As massage therapy becomes more accepted as a complementary approach for mental health conditions, massage therapists will need to devote significant study towards learning about mental health care. This article will examine how trauma may present within the body and discuss important considerations when working with trauma patients in a massage setting.<\/p>\n
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) fifth edition<\/a> defines trauma as direct personal experience of an event that involves “actual or threatened death, serious injury, or sexual violence”. Trauma affects both the body and the mind, so discussions about trauma must address physical healing as well as the emotional and psychological dimensions.<\/p>\n Before working with trauma patients, a massage therapist needs to ascertain their level of training and understanding of trauma. Entry level schooling is not enough to understand trauma at a significant depth regarding client care and effects within the body.<\/p>\n Everyone will have differing experiences with trauma engagement. As a massage therapist learns more about how trauma processes within the mind and expresses through the body, the nuances of the topic will demand enhanced conscious awareness. Be open to multiple ideas on expanding one\u2019s practice of providing appropriate care for trauma patients. The presence a therapist brings to the treatment room will be paramount in the effectiveness of the session.<\/p>\n Dr. Paul MacLean describes how the brain processes trauma related messages by way of the Triune Brain Model. This model explains how three distinctive brain portions help the body process stress: the brain stem (Primitive brain), the limbic system (Paleomammalian complex) and the neocortex (Neomammalian complex). Essentially, the brain stem activates the other two complex portions to facilitate a stress response. Primal instincts and protective means acquired early in life initiate to engage a sympathetic response within the body.<\/p>\n The body\u2019s HPA neurological wiring is involved within any trauma response. HPA stands for three glands communicating hormones in response to trauma: hypothalamus, pituitary and adrenal glands. Communication amongst these three glands initiates the physical manifestations of trauma.<\/p>\n When the body experiences stress, the hypothalamus releases corticotropin-releasing hormone (CRH) towards the pituitary gland. This instructs the pituitary to release adenocorticotropic hormone (ACTH) towards the adrenal glands. This facilitates the release of Epinephrine and Norepinephrine (aka Adrenaline) as well as cortisol to facilitate a sympathetic stress response.<\/p>\n Elevated levels of cortisol indicate long-term stress exposure. Cortisol in significant quantity can signal to the hypothalamus and pituitary to continue producing CRH and ACTH, thus perpetuating the stress response cycle. This constant positive feedback can create a condition called HPA axis dysfunction. In the long run, this dysfunction creates a cortisol deficit as the body cannot maintain high levels of cortisol for long. This makes the body reliant on adrenaline hormones for stress response. Common symptoms of HPA axis dysfunction include waking up fatigued, insomnia, cognitive issues, weight gain and hyperirritability.<\/p>\n Trauma expresses itself through the body in many fashions. Sympathetic responses, also referred to as \u201cfight, flight, or freeze\u201d responses, can grip a person recalling trauma. Heart and breathing rates increase, nerves become hyperactive, eye pupils dilate, digestion shuts down, and muscles activate.<\/p>\n On the massage table, the body\u2019s sympathetic response may present in many ways. A client\u2019s breathing rate may increase enough to make a session seem noticeably uncomfortable. Their body may twitch as muscles spasm or tighten. Their body may also become rigid. Muscles may be too difficult to apply pressure upon. A client may ask you to avoid a certain region of the body or end session entirely. We must respect client requests and steer away from bodywork that overstimulates their body.<\/p>\n The client may also verbally recall events, sharing deeply personal and intimate information. The ability to listen without offering counseling is important for a therapist to remember. Be sure to remain within scope of practice, which is to mindfully listen, hold professional space<\/a>, and refer the client to appropriate professionals.<\/p>\n The potential for somato-emotional releasing is likely with trauma patients. What I present in my continuing education courses is a three-step approach when interacting with clients experiencing such releases:<\/p>\n There are many considerations for massage therapists to review as treatment plans are devised and a client is expressing their trauma upon the table. One of the first considerations is whether the therapist can maintain poise during the session. Poise refers to the ability to gracefully maintain focus and composure within a situation which becomes unpredictable and uncomfortable. Countertransference can cloud the clinical picture for a therapist so they need to refer a client to another practitioner if they cannot maintain poise with a client.<\/p>\n Also, deducing myofascial patterns of tension and determining where a client \u201cholds tension\u201d can be valuable. The Fascial Research Society has highlighted numerous studies demonstrating that fascia is richly innervated and closely connected to the nervous system. Some researchers and clinicians believe fascial restrictions may play a role in how the body manifests stress and trauma. This may help explain why some clients experience somato-emotional responses when tissues are engaged during bodywork.<\/p>\n Activating the neuronal tissue of fascia can literally activate memories stored within a body region. This will facilitate a physical response of myofascial tightening and restrictions. A therapist can seek the patterns of \u201cstress\u2014strain\u201d where the body holds trauma. Modalities to assist in the softening of these restrictions include Myofascial Release<\/a>, Cranial Sacral Therapy<\/a>, Reflexology<\/a> and point-focused therapies such as engaging with Chinese Tsubos and Ayurvedic Marma points<\/a>.<\/p>\nHow Trauma May Present During Massage Therapy<\/h2>\n
Responding to Emotional Release During a Session<\/h2>\n
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\nWhen a somato-emotional response is occurring (or soon to occur), there can be a palpable shift in energetic feel of the client. When this occurs, immediately stop performing massage and check in with the client. Their response will inform you of how to proceed next.<\/li>\n
\nSome clients may not want to share their feelings or allow feelings to be felt while laying upon the table. Saying statements to validate that feelings are valid such as \u201cIt\u2019s OK to have this feeling\u201d and \u201cThis is a safe space to feel what you need to feel\u201d can provide permission for a client to feel appropriately.<\/li>\n
\nWe hold space for clients and wait for them to provide a directive on how to proceed next. Some clients may request a simple touch gesture such as holding their hand. Other clients may want you to back away or leave the room. Many clients may ask you to wait a few minutes before proceeding with the massage while others may end the session entirely. We simply respect their wishes for this step.<\/li>\n<\/ol>\nTreatment Planning Considerations<\/h2>\n
Boundaries, Consent, and Scope of Practice<\/h2>\n