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In the details: Treating patients of assault, part 2

May 19, 2020  By Robert Libbey

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Trust is built not in huge defining moments, but over time with very small moments. Therapists typically reflect on different techniques or strategies they can utilize to treat an orthopaedic dysfunction. It’s time to recognize that it is equally important to reflect on how your verbal and non-verbal communication and interactions influence the building of trust within the therapeutic relationship.

The role of post-traumatic stress
Everyone is dealing with their own life challenges in the best ways they know how. Many patients are managing with some level of post-traumatic stress (PTS) as best they can. Some days are worse than others. On these days, a patient can present feeling various levels and mixtures of anger, grief, guilt, and sadness, among others. These moments can and will occur during treatment. Recognize and realize what the person in front of you is going through. RMT’s generally ask a patient about how they are feeling and then continue the conversation from there. It’s part of our history taking. Depending on what the patient then confides in us will determine if treatment continues that day. When a patient says to me that they only came to the appointment because it was scheduled and that they are unsure of they want to be touched that day, I postpone the treatment. My concern is always the safety of the patient and myself.

Sometimes patients’ will discuss what they are going through, sometimes they won’t, but RMTs should never initiate those conversations. But if a patient starts a conversation, the therapist immediately needs to self-assess to determine if they themselves are comfortable continuing the conversation. I have no problems being a sounding board for a patient, but I always educate the patient and make sure that they understand what our scope of practice is. If they want to continue to confide in me, I have no problem listening and acknowledging them.

RMTs should remember that emotional reactions are multifaceted and have many depths/layers. Depending on the situation, a client may express anger can be about an event, and it doesn’t have to be an assault situation. Patients come in expressing emotion from daily their interactions. When a patient express’s anger towards the RMT, the RMT needs to remember that the anger is about something/someone else. Be concerned and caring. This is where listening skills, empathy and understanding will be best utilized. Recognize as a health professional, that you have done nothing wrong. Today may not be a good day for treatment. Ultimately the patient must be made aware that it is their choice if they want to continue with the appointment, and can stop the treatment at any time.


If the decision is made to stop treatment it’s important to ensure that the patient is capable of leaving your office feeling safe and that they have somewhere safe to go to. If the decision is made to stop treatment, it’s important to ensure that the patient is capable of leaving your office feeling safe and that they have somewhere safe to go to. In many cases, I’ve requested who the patient’s main emergency contact is and asked for permission to contact them. Remember your confidentiality when speaking about your patient.

Other Considerations
Are there any areas of the body that should be avoided?

An aspect of treatment with any patient is obtaining consent which involves confirming boundaries both legal (defined by your regulatory body) and areas that the patient has deemed off limits. Remember, there are many techniques that never require the patient to remove much, if any clothing. A very common comment I receive from patients is “I never realized I could receive a massage treatment without ever taking my clothes off!”

Once treatment boundaries are established, part of gaining informed consent is having both parties agree on how accessing certain body areas within the boundaries will happen. Typically, only undraping the area of the patient’s body where treatment is delivered is required. Many times, during treatment, other areas are determined to require treatment. When this occurs, revisiting the discussion on boundaries and consent to treat strengthens trust and minimizes the power imbalances of the therapeutic relationship.

Personally, I have a few topics that should be avoided for conversations with all patients. These include but are not limited to: religion, politics, right to life, gender topics, ethnicity/race, conspiracy theories, etc. I also avoid offering or giving advice when asked “What would you do?” or “What do you think I should do?”

It’s professional for you to say that as a health care professional, its outside your scope of practice to offer advice and that you don’t have the professional training to help in this area. Then make the appropriate referral either back to the patient’s M.D. or onto a clinical counselor.

Generally, I have a scent-free environment. The connection of scent to memory is strong and you never know what experience or memory a certain sent will trigger in any of your patients. I also avoid strong food scents for the same reason. Save the fragrant herb and spice foods for home.

Sometimes you can control the noise environment and sometimes you can’t. Outside world sounds such as traffic can be difficult to block out. In an office, sounds such as voices that travel from one treatment room to another can be challenging to control. With my assault patients who have great sensitivities to sounds, I do my best to schedule them at a time of day when the clinic tends to be quieter.

I typically avoid any mainstream music from any decade or genres. Generally, I play original instrumental music unless the patient requests certain music. One patient likes heavy metal music. Some patients prefer to have complete silence.

As much as we would love to live in a utopian world where all things were equal, this is not the case and the gender of the therapist can be taken into consideration. You never know why someone feels more comfortable with one sex over the other. To be honest, it doesn’t really matter. All a practitioner should be concerned about is the suffering, and the fact they are receiving treatment from someone whom they trust and believe is the best fit for them in that moment.

Never be offended by a patient who has a preference for whom (male or female) they wish to receive treatment from. They’re advocating for themselves and getting help. That’s all that matters.

Put yourself first. In order to best help those around you, you must put yourself first. Self-care is a part of our profession that typically focuses on our physical abilities, like how to avoid tendinopathies, how to have better posture and biomechanics, etc. Health care providers, including RMTs, need to focus more on learning how to manage their mental health.

When patients confide in you, it can seem overwhelming. Adding this information to what you are already managing in your own life can slowly pick away at your coping strategies.

Caregiver fatigue is very common among health care professionals. Psychology and physiology are intimately linked. When you need help and don’t give yourself a break, your body goes into survival mode and your cortisol levels increase, exacerbating your stress. You can start to feel worn down, need a holiday or feel exhausted and you may even start to lose the joy you have for helping others. Distancing yourself is an instinctual coping strategy, that may work short term, but long term is noticeable by your family, friends and by your patients. This means pulling in reinforcements from parts of our brain reserved for things like love, connection and contentment. When you overextend one part of you, everything (and everyone) suffers.

If you are unable to cope physically, mentally and socially with the challenges we all face in daily practice, it’s vitally important that you ask for help. It’s a sign of strength to ask for help so that you may continue to help others.

Appreciating the opportunity to work with victims of assault

Some massage therapists are more likely to work with athletes, the elderly, pediatrics, orthopedics, cancer/oncology, central/peripheral nervous system injuries and so on. Many factors come into play when it comes to our patient population. Such factors could be the demographics of the area of practice, referrals between groups of the public or a group of healthcare professionals, as well as just a keen interest in a particular topic.

Many therapists’ professional interests are varied and tend to shift over their career. It’s a constant process of reflecting on what your practice is about. Ask yourself; who do you want to serve, what do you want to give to the world, what do you want to stand for, what do you find meaningful, what are you passionate about, what brings you joy? Sometimes it’s just about looking at who is “NOT” being served by your profession and recognizing the impact that can be made in their life.

If you happen to work with victims of abuse it’s important to educate yourself first and set up your own sources for treatment. Focusing your practice in this area can be challenging. As discussed earlier, you must put yourself first in order to continue to help others.

Become knowledgeable on the facts around abuse and the benefits of manual therapy. Contact and connect with other medical professionals in your area that focus on treatment of assault. These relationships are vital to providing a multi-dimensional treatment approach to provide comprehensive care.

Today there is an ever-growing population of people seeking massage therapy in order to recover from traumatic body experiences and reclaim the capacity to receive nurturing touch. Those who have experienced abuse, suffer greater psychological distress, physical symptoms, interpersonal and sexual problems, PTSD, and dissociation compared to those who have never experienced abuse. They often experience the loss of feeling safe, the loss of caring relationships with others, and the loss of an internal sense of wholeness. An important part of recovery is reclaiming and reconnecting the physical, psychological and emotional aspects, reducing dissociation and physical symptoms, improving quality of life.

Massage therapy allows people to experience positive, non-violent touch in a therapeutic environment. Research has documented that Massage has been shown to help people experience a somatic release of trauma, increased self-awareness, feel an increased mind/body/spirit connection, decreased depressed mood, decreased anxiety, decreases cortisol levels and provides feelings of safety and control.

Robert has been a Registered Massage Therapist (RMT) in Canada for over 25 years. He has been a Senior Clinical Examiner instructing Orthopaedic and Neurological Examination, and teaches Ligamentous Articular Strain Techniques (LAST) at international conferences and online. and maintains a full-time practice. Robert has a passion to advance and improve manual therapy education, encouraging innovation in manual skills and inspiring therapists to incorporate research into practice to better serve their community.

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