raumatic events, such as fire, earthquake, bombing, and hurricane, occur daily.  Such devastating circumstances, like those the Gulf Coast endured during Hurricane Katrina, often cause an acute reaction of fear and terror known as post-traumatic stress. It occurs when traumatized individuals cannot safely assign to the past what has happened in their life. The experience of trauma undermines one's expectations of safety and security in the world.

The overall goal in the massage treatment of PTSD is to help the client to become safely "embodied within the self."

As they struggle to make sense of what has happened to them, the majority of individuals who experience severe trauma develop such acute, short-term symptoms as sleep disturbances and physical pain. Others, unfortunately, develop chronic symptoms related to their traumatic experience, such as nightmares and flashbacks, difficulty sleeping, and feeling detached or estranged.  These symptoms, when they occur together, are indicative of post-traumatic stress disorder, or PTSD. The impact of such symptoms has a neurobiological basis and crosses physical, emotional and spiritual boundaries. Such clients present significant challenges to the massage therapist’s skills and knowledge.

This article examines the role massage therapists can have in dealing with post-traumatic stress. While they cannot diagnose PTSD, massage therapists can be an integral part of a person's comprehensive recovery plan. The overall goal of massage for PTSD is to help the client to become safely "embodied within the self." People who have been traumatized are no longer at home in their bodies. In a multidisciplinary context, massage therapy can help bring clients back into themselves by increasing their ability to feel safety, to be freely curious without fear, to feel comfortable with their bodies.

Clinical Manifestations
It is important for massage therapists to understand the clinical manifestations of trauma, in order to understand the risks and benefits which massage therapy offers to clients with PTSD. Many clients have traumatic histories and exhibit the signs and symptoms of PTSD, whether or not the massage therapist is aware of it.

In their book, Transforming the Pain: A Workbook on Vicarious Traumatization, Saakvitne and Pearlman postulate that the experience of trauma undermines five basic human needs:

Nowhere is this more evident than in the massage therapy room. Those who have experienced a deeply traumatic event may not be easily soothed by simple words or touch. For them, trauma continues to live on in their body and spirit, as if it were still happening in the here and now. The loss of confidence in the body's ability to keep them safe is experienced as the ultimate betrayal of all that they have come to know and trust about the world and other people. The longing for safety remains but is buried deeply under the guard of perpetual mistrust and fear.

Response to Massage
In the ordinary course of events, massage therapy can offer a profound sense of peace to those who are able to feel strong enough at their core to let go and relax. For those who carry the effects of trauma, however, the world does not feel safe and they cannot trust their bodies to give the appropriate signals of safety. Alarm bells are always being rung by the flood of stress hormones. They either remain on full alert or alternate between numbness and hypervigilance.

Massage therapists may feel frustrated at the noncompliance of clients and their seeming inability to allow the therapist to work deeply when trying to alleviate tension and muscle pain. A more helpful approach may be to look closely at the reactions of clients, observing these reactions as clients' courageous efforts to keep themselves together in the face of overwhelming fear. The massage therapist must repeatedly offer the client the opportunity to experience the body in the present in a respectful, nonjudgmental environment, to put the memory of trauma in context and live more fully in the present.

Technique Considerations
There are no specific physical manipulation techniques for working with trauma clients. Swedish massage can be as effective and enlightening to a client as the most advanced fascial mobilization. According to Genie Martin's "Trauma and Recall in Massage: A Personal Experience," no matter the technique, massage therapy can inadvertently trigger traumatic memory, which, as massage therapists know, also can be a powerful tool for healing and growth.

Getty Images Rose petals bring emotional comfort and inner peace to you and your clients.

Establishing trust is essential when working with clients with PTSD. Philosophically, engaging in massage therapy represents a commitment to wellness on the part of the client and the therapist. It is a caring, safe way for individuals to experience touch and receive release from pain. In a healthy therapeutic massage relationship, the client participates in creating accomplishable outcomes. Decisions for care are widely discussed, and the process is one of consensus and cooperation. This approach is critical for successfully working with a PTSD client. For these clients, safety needs to be paramount. They need to know unequivocally that they have the power to stop, change, or modify a massage at any time. 

The Treatment Continuum
Predictability and routine can be a great solace and comfort for clients with PTSD. It is important for the massage to include a well-understood beginning, middle and end. Beginnings and endings should have familiar, repetitious aspects that signal to the client where they are in the session. The beginning of the massage session establishes safety, boundaries and goals. The middle part is primarily experiential, and builds on the client's capacity to sustain safe touch. The ending provides an opportunity for the client to articulate some of what has occurred, to acknowledge what may need to be processed in psychotherapy, and to take home strategies for healthy self-care and self-soothing.

Likewise, the overall massage therapy plan follows a predictable course where there is a definitive beginning phase, an exploratory midphase and a concluding phase. Judith Hermann, author of Trauma and Recovery, calls these stages safety, remembrance and mourning, and reconnection. The beginning of the plan focuses on offering choices and establishing ways in which the client wishes to be massaged.

The middle phase can be intense, sometimes emotionally painful, and often liberating as clients experience their bodies as they really are in the here and now without being overwhelmed by sensations that originate in the past. It is extremely important to note that it is not the massage therapist's role to analyze or interpret what the client is saying or feeling. In massage therapy, clients may be very vulnerable to accepting the massage therapist's interpretations as literal truth. It is always the client's right to define an experience.

As the therapy shifts to the final phase, the therapist begins to notice subtle changes in the client's reactions to being touched. While being touched, the client may talk about the ordinary events of life and yet remain relaxed and present. The therapist should take this as a cue that the third phase has begun. Good closure is just as important for this client as is a good beginning. In the final phase, the client reviews what has happened over the course of therapy, embraces whatever changes the massage therapy has given, taking learning out of the massage sessions and into everyday life — a life that is now more enhanced by the possibilities of a more embodied self.

Conclusions
The experience of trauma assaults a person's sense of safety in the world. Post-Traumatic Stress Disorder, a noxious presence, can demolish confidence, enhance shame, and have terrible consequences on social relationships. Yet it is considered to be one of the most treatable causes of psychic pain.

In the hands of a skilled therapist, massage therapy for clients with PTSD acknowledges and helps to restore the most basic of human needs. When the ability to satisfy fundamental needs is damaged, an individual may be unable to function easily or happily in the world. When these needs are satisfied in the context of a healthy therapeutic relationship, an individual may not only survive but relearn or discover for the first time how to thrive.

Trish Dryden, MEd, RMT, director and co-owner of the Sutherland-Chan School and Teaching Clinic and a professor in Applied Arts and Health Sciences at Centennial College at Toronto, Ontario, Canada, experienced workshop facilitator and lecturer, international consultant, and author of numerous articles and papers, maintains a private practice.

Pamela Fitch, BA, RMT, in private practice since graduating from Sutherland-Chan in 1988, specializes in treating trauma and body image, has written extensively on ethics, professional boundaries, and breast massage ( Winter 1998), served as president of the Ontario Massage Therapist Association, and is a consultant, facilitator, writer, and practitioner in Hong Kong.

*This article originally appeared in the Spring 2000 issue of Massage Therapy Journal. Click here to read it in its entirety.

MASSAGE THERAPY Q & A: HOW CAN I RELAX DURING MY MASSAGE?

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