In Safe Hands


According to the National Institute of Mental Health, post-traumatic stress disorder (PTSD) develops in some people who have seen or lived through an event that is shocking, scary or dangerous. These events might be combat related, for example, or involve violence, abuse or trauma.

According to PTSD United, an organization dedicated to providing support and resources for people who suffer from PTSD, roughly 24.4 million people are dealing with PTSD at any given time. Although nearly everyone experiences a traumatic event at some time or another, the difference for people who develop PTSD is that their reactions to the trauma continue instead of resolving naturally over time. Often, people with PTSD will feel stressed even when they aren’t in danger.

“People experience PTSD when their choices over what happens to their bodies are taken from them,” says Pamela Fitch, the author of Talking Body, Listening Hands: A Guide to Professionalism, Communication and the Therapeutic Relationship, and a massage therapist with extensive experience working with clients with PTSD. “When actions are taken that they have no control over, then no place or person feels safe. Add to this the context of how a person was loved or not loved, and the more strikes against them, the harder it is to overcome the trauma.”

What Are the Symptoms?

PTSD is highly individualized, meaning that few people are going to experience PTSD in exactly the same way. Being familiar with some of the primary symptoms, however, will help you better understand how massage therapy may prove helpful. According to Fitch, symptoms usually manifest in some of the following ways:

Hyperarousal. Generally speaking, hyperarousal refers to an increased psychological and physiological tension. For example, the person might feel anxious or tired, or suffer from insomnia. Additionally, their tolerance for pain might decrease while their startle responses become exaggerated. Here, too, personality traits might become accentuated.

Hypervigilance. Abnormal awareness of environmental stimuli, or being alert and attentive to potential threats, are signs of hypervigilance. You might also notice clients holding their breath or clenching their fingers, for example.

Guilt and shame. Clients who suffer from PTSD may also feel guilty or shameful, faulting themselves for what happened or having feelings of humiliation and unworthiness.

Dissociation. Dissociation describes how a person might distance themselves from a traumatic event. Some may detach emotionally or appear absent or unconscious. Other people suffering from PTSD might “lose time” and be unable to remember significant aspects of the trauma, for example. Panic, nausea and fear can also be aspects of dissociation.

Intrusive thoughts. Recurrent, unwanted and distressing memories of the traumatic event might also occur, along with upsetting dreams or flashbacks. According to the Mayo Clinic, PTSD symptoms typically begin within three months of the trauma occurring, although it’s also possible for years to pass before symptoms surface.

No matter how symptoms manifest and when they appear, the one constant for many people dealing with PTSD is that their symptoms significantly affect their daily lives, sometimes making it difficult to work and develop and maintain personal and professional relationships.

Remember, however, that even with an understanding of symptoms, you absolutely must stay within your scope of practice when working with clients with PTSD. “It is not within a massage therapist’s scope of practice to actively engage in conversation about the trauma, other than to listen, support and refer,” says Fitch.

Treatment for PTSD

Similar to other mental health diagnoses, like depression or anxiety, PTSD is commonly treated with an integrative approach that may include both medication and some form of psychotherapy, with the goal being to help the person effectively work through the trauma.

Cognitive therapy, for example, is a type of talk therapy that focuses on helping the person recognize patterns in their thinking that keep them “stuck,” like misinterpreting normal situations as threatening. Exposure therapy, where a person works to re-enter the setting where trauma was experienced, sometimes through the use of virtual reality, aims to help people suffering from PTSD safely confront what they find threatening or frightening so they can learn to more effectively cope with the traumatic event.

Many times, talk therapy (such as cognitive therapy) and exposure therapy are used in combination, along with anti-depressants or anti-anxiety medication, in some cases.

For clients with PTSD seeking massage therapy, Fitch believes working through their trauma history with an experienced psychologist or psychotherapist is a must. “If clients with PTSD seek massage therapy before they have done some reflection with a psychotherapist, they could be at risk of worsening their symptoms, becoming triggered by the touch, or feeling depressed or angry,” she explains.

How Can Massage Therapy Help?

Stess relief, decreasing anxiety, reducing depression1 and improving personal mood are all positive outcomes massage may provide clients. Additionally, a 2012 study focusing on how integrative therapies can help promote reintegration among veterans found that those participants who received massage therapy reported significant reductions in physical pain, tension, irritability, anxiety/worry and depression.2 Another recent study of Somali women refugees with chronic pain—the majority of whom reported military and/or sexual trauma—found that massage therapy provided enormous relief for distressing physical and psychological symptoms largely attributed to the exposure to trauma,3 according to Cynthia Price, a research professor at the University of Washington and massage therapist.

Research also indicates massage therapy may be effective for those clients who experience dissociation as a symptom of PTSD,4,5 allowing these clients to experience a more coherent sense of self, which for some is a primary reason they initially seek out massage therapy .6,7

While almost all studies on the subject point to the positive effects of massage therapy, making sweeping generalizations about its effectiveness for PTSD would be unwise. “Given that the studies to date have involved small samples, we do not know the magnitude of these effects, nor do we know how massage facilitates health in trauma recovery,” says Price. “However, research findings suggest that dissociation reduction, i.e., a more coherent sense of self, may play an important role in positive massage therapy effects.”

There are aspects of massage therapy, too, that appear to provide some unique benefits to clients with PTSD—mainly giving these clients a feeling of comfort, safety and control they often can’t achieve on their own.

According to Fitch, some of the massage therapist’s most powerful tools come from how the massage therapy session itself is handled, from the informed consent and opportunity for a client to ask questions that start each session to the therapist’s ability to respond to the individual’s needs during a session, whether that’s stopping altogether, changing positioning or adapting levels of pressure. “All of these actions ensure that clients are safe and know they can stop the treatment at any time, providing them a safe environment to experience touch,” she explains.

Massage therapists can also provide clients with self-care strategies to help prolong the positive benefits achieved, not only in massage therapy sessions, but with other integrative treatment approaches as well. “People who have been traumatized are no longer at home in their bodies,” Fitch says. “Massage therapists can teach clients safe and effective ways of self-soothing and stress management.”

What Massage Therapists Need to Know

Two words are going to be the focus of every massage therapy session you provide for clients with PTSD: trust and safety. “For a person to allow you to touch them, they must trust,” Fitch says. “People with PTSD have difficulty trusting, and that’s why it’s so essential that therapists work first on building trust and ensuring the client understands they can refuse treatment. Without client trust, there is no proceeding.”

Relationship building. Developing a professional relationship with clients who have PTSD often means more than simply explaining the benefits of massage therapy. Again, these clients are going to need to know they can trust you, and that may require spending more time talking before a massage therapy session begins, Fitch says, or in some cases before they ever enter your practice space. “Clients who have a history of trauma may ‘suss’ out the therapist, ask questions, call ahead and even interview the therapist prior to allowing themselves to become vulnerable in the treatment room,” she adds.

Get experience. Working with clients with PTSD is best-suited for massage therapists who have some massage experience. “Definitely, years in practice will help to ensure that the therapist does not try to do too much,” Fitch says. Price agrees, though adds that additional training specific to working with mental health issues and trauma in particular is a good idea, too. “This can include reading the literature as well as taking courses,” she explains. “There is a lot of training available for mental health practitioners that is excellent background for massage therapists.” Here again, however, you need to be mindful of your scope of practice as a massage therapist.

Both Price and Fitch suggest having other health care professionals you can rely on should you need support. “Peer supervision and consultation with more experienced therapists allow massage therapists to support clients without taking the client experience too far,” Fitch says. Price echoes this recommendation: “Getting supervision from a clinician with expertise in mental health is helpful,” she explains.

Communicate, communicate, communicate. From the intake to the massage therapy session to the close of the session, communication is imperative for clients with PTSD. For the most part, intake with a client with PTSD will be very similar to all the other intakes you do, with one distinct difference: “The intake process can appear the same, but the therapist’s intention should be to ensure the client’s safety,” Fitch says. “This may require that the therapist ask about a client’s touch history.”

Colleen O’Connor, a massage therapist who has worked with veterans suffering from PTSD, believes the intake is incredibly important for these clients. “Setting the stage for what the veteran can expect during the session is key,” she explains. “We were very clear that the veteran was in control of everything, including how dark the room would be, how much pressure would be used, what areas of the body I could touch, and that they could stop the session at any time.” For veterans who are amputees, O’Connor says, how that area of the body will be addressed—if touched at all—is decided during intake as well.

During the session, make sure the client is comfortable giving you feedback, as knowing if or when something is making the client feel uncomfortable or unsafe is key with clients with PTSD. “Ensure that the client feels safe enough to provide feedback,” Fitch says. “Encourage feedback, even if it’s negative.” And if, for some reason, massage therapy is making a client’s symptoms worse, then massage would be contraindicated, Fitch adds.

Julie Finn, a massage therapist who also works with veterans suffering from PTSD, says massage therapists must be aware of what might trigger aresponse from the client. “You need to understand the sounds, smells, loud noises or even touches that might trigger a flashback or response,” she explains.

Go slow. Clients with PTSD are going to need you to work at their pace, whether that’s during intake or a massage therapy session. “The biggest challenges are to work slowly, conservatively and try not to rush,” says Fitch. “Taking the time demonstrates to the client that the therapist appreciates their need for feeling safe and in control.”

Fitch also reminds massage therapists to think about their practice space. “People who have PTSD usually feel vulnerable when in a confined and intimate space,” she says. “It’s exactly the kind of environment that massage therapists work in.” Lying face down may make some clients with PTSD feel less in control, she adds, so be aware of positioning. Also, reiterate the fact that they should undress only to their comfort level so they understand they are in charge of the session.

As a massage therapist, you are in a good position to help clients with PTSD—but you need to know how massage sessions may differ with these clients. “People living with trauma need compassion, care and a willingness to work at their pace,” says Fitch. “The therapist’s job is to ensure safety and protect the client from experiencing intrusive symptoms of trauma. Breathe, settle, allow your own body to become still. With informed consent at the heart of the treatment, massage therapy is powerful medicine.


References

1. Hou WH, Chiang PT, Hsu TY, Chiu SY, Yen YC. Treatment effects of massage therapy in depressed people: a meta-analysis. J Clin Psychiatry. 2010 Jul; 71(7):894-901.

2. William Collinge, MPH, PhD, Janet Kahn, PhD, LMT, and Robert Soltysik, MS. Promoting reintegration of National Guard veterans and their partners using a self-directed program of integrative therapies: a pilot study, Mil Med. 2012 Dec; 177(12): 1477–1485.

3. Price CJ, Abdullahi, A Community Massage Program for Somali Women Immigrants. In: International Massage Therapy Research Conference; Boston, MA USA; 2013.

4. Price CJ, Donovan D, Wells E, Rue T. Mindful awareness in body-oriented therapy as an adjunct to women’s substance use disorder treatment: A pilot feasibility study. Journal of Substance Abuse Treatment. 2012; 94–107.

5. Price CJ. Dissociation reduction in body therapy during sexual abuse recovery. Complement Ther Clin Pract. 2007;13(2): 116–28.

6. Price, C. (2012). Massage for adults with a history of sexual trauma. Chapter In: Dryden, D. & Moyer, C. (Eds.) Massage Therapy: Integrating Research and Practice. Human Kinetics, Champaign, IL., pp. 165-170.

7. Price, C. (2004). Characteristics of women seeking bodywork as an adjunct to psychotherapy during recovery from childhood sexual abuse. Journal of Bodywork and Movement Therapies, 8(1): 35-42.

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