Massage, Touch and Trauma by Rachel Fairweather for Massage World Magazine

STOP! …Before you pass over this article thinking “Not relevant -I don’t work with anyone who has experienced significant trauma”. On the contrary, there is a strong probability that a significant proportion of your clients have experienced severe trauma during their lifetime – and they probably won’t tell you about it. There are a disturbing number of adults who have experienced the horrors of sexual, physical abuse or domestic violence; just look at the statistics that speak for themselves:

• Nearly a quarter of young adults have experienced sexual abuse during childhood.
• One in nine young adults has experienced severe physical violence during childhood at the hands of an adult (Source: http://www.nspcc.org.uk/)
• 1 in 4 women experience domestic violence over their lifetimes, and between 6-10% of women suffer domestic violence in a given year. (Council of Europe, 2002)

And this is only the tip of the iceberg of traumatic incidents that can affect physical and emotional health. Add to the list the ongoing trauma of, for example, living with a parent who is alcoholic or has mental health problems; chronic illness of relatives, bereavement and the trauma of life threatening accidents (203,950 road traffic accidents resulting in personal injury in 2011), and you start to have an idea of why understanding this subject is important to massage therapists.

The effects of trauma and its relevance to bodywork

Clearly, experience of severe and repeated trauma can have extreme effects on not just our emotional health but our physical health too. Prolonged or extreme stress has been linked with a host of common illnesses and chronic pain conditions including headaches, back pain, RSI, digestive problems, lowered immune response, fibromyalgia, ME, chronic fatigue syndrome, rheumatoid arthritis, allergies, asthma, cancer and heart complications. Not to mention the psychological counterparts such as depression, anxiety or more serious mental health problems. Several research studies show that violence against women has serious consequences for physical and mental health, and women who have experienced abuse from her partner may suffer from chronic health problems of various kinds.

There is a complex and often self-perpetuating relationship between pain and emotion – for example depression can lead to episodes of chronic pain and chronic pain can lead to depression (Tunks 2008). A systematic review (Linton 2000) showed that stress, distress and anxiety are significant factors in the development of neck and back pain and another study showed a strong correlation between a diagnosis of anxiety and chronic widespread pain (Benjamin 2000). Recent brain imaging studies have shown that emotions have a powerful effect on modulating pain – when experimental subjects were shown pictures that provoked different emotional states, this caused corresponding changes in relevant structures involved in pain processing in the brain.(Roy 2009)

Many of the conditions that we treat in clinic are clearly inextricably linked with the effects of stress and trauma in the body. So what do we need to know to help us treat effectively?

How trauma affects the body

Both ancient and modern wisdom unite in the assertion that trauma can affect both physical and mental health. The ancient healing practices have recognized the mind and body as indivisible for centuries – trauma affects the balance of our energetic life field that in turn affects our physical and mental wellbeing.

Long before Western psychology and the fields of psycho neuro – immunology caught on, most ancient systems of healing were clear about the role of stress and imbalance as a fundamental factor in pain and disease. Traditional Chinese medicine views imbalance as a primary causal factor in disease, identifying a particular emotion with each organ – joy for the heart, anger for the liver, worry for the spleen, sadness for the lung, and fear for the kidney. Excess or insufficiency in emotions can cause imbalance and therefore ill health and pain.

The Hawaiian concept of health is based on the word “ola” which means “life” and the “attainment of peace” with strong root associations with abundant energy. Sickness is called ma’i with the root meaning of a “state of tension” – a very clear indication of ill health being related to stress. The shamanic approach sees all sickness to be self generated as an effect of stress, The location is simply where the stress is focused. The source of stress is seen as resistance – our desire for things to be different than they are.

More recently, bodyworkers interested in the somatic understanding of trauma are indebted to the work of Peter Levine and his seminal work “Waking the Tiger; Healing trauma”. Levine explores our reaction to those situations we perceive as life threatening and how this compares to instinctual animal behaviour. Our reptilian brain (brain stem) still responds to threat or danger by adrenalizing the body into flight or flight mode. However, as humans, often our rational brain prevents us from taking action as we are unable to decide between these 2 choices. A third, lesser known, reaction – the freeze response – is often adopted by animals where they literally “play dead”, decreasing metabolic activity and collapsing into immobility. This is like having the foot on the accelerator and the brake pedal at the same time – although the animal appears immobile, in actuality there is an inner racing of the nervous system coupled with an outer immobility – the result of this literally creates a “tornado” of energy in the body. Animals in this position will literally “shake off” the energy following the freezing period and then go happily about their business with apparently no ill effects. However for a number of reasons humans have lost the instinctual ability to discharge this residual energy leading to a wide variety of symptoms following trauma; i.e., anxiety, depression, psychosomatic and behavioral problems. In extreme cases this can manifest as post traumatic stress disorder or PTSD which is incredibly debilitating.

Moreover, as the system is now stuck in hyperarousal, any situation which in any way looks or feels like the original trauma will lead to a re- experiencing of symptoms. This is vital to understand as there is a high possibility that bodywork can re-create the effects of the traumatic situation unless we understand the fundamentals of how to create a safe space for our clients. As you are unlikely to always know which of your clients have experienced sexual or physical abuse, it is vital that this is part of good practice for ALL clients.

Creating a safe space for all clients – “First do no harm”

The first rule of good bodywork is to create a psychologically safe space for your clients. This is well known in talk therapies but often overlooked in bodywork. A safe space involves factors such as:

• Good communication. Adopt an open listening style when taking a case history; be non judgmental, maintain good eye contact and ask questions that enable your client to give answers in their own words. Ask about current or past stress levels, family history or illnesses while growing up, any significant emotional or physical traumatic events – this can all help to give you an all round picture of the person you are dealing with. Make sure you don’t slip into role of counsellor; open non –judgmental listening is enough.

• Letting the client know they are in control: Clients who have been physically or sexually abused have had their boundaries completely violated. Their bodies will be hypersensitive to any perceived re-creation of this. They need to know you are trustworthy and that you will do what you say. Explain exactly what is going to happen in the session; how to position themself; how they will be draped. Ensure a “safe space” emotionally and physically by letting the client know that this is a confidential space and whatever they need to do during the session is OK. Let them know they are in control and if anything doesn’t feel right in any way you will back off and change what you are doing. Remind them that pain does not lead to gain during therapeutic massage and to let you know if you are doing anything that is making them grit their teeth or clench their fists.

o   Explain what will happen at the end of the session. For example say something like “I will leave the room and let you get dressed in your own time. When you are ready, just wait in the chair and I’ll come back after a few minutes. It is really great for me to get feedback on how you found the session as that will help us in future sessions to design a treatment plan that is most appropriate for you.

• Professional draping: Draping is there for a reason. It lets the client know where you are going to be touching and which areas are private. NEVER work under a drape unless you have a really good reason and have explained to your client why you are doing this and gained their permission. Keep your draping clear and tight and remain mindful of any potential exposure during the session.

• NO means NO – Always respect your client if they ask you to stop or not to work an area! This may seem obvious but I have seen excellent and well – meaning bodyworkers overrule something a client has said because “your body needs it”. This is the quickest route to re-traumatising a client or allegations of misconduct. If you feel an area needs work but your client has asked you not to, you will need to gain trust over several sessions, months or years and work towards this with full permission.

• During the session, if you are going to radically change your mind about what you stated you are going to do, let the client know and why, i.e. you’ve seen a more effective way to do what you wanted to do

o   Let them (get them to) speak first when you come back in. You want immediate feedback. As part of the feedback, ask them if anything didn’t feel OK (emotionally or physically) and respect that in the next session

o   Maintain good boundaries: You are a massage therapist. Do not slip into role of counsellor, friend or spiritual guru for any client. Be clear about who you are and what you provide. Be precise about your timing and do not give extra time for sessions unless this has been asked for and paid appropriately. All of this helps your clients to feel safe and that you are trustworthy – you will do what you say and say what you do.

Dealing with emotional release or re-traumatisation during a session

It is extremely important to be able to recognize the signs of re-traumatisation during a session as this can be damaging and distressing to the client. There is a distinct difference between someone having a healthy and manageable emotional release on the table and the client who is becoming re-traumatised. Red flags to watch out for which means that you need to intervene are:

• Rapid body movements that are becoming uncontrollable
• Feeling uneasy in your own body
• A feeling that the client “isn’t there”
• Client refusing to engage with you verbally – not answering questions or staring blankly
• Uncontrollable crying, shaking, laughing
• Sudden change in breathing pattern
• Client putting hands over eyes or refusing to look at you

In these cases it is vital that you re-orient your client back to reality and the here and now as it is very easy to disappear into a literal “black hole” of trauma where they are unable to think, feel or react to you clearly.

Use the following steps as a guide to deal with the situation:

1. Ground yourself- take a deep breath, feel your feet against the ground and breathe out any anxiety or helplessness you are feeling
2. Orient your client to the here and now by directing her to current sensory experiences. A good start is to ask her to wiggle her toes and wiggle her nose. Then get her to open her eyes and look at something neutral – ask her to describe the colour or count how many ceiling tiles there are or something similar. If she is not doing as you ask you will need to keep asking and be very firm until you get an appropriate response
3. Do not get involved in conversation about recounting the traumatic event – your job is to bring the client back to the here and now.
4. If your client is crying or upset do not get involved in “comforting” or “trying to make it better”. Just listen and say something like “that’s fine – just feel what you feel and be aware of the feeling of your body against the couch at the same time”. In this way the trauma does not become overwhelming.
5. When your client is clearly back in the here and now you can discuss whether it is appropriate to continue the session or not. If you decide to continue the session, make sure your client stays in a position where they are able to feel in control of any cathartic energy release ie: telling them to feel what they feel but noticing the feeling of their body at the same time.
6. At the end of the session discuss ways forward together – unless you have been appropriately trained in bodywork and trauma you may need to suggest additional support such as talk therapy or another appropriately trained bodyworker

Ways forward in mind-body work with trauma

Without a doubt, the field of working with both mind and body is being recognized in both talk therapy and bodywork as the way forward for the distressing symptoms of PTSD and other mental health symptoms that do not respond to the sole use of bodywork or talk therapy alone. Therapies such as EMDR (Eye Movement Desensitization and Reprocessing), somatic experiencing (based on the work of Peter Levine), SER (somato emotional release – used in advanced cranial therapy) and Hakomi to name a few, all use the concept of a combination of touch and talk therapy directed at releasing energy or re-calibrating the nervous system. This is an exciting but highly skilled area and I would urge any readers interested in working with trauma to gain thorough training in any of these disciplines.

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