Communicating with people in withdrawn altered states of consciousness

As a healthcare professional, family member or friend have you experienced a sense of helplessness at the bedside of a loved one in coma or altered state of consciousness?

Do you believe that people in altered states of consciousness such as coma and dementia are lost to this world and any form of communication?

Are you willing to explore new possibilities?

Through more than 30 years of application and research, Process Oriented Psychology, also called Processwork, is a cross-disciplinary practice which can be applied in the context of both one-to-one sessions for individuals as well as for couples. It is also a highly effective modality for small and large groups and organisations. It is used in psychotherapy, couple work, dream and body work, mental health, conflict resolution, creativity and the arts, the environment, organisational development and for domains related to world issues.

This well-tested approach is also of profound benefit to those in coma, late stages of dementia, and autism. Empirical evidence of the effectiveness of process oriented coma work is now available (“Reaching Out to People in Comatose States: Contact and Communication” Ammann, 2012).


Underlying elements

Arnold and Amy Mindell presuppose that comatose people are not in an unaware, empty state, but in a deep altered state of consciousness even when under sedation or undergoing artificial respiration. In this approach, comatose people are not just seen as physically ill and needing help, but as going through important experiences and inner processes in their lives. Even in such withdrawn and altered states of consciousness, people are able to use their senses to perceive themselves and their environment - although with some such senses this may be the case only to a minimal extent. Every sign emerging from the patient such as tiny movements, muscle reactions, breathing sounds or changes of skin colour - although perhaps minimal and seemingly coincidental - can be recognised as being potentially meaningful and as a sign that the patient is aware, and seeking to communicate and express themselves. These signals can be worked with by the facilitator as a means of making contact, keeping the patient company and for communication.

Since awareness processes are connected to physical processes, coma work can also contribute to rehabilitation and also in the process of death and dying.

In addition to being given basic medical treatment and nursing care, comatose people also require human, psychological and even spiritual support and company.



The first goal of coma work is not to wake people up from coma, although this can often happen, but to encourage people to trust their own experiences and support them in their perception of themselves and their environment. It is about making contact, establishing connection and thereby supporting deep communication. It is about supporting the patients’ participation in social interaction and, as far as possible, giving them assistance to make decisions about their own care and status.


Basics and methods

2016 04 22 14.02There is an elaborate body of theory and methods available to be worked with as tools within Processwork. There exist methods on the one hand, which are easily learnable and can be acquired and applied immediately by family members and friends and, on the other hand, there are more complex methods which are implemented by trained therapists.

Generally, the aim is to deeply relate to people in a coma and to move towards them by following their nonverbal communication signals, endeavouring to attune to their altered state of consciousness and to the atmosphere around them.

The minimal signals communicated by comatose patients are not expressed from an ordinary state of consciousness; it is important to realise that the task for the practitioner is not to ‘interpret’ such signals as much as to help amplify them.

Thus amplification1 is the one of the most important interventions. Amplification means strengthening and increasing the awareness of the emerging process - communication evidenced by the patient through their minimal signals - by connecting in full in the shared experience and encouraging the patient’s signals so that the expression of such signals through the shared process becomes more conscious.

This means that even the smallest signs from the patient are carefully observed by the therapist as a signal of communication which needs be communicated with, amplified and explored. The first stage of amplification is to acknowledge these signals verbally and reply back to the patient in a fully encouraging way. Additionally it can be helpful, for instance, to give feedback to the patient about what is going on in a positive sense around the bed – the prevailing atmosphere etc. More specific approaches in the early phases can consist of breathing and speaking in rhythm with the patient. Physical signals or motions can be further amplified with gentle touch, consensual movement or also light resistance. These interventions are always done with great sensitivity to the patient and their circumstances and any responses/active signs of further communication. Under some circumstances, and at further stages in the process, a yes/no communication2 can also be established.

The support and proactive amplification of the patient’s signals is very accurately based on the patient's feedback which is perceived by the therapist. In this way patient feedback controls the interaction and there is no force or ‘imposition’ at all involved in the interaction, but rather a respectful following of patient signs and signals is offered.

Repeated support and encouragement to trust and follow the experiences of the patient in coma, is essential.



Even more important than the techniques themselves are the attitudes with which the interventions are used and conveyed. In Processwork these are called metaskills. Due to the sensitive nature and depth of this work, coma facilitation training requires the facilitator to commit to becoming aware of their own attitudes about living and dying and to be continuously self-reflective.

Especially with regard to such altered states of consciousness, loving, attentive and appreciative attitude is required. It is important to recognise all states of consciousness, levels of reality and forms of life as being equally important. By their very existence, and regardless of how this existence is given expression, the person is fully accepted. Metaskills employ sensitivity and perceptiveness and the welcoming of experience, empathy and love give these interventions a transformational effect.


Conclusions of process oriented coma and near-death work

Process oriented coma work, as noted by Mindell, is not only helpful in processes such as coma and minimal states of consciousness, but can also be of benefit in other nonverbal and altered states of consciousness such as with forms of dementia, delirium, autism and after a stroke or during the process of dying.

Process oriented coma work can contribute considerably in reducing feelings of isolation or helplessness on the part of patients, immediate family or care givers, and allows space for deep interaction.



Reaching out1 = Amplification (of signals): originally a method developed by C. G. Jung to extend dream contents through enriching and supplementing the dream images; later also extended and applied by Mindell to other experiences or perceptions, such as physical symptoms or movements.

2 = What is meant is a binary communication: communication in which messages can be communicated with sequences of precisely two different signs (e.g. 1/0 or yes/no). This means that, in combination with coma work, the therapist asks questions and the comatose person reacts with previously agreed yes/no signals, e.g. raising the little finger for 'yes' or no movement for 'no'.



  • Coma Work Mindell AmyAmmann, Peter (2012). Reaching out to People in Comatose States: Contact and Communication. Norderstedt: Book-on-demand
  • Mindell, Amy (1999). Coma: A Healing Journey: a Guide for Family, Friends and Helpers. Portland, Or.: Lao Tse Press
  • Mindell, Arnold (1989). Coma: Key to Awakening. Boston, Ma.: Shambala Publications

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