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Recovering Body & Soul From Post Traumatic Stress Disorder

Whether embarking on the first treatment, or considering how the overall treatment plan is going, the massage therapist must be able to articulate to himself and to the client where they are in the treatment continuum.


September 22, 2009
By Pamela Fitch & Trish Dryden

Topics

Whether embarking on the first treatment, or considering how the overall treatment plan is going, the massage therapist must be able to articulate to himself and to the client where they are in the treatment continuum.

This helps to ensure the safety of the client, increases the effectiveness of the treatment, and reduces the potential for conflict and inadvertent retraumatization by the massage therapist.

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Predictability and routine can be a great solace and comfort for clients with Post Traumatic Stress Disorder. It is important for the massage therapy treatment hour to include a well-understood beginning, middle, and end (see Figure 2).

Beginnings and endings should have familiar, repetitious aspects that signal to the client where they are in the treatment hour. The beginning of the treatment hour establishes safety, boundaries, and goals for the day. The middle part of the treatment hour is primarily experiential, and builds on the client’s capacity to sustain safe touch.

The ending of the treatment hour provides an opportunity for the client to articulate some of what has occurred during the treatment hour, to acknowledge what may need to be processed in her psychotherapy, and to take home strategies for healthy self-care and self-soothing.

Likewise, the overall treatment plan follows a predictable course where there is a definitive beginning phase, an exploratory mid-phase, and a concluding phase. Judith Hermann calls these stages: “Safety, Remembrance and Mourning, and Reconnection.” 24

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Response To Massage
The initial stage of massage therapy treatment may take anywhere from one month to several months before the client feels genuinely safe in the treatment room. Emphasis at this stage of the treatment plan is on offering choices and establishing ways of contracting the ways in which the client wishes to be massaged.

When she is confident enough and ready for whatever sensory and emotional material may surface, the client generally expresses a wish to explore sensation in parts of her body that have previously not been touched, or have been either hypersensitive or numb during the massage.

The middle phase of the treatment can be intense, sometimes emotionally painful, and often liberating as the client receives validation from her body that she has not made all of it up, and that she can experience her body as it really is in the here and now without being overwhelmed by sensations that originate in the past.

It is extremely important to note that it is not the massage therapist’s role to analyze or interpret what the client is saying or feeling. In massage therapy, clients may be very vulnerable to accepting the massage therapist’s interpretations as literal truth. It is always the client’s right to define for herself what she is experiencing. The massage therapist must remain in the role of compassionate witness, and never suggest to clients any literal explanations of their sensations, musings, and experiences.

As treatment shifts to the final phase, the therapist begins to notice subtle changes in the client’s reactions to being touched. The client may begin talking about simple and inconsequential topics during the massage – such as what she is planning to have for dinner – that do not relate to the treatment. While she is being touched, she may talk about the ordinary events of her life and yet remain relaxed and present. There are no more ghosts of negative forces, people, and events who hurt her in the past in the treatment room. The therapist should take this as a cue that the third phase has begun.

Good closure is just as important for this client as is a good beginning. In the final phase, the client reviews what has happened over the course of therapy, embraces whatever changes the massage therapy has given, taking her learning out of the treatment room and into everyday life – a life that is now more enhanced by the possibilities of a more embodied self. Great care must be taken by the massage therapist during this stage, to abstain from overindulging herself by encouraging the client to stay on in therapy. For many clients, the massage therapist is a surrogate caregiver, a stand-in for those who did not or could not protect her in the past.

There is often a parent-child quality to the relationship. As with all children, there comes a time when they must leave the nest and fly on their own. In many ways, the safe, boundaried intimacy achieved with the massage therapist is simply practice for clients in order to enhance their capacity to go back out into the real world, and develop new and more satisfying relationships with friends and family.

At this point, as throughout the treatment process, it is most helpful for the therapist to have supervision, peer support, and a commitment to her own self-care.

Self-Care Importance

Self-care is one of the most important preservatives and strengtheners for those who work with clients who have experienced trauma. Without good self-care for the therapist, commitment and compassion weaken, interest wanes, and integrity may be challenged.

If the therapist is in an unhealthy frame of mind, a client with PTSD, potentially so attuned to the will and interest of others, will often perceive the shift immediately.

Clients may then hide aspects of pain and confusion so as to protect the massage therapist, harkening back perhaps to earlier situations in their lives where their needs may have been distorted or ignored.

The massage therapist can then be lulled into a false sense of comfort with the client.

It has been said many times: Before one attempts to guide another, one should be very sure of one’s own ability to tell up from down and left from right.

A massage therapist who cannot budget adequate time for her own relaxation, rest, and fun may be a poor example for a client who struggles with over commitment and poor self-care. It isn’t enough to say: “Do as I say, not do as I do.” A massage therapist must be a model of healthy choices regarding self-care.

When the massage therapist lets the client know that she does not have to take care of the therapist, and that the therapist can genuinely take care of herself, a burden is lifted from the client. She may proceed with the work of healing herself, and not having to worry about pleasing the massage therapist.

On the other hand, if a massage therapist suggests that she can take care of herself and then is discovered by the client to be overly committed, exhausted, and unable to concentrate, the client may become overly concerned to the detriment of the therapy, and her sense of the therapist’s integrity will be shaken.

She may think, “If I cannot trust my massage therapist to do what is necessary to take care of herself, then how will she take care of me and how will I ever learn to take care of myself?”

The ABCs of Self-Care
Saakvitne and Pearlman25 eloquently outline the ABC’s of self-care as follows:

Awareness
Be attuned to one’s needs, limits, emotions, and resources. Heed all levels of awareness and sources of information, cognitive, intuitive, and somatic. Practice mindfulness and acceptance.

Balance
Maintain balance among activities, especially work, play, and rest. Inner balance allows attention to all aspects of oneself.

Connection

Connect to oneself, to others, and to something larger. Communication is part of connection and breaks the silence of unacknowledged pain. These connections offset isolation and increase validation and hope.

Supervision Or Support
In order to help ensure that the best interests of the client are always at the forefront of massage therapy, the therapist should engage in regular, ongoing supervision or peer support. Supervision describes the process where a massage therapist consults on cases and questions with a more experienced therapist.

The confidential conversation is usually focused on the therapist’s feelings and responses rather than the client’s. It is a strong means of keeping the client’s therapeutic process on track by gently and truthfully assessing the therapist’s clinical decisions and intention.

A good rule of thumb might be that when a massage therapist is uncomfortable with a client, she needs to describe the events of this therapy session to another therapist. There may be events occurring which are outside the bounds of safe therapeutic interaction and which need attention and adjustment.

Peer support is another way to provide checks and balances to one’s therapeutic approach. In peer-support groups, two to six therapists agree to meet confidentially and to share the joys, burdens, and confusions of their work with each other. This can be an immensely rewarding and enriching experience, which strengthens each therapist, challenges questionable practices, and explores difficult ethical dilemmas.

When the massage therapist has both professional support and a balanced personal life, the challenges of work are less likely to lead to professional burnout. When she is confident and solidly based, then she can provide the necessary emotional shelter and support for her client. When the client feels the strength and support of the therapist, the client is able to make choices and question old beliefs in her own life.

When the beliefs evolve into new ways of thinking and behaving, the client shifts towards more healthy choices and the therapeutic process moves into a new and affirming dimension for the client.

Conclusions
The experience of trauma assaults a person’s sense of safety in the world, and can destroy her ability to control what happens to herself.

Post Traumatic Stress Disorder, a noxious presence, can demolish confidence, enhance shame, and have terrible consequences on social relationships. Yet it is considered to be one of the most treatable causes of psychic pain.

The massage therapy treatment of PTSD must take into consideration the neurobiological consequences of this human experience. Massage therapists must offer choices in treatment, ways of being massaged that help to restore safety and control.

This is client-centered care at its best. In the hands of a skilled therapist, massage therapy for clients with PTSD acknowledges and helps to restore the most basic of human needs-for safety, trust, control, self-worth, and intimacy.

When the ability to satisfy these fundamental needs is damaged, an individual may be unable to function easily or happily in the world.

When these needs are satisfied in the context of a healthy therapeutic relationship, an individual may not only survive but relearn or discover for the first time how to thrive.

If a client with PTSD has the courage to transform her speechless terror into narrative memory, the traumatic memories become woven into the ordinary fabric of her life.

She is given the opportunity to learn that she can be touched safely and with compassion by another human being. This enhances her ability to reconnect with others in her real life and to rekindle her hope and belief in the future.


Trish Dryden, M.Ed., RMT, director and co-owner of the Sutherland-Chan School and Teaching Clinic and a professor in Applied Arts and Health Sciences at Centennial College at Toronto, Ontario, Canada, experienced workshop facilitator and lecturer, international consultant, and author of numerous articles and papers, maintains a private practice.

Pamela Fitch, B.A., RMT, in private practice since graduating from Sutherland-Chan in 1988, specializes in treating trauma and body image, has written extensively on ethics, professional boundaries, and breast massage (Winter 1998), served as president of the Ontario Massage Therapist Association, and is a consultant, facilitator, writer, and practitioner in Hong Kong.

Dryden and Fitch have collaborated on running PTSD workshops, and are writing a book about massage therapy, trauma, and the body-mind connection.


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