Features Practice Technique
Nourishing touch

In memoriam: Christopher Terrence O’Connor passed away suddenly on March 27, 2018. Massage Therapy Canada was fortunate enough to work with Chris over the years and share in mourning with his friends, family and the rest of the profession. 

The Homewood Health Centre, in Guelph, Ont., is one of very few private health-care facilities in Canada specializing in the treatment of addictions, eating disorders, trauma/PTSR (post traumatic stress recovery), chronic pain and psychiatric disorders. RMT services have been provided out of this facility for almost 20 years – the demographic certainly creating an extraordinary setting for a massage therapy practice.

Keeping the treatment room light and maintaining a non-judgmental atmosphere is key when massaging patients with eating disorders and depression.

The Homewood’s Eating Disorders Program (EDP) is Canada’s largest in-patient treatment program, with patients staying for three months or more until they reach a healthy weight. Patients are part of an interdisciplinary treatment milieu integrating emotional, spiritual and physical components of well-being.

Massage therapy can be a significant influence on patient outcomes in the EDP. Research is showing, increasingly, that manual therapies and acupuncture are a useful adjunct to standard treatments and lead to improved mental health outcomes (decreases in body dissatisfaction). More than this, it is proven that touch deprivation is a contributing factor in eating disorders and that restoration of healthy touch can improve a patient’s brain chemistry (decreases in cortisol, and increases in dopamine and norepinephrine). Putting the hard science aside, research subjects reported that the most significant factor in the success of manual therapies (within the context of healing from eating disorders) was practitioner empathy and the therapeutic relationship.

Patients also valued positive regard, acceptance, non-judgmental responses and the ability to trust a practitioner. These subjective measures help to paint some of the big picture of the therapeutic relationship – of honouring the individual. There are also very objective and essential details to remember when working with this patient group to honour the profession.

The people
It is not just the underweight experiencing eating disorders. Obesity, stress and over-exercising can also develop into an eating disorder. Becoming aware of some of the signs and symptoms associated with ED can help massage therapists to identify clients they may feel are at risk, but whose symptoms are less obvious. Bulimia, anorexia and obsessive orthorexia are the main disorders treated. Men are occasionally treated, but are often less forthcoming than women, so it is still women who make up the majority of the EDP clientele.

It is outside the scope of practice of registered massage therapists to diagnose an eating disorder but it is still important to have literature available for clients, and strong referral resources that offer education to the pre-contemplative patient. Anorexia has the highest death rate of all psychiatric disorders. It would be difficult to know that someone at risk had been overlooked due to lack of education or available resources.

The problems
Low self-esteem and negative body image go hand-in-hand. Body image disturbances can be multifactorial and deeply rooted. The media, peer influence, gender roles and adverse events in early life (including sexual abuse, sexual harassment, early sexualization and appearance harassment) have all been cited as damaging. Learning to trust with touch again is very important in the eating disorders population with at least 50 per cent of clients also being trauma survivors. A counsellor (who prefers to not be named) who has spent years in the program mentions that self-image is the big problem.

“It seems obvious but is not to be forgotten, that these individuals have problems that run deeper than just the body. They struggle with body esteem, and with kinaesthetic sense – how they move and feel and how they live in their body. They are self-conscious because they believe they are being judged. They feel disconnected, and numbed to their bodies. It’s an alien feeling,” the counsellor says.

The gentle and safe atmosphere created as well as touch offered by a massage therapist can be the first important step in the development of a healthier body image.

The treatment room
From a very physical therapeutic point of view it is important to remember to take care with very underweight clients. Very gentle touch is needed in areas around bony prominences that will be obvious and often painful. Rib raking and squeezing techniques may be too much for someone with very prominent ribs. Care must also be taken in areas that are more robust in clients who are overweight, in order that undue, uncomfortable attention is not given. Make it the main goal of the treatments to offer safe, comfortable touch that focuses on relaxation and benefit to the delicate digestive system.

Respecting client-practitioner boundaries is always important and no less so with clients in the EDP. It is best to avoid talking about yourself, and any body image issues you may have. It is never appropriate in this therapist/client relationship to mention your anorexic friend, or your sister with bulimia. Steer conversations toward healthy attitudes about body image. If, for example, an underweight client apologizes for the amount of “flab” they think they have due to skin laxity from muscle wasting and adipose loss, let them know that this is a normal part of the body adjusting to its new shape and size. It is okay to validate their feelings, but keep yours to yourself.

Always keep a positive attitude in the treatment room, about health and about life as a whole. Eating disorders and depression are common comorbidities so keep the treatment room light and non-judgmental. Don’t let the conversation swing to the dark side.

With each unique group at the Homewood – such as individuals dealing with addiction, post-traumatic stress and eating disorders – it is important to take care with the language used in the treatment room. It is too easy to use triggering and stigmatizing language without realizing it. One slip of the tongue and you may set back your client’s progress and your professional reputation. We would no sooner want to say, “I’m going to hit the road” to someone suffering PTSD after a car wreck, than say, “I’m a television junkie” to a recovering addict.

There are a few sensitive areas to avoid with individuals with eating disorders. Do not talk about an eating disorder that you may have had earlier in life, or are still struggling with. Don’t talk about how you overdid it the night before at the local buffet, and don’t say that you’re planning to starve yourself to fit into an outfit for a friend’s wedding or a high school reunion. It may seem like common sense, but it is easy to use colloquialisms and inappropriate language without even thinking about the implications.

Therapist as teacher
As delicate as these treatments must be, they are also an opportunity for change. Be sure that your treatment plan helps clients understand their bodies better. Explain the importance of the musculoskeletal, nervous and lymphatic systems of their bodies in a language they will understand. Stress the importance of how keeping these systems healthy is crucial to overall health, and explain the ways in which these systems have undoubtedly suffered in the midst of their disorder.

Inflammation, pain, frequent illness and injury are common when the body isn’t being properly nourished. When a symptom is better understood from a physiological perspective, it can often become less disheartening for a patient who feels like everything is going wrong.

One of the valuable exercises that patients at the Homewood EDP are encouraged to complete is what is called The Body Talk Letter. Patients write a letter to the body part that they feel is their worst feature. When finished, they reply from the perspective of the loathed body part. Some may complain about their “fat legs” but when encouraged to speak on behalf of their legs, they are reminded that their legs allow them to sit and stand, walk and run. This helps them gain perspective on just how important the body part is and how harshly they are judging it for its appearance. A massage therapist is in a wonderful position to encourage clients to honour function over form, body part by body part.

Acknowledging the positive, including all gains between treatments, is crucial to this population. Make sure that clients with eating disorders see the progress they have made. Increases in energy, decreases in stress levels, any increase in appetite, positive body image or improved sleep is worth celebrating.

Teaching self care in order to build on these successes can be a wonderful thing. Massage therapists can lead by example with their gentle and meaningful touch, and clients can begin to learn a little about how to care lovingly for themselves again.

This article is the third of a three-part series I wrote, highlighting some of the most vulnerable, yet underserved, people in the community (see Fall 2013 and Spring 2014 issues of Massage Therapy Canada).

By describing my experiences and how valuable manual therapy has been to my clients’ recovery, I hope RMTs will be encouraged to reach out to those suffering from addictions, post-traumatic stress and eating disorders. Reaching out to known support groups is a great place to start. Educating yourself and having resource materials in your clinic can greatly enhance your ability to provide compassionate treatments, and may enable one person to acknowledge their problem and begin the recovery process. (This article was edited for content by Heather MacRae, ND.)

Chris O’Connor is a RMT, public speaker, osteopathic practitioner, provider and instructor of contemporary medical acupuncture.
For more information, visit www.chrisoconnorconsulting.com .