal cues is a form of worship and love, so to speak. We are using everything we have and making something out of almost nothing.