Other than the occasional checked box on her intake form, Jenny Cheek, LMT, has never in her 16 years of practicing massage therapy had a client discuss their mental or emotional health. “The only reason it comes up at all is in the context of informing me of medications they’re taking,” Cheek says.
Up the coast from Cheek’s Charleston, SC, practice, New-York-state-based Sakinah Irizarry, LMT, says the same. “When I ask a client what brings them in, they almost always respond with something physical,” she says.
Yet, in a time when the Anxiety & Depression Association of America (ADAA) ranks anxiety as the country’s most common mental illness—and depression as the leading cause of disability for people ages 15 to 441—it isn’t a leap to assume at least some of the people receiving massage therapy are experiencing issues with their mental health. According to AMTA’s 2021 Massage Profession Research Report, 27 percent of consumers who received massage in the last 12 months did so for relaxation and stress reduction. Add to that massage’s potential for relieving tension and chronic pain (two major manifestations of stress and anxiety), and what’s left is a high likelihood of missed opportunity.
Intaking the Invisible
About five years into her massage therapy practice, Cheek says she began picking up on certain patterns in clients. Some of the patterns were physiological in nature. Others were behavioral or verbal. All served to fill in the gaps left by her formal and verbal intakes—especially those pertaining to mental health. “One big tip-off is when people describe physical pain in an emotional way,” she says. “Perhaps their eyes well up as they’re talking about it. Or they say things like, ‘I’m not sure I can go on like this.’”
Cheek automatically assumes a certain degree of depression in clients who have endured chronic pain for more than a few years. Research supports her observation. In a 2019 Australian study, 169 individuals with chronic pain reported an array of affective-disorder symptoms, including depression and anxiety.2 “When it has permanently altered the way they walk or hold themselves—that represents a decrease in quality of life, in my opinion,” Cheek says.
Irizarry notes changes in clients’ talking patterns as possible indicators of anxiety or depression. “They may start out very talkative and then settle into silence as the session progresses” she says. “Or I’ll notice a typically talkative client shows up abnormally quiet.”
TMJ issues are a strong suggester of mental strife, with the jaw, neck and shoulders acting as a storehouse for tension and stress. “When I started out in Charlotte, NC, I worked with a ton of bankers and nurses who were stressed out of their minds,” Cheek says. “I could feel the tension in their occipitals wrapping around to their ears.”
In her practice in Long Island and New York City, Megan Fortunato, LMT, sees many pre- and post-natal clients and has learned to watch for depression and anxiety in both stages. “A lot of expecting moms get anxious as they near their due date, and a lot of new moms experience both depression and anxiety,” Fortunato says.
Here again, the stress, tension and exhaustion inherent in early parenting tends to express heavily in the neck, chest and shoulders. “They call it ‘new mother’s neck,’” Fortunato says.
Massaging the Mental
In the grand scheme, the ability to assess clients’ mental health may not matter nearly as much as the potential to bolster it. Each year sees new research linking massage therapy to mental wellness, particularly as it relates to chronic pain, sleep and stress. “I’m not a physiologist, but my knowledge suggests that what’s happening in massage therapy is we are facilitating the engagement of the parasympathetic nervous system, which we know contributes to wellness through its support of sleep, digestion and relaxation,” says Pam Fitch, RMT, a retired professor of massage therapy in Ottawa, Canada.
Still, even amid mounting scientific data, Fitch believes the real power of massage therapy lies in the areas of socialization and community. “We can talk all we want about the physiological responses to massage, but frankly, after 35 years of practice, it is my humble opinion that what we are doing is providing safe, empathetic connection via human touch,” Fitch says. “And that is what makes people feel better.”
Looking back on the first-ever massage she received as a student, Cheek concurs. “I cried on the table,” she says. “I had no idea what was happening then, but now I know it was likely the experience of receiving safe, positive, healing touch with my consent.”
Irizarry prioritizes consent above all else in her approach to new clients. “Until I build that trusted, therapeutic relationship, I am very careful about placing my hands on them,” she says. “I remain extremely calm; I take care in how I enter the room; and I make sure they are covered.”
Gentle, slow technique tends to gain the most ground in achieving trust and consent. “Swedish plus myofascial is a great combination for clients who need focus work but want a relaxing delivery,” Cheek says. “I apply just enough lotion so that it doesn’t feel like I’m dragging their skin and use both palms to compress and move in opposing directions.”
Scientific journal Brain Sciences recently covered a 2020 trial on women with chronic back pain whose depressive symptoms and negative body image were significantly reduced after receiving slow, superficial strokes along the back, neck and dorsal limbs.3 For some people, rocking can be calming, so long as they’re not sensitive to motion sickness or vertigo. “Anytime you’re dealing with someone who is stressed out, slow and steady strokes are important,” Fortunato says.
That approach applies as much to the client as it does to the therapist. “Project the response you want to see,” Irizarry says. “If you’re moving and breathing slowly, it signals to the client that it’s OK to slow down and breathe as well.”
Fortunato says many of her new-mom clients simply need time and space to rest. “They’re often exhausted, so it really becomes a space for resting and reconnecting with their bodies.”
Sticking to Scope
As trust and therapeutic bonds build, many clients will begin to open up about the stresses and emotional challenges going on in their lives. Massage therapists have varying preferences when it comes to intra-session chit-chat, but it is crucial that all massage therapists remain within the scope of their profession. “It is extremely important to give our clients the message that we are not talk therapists,” says Fitch, who develops continuing-education courses on massage for depression.
“Good practice to me is to never lead the conversation,” Irizarry says. “You want them to know that you empathize and can relate without getting too involved in the conversation.”
Irizarry relies heavily on the conversational technique known as “mirroring” to navigate that fine line. “Someone may express something difficult about their family, for instance, and I simply reflect it back to them,” she says. “I’ll say, ‘Yeah, family stuff can be tough,’ or ‘I know what you mean.’”
When clients are extremely agitated, Irizarry contains her responses to single, affirmative words. “I’m saying things like, ‘Mmm hmm, I hear you,’” she says. “A lot of folks just want to know that someone is listening anyway. That alone is enough to calm them.”
On the occasional instance that she observes urgent distress or trauma in a client, Irizarry is prepared to recommend a clinically appropriate professional. In her office she keeps business cards of reputable therapists and physicians and hands them off as needed. “I’ll say, ‘That sounds like a lot—do you have someone you can talk to about that?”
Many of Fortunato’s pre- and post-natal clients come to her by recommendation of a therapist, some of whom may have been recommended by the client’s obstetric physician. It’s a chain of events that she would like to see play out more often. “I’d like to see more OB/GYNs referring,” Fortunato says. “To be able to remove them from that fight-or-flight stage—even if it’s just for 60 minutes—it’s huge. And it’s what we do.”
Massage Therapy Journal
The Science of Stress
1. Anxiety & Depression Association of America (ADAA): Facts & Statistics | Anxiety and Depression Association of America, ADAA.