Features Practice Technique
Recovering Body & Soul From Post Traumatic Stress Disorder

There are no specific physical manipulation techniques for working with trauma clients. Swedish massage can be as effective and enlightening to a client as the most advanced fascial mobilization.

No matter the technique, massage therapy can inadvertently trigger traumatic memory, which, as massage therapists know, also can be a powerful tool for healing and growth.¹³

For example, there is ample documentation that touch stimulation is essential for babies to thrive.

The results of Tiffany Field’s research on preterm infants is most compelling, where each was given 15-minute massages three times a day for 10 days while still in incubators.¹⁴

The treated infants gained 47 per cent more weight and were hospitalized for six days less. They performed better on the Brazelton Neonatal Behavior Assessment Scale.¹⁵

The babies averaged 12 points higher on the mental scale and 13 points higher on the motor scale than the control group. In another experiment,¹⁶ rat pups were stimulated with tiny wet paintbrushes, a procedure designed to mimic the licking of newborn litters by their mothers.

The rat pups which were “licked” with the paintbrushes thrived similarly to those which had received normal care by mothers. Those that received no stimulation became ill, had small growth rates, and failed in many instances to thrive.

In 1958, Harry F. Harlow demonstrated that artificial or surrogate mothers made of terrycloth and wire mesh and which offered no food, were preferable to either infant rhesus monkeys or wire-mesh structures providing milk. Rhesus monkeys spend most of their infancy in close contact with the ventral portion of their mother. Harlow postulated that the monkeys needed contact and nurturing as much if not more than food in order to thrive.¹⁷

These findings may be compared with the reports of emaciated, touch-deprived infants found in Romanian orphanages after the overthrow of Ceausescu. The Romanian orphans had difficulty relating to other humans, exhibited little or no language skills and showed little or no emotional response or affect.¹⁸ Follow-up of the orphans indicated a number of attachment disorders.

A 1997 study by Kim Chisholm, of St. Francis Xavier University, examined adopted Romanian orphans and evaluated their degrees of attachment.

On parent questionnaires, the later-adopted children scored much higher on “indiscriminate friendliness,”
a behaviour recently described as a criterion for attachment disorder.¹⁹

Chisholm found that the children “… tried to cuddle and kiss strange adults without the caution one might expect from young children.”

“The behaviour is as a result of not having a primary caregiver to form an identity in relation to; to fill the void, these children will grab at anyone who seems friendly.”²⁰

There are a large number of studies which examined attachment and nurturance. Their findings seem to suggest that healthy nurturance and loving touch are essential for human beings to develop and thrive.

Response to Massage
Many therapists express frustration with clients who are unable to receive a massage treatment. Indeed, in some circumstances a powerful battle of wills ensues when the client appears to put up barriers against each of the therapist’s efforts to encourage the client’s relaxation.

Experience indicates that when the therapist demonstrates close attention, acknowledgment, and respect for such survival mechanisms, his client will eventually come to trust the process of massage as a safe way to receive the soothing she so deeply craves. With soothing comes a thawing from long-standing fear and the opportunity to reacquaint the client with her normal body signals.

In the ordinary course of events, massage therapy can offer a profound sense of peace to those who are able to feel strong enough at their core to let go and relax.

For those who carry the effects of trauma, however, the world does not feel safe and they cannot trust their bodies to give the appropriate signals of safety. Alarm bells are always being rung by the flood of stress hormones. They either remain on full alert or alternate between numbness and hypervigilance.

If the trauma relates to sexual abuse, the intimacy of the massage treatment room may increase the sense of fear. Touch of any kind may trigger memories of both desired and unwanted information.

Ways that a client manages to live with the memory of a traumatic event is simply not to think about it, to deny its existence, or, at the very least, never to allow herself to consciously dwell on the horrible event.

The client may not think too much about what really happened, yet is plagued by extraordinary levels of tension. The touch of the therapist may open the floodgates of sensation which she had carefully kept closed, in order to avoid reliving the traumatic memory. If traumatic memory, stored in the amygdala of the limbic system, is triggered, then flashbacks, speechless terror, numbing, hyperarousal and/or disassociation may result. Witnessing this may be alarming and frightening to therapists who do not expect such occurrences or who are unaware of the signs and symptoms of PTSD.

Clients who, when babies and small children, were coddled, held, stroked, and nurtured, are likely to have grown up with strong senses of self and safety in the world^.21

If, on the other hand, touch had been forbidden or abusive, laced with malevolence or manipulation, they may not have developed ways of appreciating healthy, boundaried, and safe touch. As Judith Hermann suggests, three major forms of adaptation permit a child to survive in an environment of chronic abuse:

• Elaboration of disassociation defenses;
• The development of a fragmented identity;
• The pathological regulation of emotional states.

Inevitably, when the child grows up, the systems for coping that helped her to tolerate and survive an abusive situation, create great difficulty for her when faced with adult relationships and intimacy.²²

When clients lay on a massage table without clothes and between two sheets, the very act of lying down nude may evoke sensorial and historic responses that are deeply attached to how they perceive themselves in the world.

If gentle touch was historically associated with a subsequent beating or assault, then the gentle touch of a massage therapist may have surprising and unpleasant associations for the client. If, in addition, the client was constantly criticized for the size and shape of her body, she may feel a deep sense of shame, disgust, and vulnerability at exposing herself to anyone, and especially to the massage therapist.

Massage therapists may feel frustrated at the noncompliance of clients and their seeming inability to allow the therapist to work deeply when trying to alleviate tension and muscle pain. A more helpful approach may be to look closely at the reactions of clients, observing these reactions as the client’s courageous efforts to keep herself together in the face of overwhelming fear.

A massage therapist can assist the client to “climb back into herself.” This requires consciously working with her strengths. The massage therapist must repeatedly offer her the opportunity to experience her body in the present in a respectful, nonjudgmental environment, to put the memory of trauma in context and live more fully in the present.

Treatment Considerations
Establishing trust is essential when working with clients with PTSD. In order to treat them successfully, the massage therapist must understand the nature and essence of the therapeutic relationship and behave at all times in a trustworthy manner. It is the therapist’s role to create a safe place in which the
client can regain confidence in herself and in her body.

As van der Kolk wrote, “Treatment of PTSD needs to address the twin issues of helping patients: Regain a sense of safety in their bodies, and complete the unfinished past.

It is likely, though not proven, that attention to these two elements of treatment will alleviate most traumatic sequelae.”²³

Philosophically, engaging in massage therapy represents a commitment to wellness on the part of the client and the therapist. It is a caring, safe way for individuals to experience touch and receive release from pain. It offers intimacy that is nonsexual, thereby providing an opportunity for clients who are fearful of intimacy to experience it safely.

Massage therapy communicates support, acceptance, positive regard, and pleasure, through the modality of the therapist’s hands, and it empowers the client to take charge of how she wants her body to be touched.

Respectful touch can be healing. Massage therapists offer a safe place to clients, who in turn, may learn to trust that touch does not have to be associated with pain, fear, or anger.

In a healthy therapeutic massage relationship, the client participates in creating accomplishable treatment plans. Decisions for her care are widely discussed, and the process is one of consensus and cooperation. This approach is critical for the successful treatment of the client with PTSD. For her, safety needs to be paramount. She needs to know unequivocally that she has the power to stop, change, or modify a treatment at any time.

By having choice over how she wants her body to be touched, the client with PTSD discovers in both a kinesthetic and cognitive way that the trauma is in the past and that here, in the present, she is in charge.

Intention
Technique is far less important than the therapist’s intention. For the sake of both the client and therapist, it is imperative for the massage therapist to know at all times what her role is and what her intention is in the therapeutic process.

Intention is the term used to describe the therapist’s purpose and intent under any given circumstance during treatment. While the therapist intends to do no harm, she can do harm unintentionally unless she is aware of the potential traps and pitfalls of the therapeutic process.

It is imperative that the therapist consider exactly how far he is willing to journey with each client, to assess her level of commitment, and to know what his boundaries are before embarking on any therapeutic relationship. Devastating consequences may arise for the client if a therapist discovers that he is unwilling, unable, or too inexperienced to complete a course of therapy.

Few therapists have the capacity to be clear about such things without the aid of supervision.

Most therapists benefit from either consulting a more experienced therapist or from peer supervision as a means of becoming clear about their intent, including unconscious motivations that may surface for the therapist during treatment.

The massage therapist takes the role of listener, teacher, coach, and surrogate caregiver. As such, he will likely play an exceptionally important role in the life of the client.

Occasionally, a client will want the massage therapist to respond in ways that would be counterproductive to the therapy. She may desire friendship or other access to the therapist outside clinic hours.

The client may test the established boundaries of the therapeutic encounter by asking for more intimate touch than is appropriate.

The responsibility for clarity, intention, and understanding of therapeutic role is not to be taken lightly. It always falls upon the therapist.

The final part of Recovering Body and Soul From Post Traumatic Stress will appear in the Fall 2003 issue of Massage Therapy Canada.