It may appear artificial and, indeed, contrary to a philosophy of holism, to examine the physiological and psychology bases for reflexology in two separate chapters (see Ch. 1). However, it is hoped that deconstructing the theories in this manner will encourage further debate and exploration of the practice of reflexology. In a Department of Health document, aimed at informing primary care groups about complementary therapies, reflexology was described as the application of pressure to the feet and/or hands in order to ‘promote well-being’ (DoH et al. 2000:37) (Fig. 2.1). We know that ‘well-being’ is so much more than just physical health, and it will be seen from the reflexology literature that well-being outcomes can be both emotional and physical (see Ch. 6). It could be argued that physical changes may primarily be a consequence of psychological processes and, given the complexity of reflexology practice, it is suggested that these are likely to be working in synergy.

Moderate amounts of stress and anxiety are a normal part of everyday life and a stimulus for activity and change. Temporary challenges to feeling good, just ‘fine’ and even normal can arise from marked anxiety and distress, as well as other strong emotional states, such as anger, disgust, panic and fear, which activate the sympathetic nervous division of the autonomic nervous system (ANS). Over time, persistent and unresolved anxiety and distress can cause an increase in muscle tension (tonus), reduction in peripheral skin temperatures and a hyperactive response to further recurrence of an acute stressor. The individual can have difficulty in being able to return to, or maintaining, a relaxed or calm state. The physical manifestations of chronic states of arousal and low thresholds to stressors can be seen in measurements of sympathetic nervous system (SNS) responses and physical complaints, including hypertension, impaired circulation, back and neck stiffness, digestive, bowel and skin problems. At the centre of the arguments in this chapter are the links between mind and body, which we will explore using psychoneuroimmunology (PNI) and other psychological theories.

In crossing the territory between body and mind, physiological consequences have been identified as a response to stressful situations. For example, fear can trigger changes in blood pressure and heart rate in preparation for ‘flight or fight’. Arousal of the sympathetic division of the ANS can become a frequently experienced state, making the individual vulnerable to serious illness, such as myocardial infarction and peptic ulceration. It has been shown that it is possible to influence the ANS through such practices as yoga and meditation, by allowing the parasympathetic division to reduce the heart rate and blood pressure and to normalise digestive processes (Sutherland & Cooper 1995). The links between the emotional state, disease processes and experience have been – and continue to be – investigated within the scientific field of psychoneuroimmunology (PNI) (Ader and Cohen, 1975 and Ader, 1982). The theoretical basis of PNI is that there is a two-way relationship between the immune system and the central nervous system (Rabin et al., 1989 and Lloyd, 1990). In understanding PNI, Carter (1998) argues that feelings of social isolation and anxiety are associated with increased stress hormones, such as cortisol.

Where moderate states of arousal and opportunities for positive social interaction and attachment coexist, physiological anxiolytic states can be created. Anxiety is central to a map of other symptoms/conditions, including insomnia, pain, depression, constipation, skin problems, irritable bowel syndrome, muscle tension, etc. If anxiety can be reduced, this will influence our tolerance and even our experience of a symptom. Improved mood and humour and relief of anxiety are linked with the release of the naturally occurring opiates, endorphins, which are believed to optimise immune function and to have analgesic, anti-inflammatory bronchodilatory effects (Jessop 2002). Opioid production is higher in individuals who exercise regularly and low in individuals who live with chronic fatigue syndrome (Conti et al. 1998). Stress hormones such as cortisol play an important part in protecting the body and sustaining fight or flight – for example, diverting blood from the gut to powerful muscles, raising blood sugar levels for energy and initiating a protective immunological response. It is when these hormones are chronically elevated that they have deleterious effects on resistance to disease and infection.

There are several schools of thought regarding the mechanism of action of reflexology including an Eastern theory, whereby treatment areas relate to acupuncture meridians and ‘chi’ energy flow, and a Western theory, that helping to relax and destress the recipient supports their innate ability to self-heal (see Ch. 1). In deconstructing the psychological processes, it is important to recognise that reflexology, in common with other touch-based complementary and alternative medical interventions, is carried out within a one-to-one encounter, usually requiring regular appointments which aid the establishment and growth of a supportive and social relationship. Sessions typically involve hands-on treatment lasting between 35 and 50 minutes, and may include cleaning the feet and applying a small amount of moisturising cream or oil, if the feet are dry. This physical contact and the holding and relaxing manoeuvres used by the therapist mean that she or he is literally holding the person through the feet (Fig. 2.2). O’Hara (2002) argued that this combination of activities presents reflexology as a complex package rather than as a simple mechanical technique. Reflexology is also a journey or process, which encompasses privacy and a sense of intimacy in the interactions; time is spent with another person to help promote relaxation and improve well-being. The semi-recumbent position of the client facilitates face-to-face contact and conversation, which includes feedback on the pressure used as well as opportunities for dialogue regarding the client’s condition and treatment expectations. With repeated treatments, there is clearly the potential for reflexology to evolve as a supportive and social event. The intervention requires the client to put aside time, to allow himself or herself to be touched and to expect health benefits. However, with any regular contact, particularly if it is perceived as beneficial and nurturing, attachment can occur over time and it is important to recognise emerging relationships and to prevent them from becoming muddled with other types of ‘being with’ someone, such as becoming a friend or seeking to parent or wanting a parent to look after us. These complexities will be revisited later in the chapter.

Integral to the ‘reflexology package’ and which differentiates the treatment from a foot massage is a map or chart of the feet, which reflexologists use to guide their treatment. Interestingly, authors of various reflexology texts often differ on precise locations of reflex zones on the various maps (O’Hara, 2002 and Tiran, 2009). The anatomical and physiological processes of the body can be a mystery for many people, who may have a resistance to talking about what occurs beneath the skin. Reflexologists claim that there are reflex areas on the feet, hands and ears, believed to be microcosms of the body. Both feet are palpated using thumb and finger pressure, pressing on all areas of the feet and focusing on specific areas of the feet that are tender or sensitive, which creates opportunities for interaction between a ‘reflexology expert’ and the person – and engagement in a journey with someone who is perceived, rightly or wrongly, to have specialist knowledge, skills and experience. The reflexology expert is also being curious about the client, who has more than likely come with concerns, and is seeking (and often paying for) skilled support, help and answers to his or her problems. The session ends with some ritualistic techniques such as ‘solar plexus’ breathing. Patients are usually advised to attend a minimum of six sessions, as benefits are argued to be cumulative and the repeated interactions enable further investigation, nurturing and support which all focus on the individual.

The practitioner’s demeanour, willingness to listen, and use of ‘quality time’ may be conducive to developing a potent therapeutic relationship, and to influencing client responses (Wall & Wheeler 1996). Emotional reactions to a series of treatments are not uncommon in bodywork, and the nurturing use of touch and the support and acceptance that evolve in the therapeutic relationship may tacitly give permission for this. Additionally, these various aspects of the package can contribute to patients sharing worries and concerns, particularly about their health (Dryden et al., 1999 and Mackereth, 1999). Investigative work on the potential of the reflexology package for eliciting worries and concerns and affecting psychological and physical outcomes is central to the position taken in this chapter (Mackereth et al., 2009 and Mackereth et al., 2009).

Reflexology can be classified as a bodywork intervention with the majority of time spent in the session dedicated to the therapeutic use of touch. Montagu (1971) has argued that touch is essential for the healthy development of the individual, and provides, even in adulthood, reassurance and affirmation that an individual is accepted, valued and needed by others. Touch is a complex intervention, which can arouse numerous responses in the individual. The tactile nature of the skin is not only a means of connecting but also of differentiating between the ‘me’ which is inside the body and that ‘which is not me’ which is outside the body. The phrase ‘skin ego’ has its origins in Freud’s comment about the body ego being a mental projection of the body’s surface (Freud 1923). Reich, a student of Freud and a pioneer of body psychotherapy, identified in the 1940s that a mother’s physical presence, smell and skin can moderate a child’s anxiety and distress. It has been suggested that being physically present and working through touch can enable a client, even when an adult, ‘to receive oneself’ to gain insight, possibly to become emotional and expressive, and then to experience a sense of calmness after working through these processes (Carroll 2002). Cameron (2002) describes this experience as ‘proprioception’, which enables an individual to develop a body schema which includes not only a physical image of oneself, but also an assessment of self-worth in relationship to others in the world/social context. The intention of any form of therapeutic use of touch and the attitude of the therapist may therefore contribute to informing and possibly revising the body schema. Therapists using touch in the form of reflexology may not consciously be working within a psychodynamic contract, but the effect on self-image is likely to have some potency and subsequent health benefits.

The nurturing presence of another can elicit responses in an individual, which can be interpreted as being cared for. John Bowlby’s early work in the late 1940s focused on the effects of children’s early separation from their mothers, evolving a theory of attachment. Bowlby’s system of attachment also included the propensity to learn to trust attachment figures from the experience of being supported when distressed. Later, Bowlby proposed guidance on how the attachment theory could be utilised in therapeutic work with clients across the lifespan (Ainsworth & Bowlby 1991). Within any therapeutic relationship, attachment issues can arise, although recognition and analysis of these aspects are more likely within psychotherapy discourse than the practices of touch therapies such as reflexology. The presence of the therapist has been defined in the literature as ‘being with’ the client in the most fully human, authentic, unique, and open way as possible (Gold 1996). Empathy is felt when the patient becomes aware of the therapist’s openness to understanding their situation. A useful way of viewing this is to see it as ‘witnessing’ how another presents him- or herself, to remain compassionate, curious and open. The process of being witnessed is two-way – clients may be observing therapists for an acknowledgement of his or her understanding through non-verbal responses, elicited from posture, facial expression, respiration and paralinguistic components of speech (Moursand and Erskine, 2004 and Yardley-Jones, 2006).

Reflexology is not a form of psychotherapy or counselling, yet the client can be nurtured by it as part of his or her processing of past or current emotional trauma and distress. Nowhere is this more apparent than for patients experiencing the existential crisis of life-threatening disease, such as cancer. Garnett (2003) conducted semi-structured interviews (informed by feminist interviewing techniques) with 18 therapists from 16 hospices providing reflexology massage and aromatherapy. The thematic analysis of the transcripts led to three observations of the impact and role of touch therapies:

Meeting an individual in such circumstances can result in the person becoming quiet, reflective and tearful. Some clients may be much more expressive, which may be the result of suppressing their emotions for some time. Emotional release can often be accompanied by physical events: release of endorphin-rich tears, changes in breathing patterns (deep and sighing expirations) and changes to the ANS, initially sympathetic arousal and then profound relaxation (parasympathetic) with reduction in blood pressure and heart rate, audible intestinal peristalsis and salivation (Carroll, 2002, Pennebaker, 1992 and Kettles, 1994). In reviewing the literature and the definition of the term ‘healing crisis’ as it relates to reflexology, Mackereth (1999) identified that it can include various physical and emotional responses following, or even during, treatment. The conclusion reached from this review was that patients were probably experiencing and expressing a much-needed emotional catharsis, with permission to unburden, triggered by the potency of the therapeutic space, the touch and attention of a skilled and supportive therapist.