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The role of empathy in trauma-informed massage therapy

July 20, 2021  By Pamela Fitch

Photo credit: © Anna Jurkovska / Adobe Stock

Trauma-informed care (TIC) means ensuring safe therapeutic environments, building trusting therapeutic relationships and enabling individuals living with the effects of trauma to establish successful coping strategies for resilience.(1) TIC has been embraced by many health care professions, but its implications have not been clearly defined for massage therapy. Nevertheless, most RMTs endeavour to ask questions safely, without worsening how a patient feels. They naturally extend empathy and compassion. These skills might be described as hallmarks of trauma-informed massage therapy, and yet they have not been widely investigated in massage therapy research. In this article, I primarily aim to discuss the role of empathy in offering TIC.

It may be surprising to learn that Canada has one of the highest rates of post-traumatic stress disorder (PTSD) and suicide in the world. Estimates on the prevalence of PTSD in Canada suggest that almost 10% of our population live with the consequences of trauma.(2) Rates of PTSD increase among those who have experienced domestic violence or sexual assault, who have actively served in the military or worked as first responders, who live with poverty or whose close contacts struggle with mental health or addiction challenges. Given these statistics, it is possible that up to 10% of massage therapy patients struggle with some form of PTSD and may even feel suicidal. And yet as a profession we have done little to no research into the effects of massage therapy on patients living with PTSD or other mental health issues.

I have worked for many years with patients living with the effects of trauma. I notice that common issues such as headache, stress or low back pain often mask deeper issues related to personal circumstances. When patients live with trauma, they may experience symptoms that can be difficult to describe, such as panic, nightmares or dissociation. Furthermore, the legacy of trauma complicates a person’s capacity to refuse what is offered because trauma removes the individual’s ability to make choices. Patients may react negatively to a therapist’s touch but be unable to explain why. When patients are unable to speak up in the treatment room, their reactions can be overlooked unless the therapist pays close attention to body language and paraverbal communication.

“Unacknowledged power imbalances promote silence”(3)


A significant power differential exists between the RMT and the patient. When patients cannot explain how they feel, they depend on their RMT to sense or discern the best approach to treatment. This puts all the responsibility for treatment planning on the therapist, enhancing the power differential even further. Patients can feel silenced or unable to ask for what they need when:

– Power differentials are ignored or discounted

– The impact of trauma remains unacknowledged

– The necessity of touch in massage therapy is assumed and not explained

Treatment goals

The following are my best-practice goals for trauma-informed massage therapy, and should be paramount to any other modality or form of treatment.

– Recognize the right of the patient to choose the form of treatment that serves them best.

– Respect the patient’s wishes and be willing to investigate the patient’s goals.

– Engage in explicit informed consent negotiations (particularly when treatment includes sensitive areas or requires consultation with others).

– Recognize the boundaries of massage therapy and clarify your professional role.

– Pay close attention to the patient’s expressed goals and adapt your treatment if those goals change.

– Match manual interventions to the patient’s somatic responses to touch.

– Respond with empathy and compassion.

The Federation of Massage Therapy Regulatory Authorities of Canada (FOMTRAC) interjurisdictional entry-to-practice competencies include the following competency and associated performance indicators:(4)

1.3.a. Display positive regard toward patient/client.

– 1. Demonstrate respect for patient/client.

– 2. Establish rapport with patient/client.

– 3. Respond with empathy.

When the CMTO created its 15 Career-Span Competencies, the terms “positive regard,” “rapport” and “empathy” were dropped in exchange for one career-span competency that requires RMTs to “apply the principles of sensitive practice.” These principles of sensitive practice are not defined, but the competency includes a list of professional challenges that massage therapists commonly encounter. The challenges include “managing power differentials” and “recognizing and addressing transference and counter-transference.” In accordance with changes to the Regulated Health Professions Act, RMTs are required to “obtain written consent prior to treating sensitive areas.” In addition, we are expected to “appropriately respond to a patient’s emotional reaction before, during and after a treatment.” However, the implications for professional practice remain undefined and unresearched. This competency represents a minefield of interpersonal challenges for RMTs who work with patients living with the effects of trauma.

An important gap?

The career-span competencies direct massage therapists toward actions that reflect professional practice, but they do not contain any reference to positive regard, empathy or compassion. This may create a huge gap in our professional practices, because our patients are human beings, not conditions or impairments. The expectations for professional practice do not connect to the human and interpersonal aspects of the therapeutic relationship. The reason that we maintain confidences and ensure we do not undermine patient trust is because patients become emotionally attached to their therapists. In some cases, patients visit their massage therapist frequently and share personal details of their lives. When patients live with the effects of trauma they are highly vulnerable to suggestion, accepting what is offered rather than asking for what they want.

It is important to acknowledge that patients are not trained to evaluate our manual skills. They may simply feel better or less lonely for receiving touch. This means that the onus for communicating intentions and negotiating a treatment plan rests entirely on the RMT. Patients need to feel heard in order to feel safe in the treatment room. They need to be reassured that the RMT will not proceed with any assessment or treatment until all questions have been asked and answered. A patient might not relate in detail that they are stressed or depressed, but their body language, posture, facial expression and verbal descriptors may suggest how they feel. This is information that must be respected to ensure the patient is safe to receive treatment. It is essential for RMTs to pay close attention to patient behaviours that might indicate fear or mistrust. If patients live with chronic anxiety, their anxiety may emerge somatically and this is essential information for the RMT. New patients sometimes suggest that they feel anxious about what massage therapy might reveal about them. If a patient appears nervous or afraid then assessment and treatment must be negotiated carefully, paying attention to guarding or if the patient holds their breath.

The human factor

In my classes and seminars, participants frequently note that asking personal questions or deepening a patient interview lies outside of the massage therapist’s scope of practice. To be clear: Asking pointed questions about a patient’s emotional state or personal life does take an RMT out of scope. However, asking a patient about their response to or comfort with touch represents responsible care and demonstrates empathy for their reality. When we ignore or discount the human factor in physical contact, we miss important context provided by neuroscience. In fact, empathy and compassion, missing from the career-span competencies, represent the most important part of my work with patients living with trauma.

Over the past 20 years, studies in neuroimaging and psychology have revealed that empathy can be mapped in a number of areas of the brain. Empathy is defined as an “emotional response to the emotional state of another without losing sight of whose feelings belong to whom.”(5) Empathy creates pathways for building social cohesion, trust and safety—the cornerstones of TIC. Touch— the principal modality of massage therapy— facilitates the production of oxytocin, a neurotransmitter that is associated with human bonding and pro-social behaviour.(6)

Interpersonally, the success of massage therapy relies on each of the following in order to determine the safety of treatment.

– Therapist awareness and appreciation of the patient’s emotional state.

– Verbal messages and non-verbal communication (e.g., body language).

– The capacity of the RMT to absorb the perspective of their patient’s experience.

– The patient’s perception of their therapist’s empathy and trust in the therapeutic process.

– The RMT’s psychological state during treatments.

– The interactions of therapist’s and patient’s personality traits.

When massage therapists extend empathy toward patients living with trauma, they demonstrate that they are aware of their patients’ challenges. It is not necessary to know the exact nature of the trauma or its associated stories. It is, however, important to discover how that trauma has affected the patient’s physical well-being, and these conversations require sensitivity, empathy and discretion. For example, we might ask questions to encourage patients to reflect on where and how their trauma contributes to their physical challenges. We encourage patients to explore their physical capacities and cheer when they achieve gains. This promotes safety, resiliency and trust.

Future directions

Unfortunately, no advanced-care directives exist and no best practices have been established for the interpersonal elements of massage therapy, particularly when working with vulnerable patients living with the effects of trauma. We do not understand the full relationship between empathy and massage therapy or the role that oxytocin plays in our work. Our profession continues to focus research and education on the physiological, pathological and functional aspects of activities of daily living. Many RMTs pay little attention to the psychological developments in neuroscience that might inform our working alliances with patients. And we do not discuss widely the challenges of the therapeutic relationship, despite the implications for poor communication and even professional misconduct.

From my perspective as an educator and a practicing massage therapist, we ignore our patients’ needs for TIC when we disconnect our manual therapies from our intentions, attitudes and values. Our profession needs a much more nuanced, evidence-informed knowledge base for responding to patient affect. We need to connect patient affect with therapist perspective. We need to acknowledge the human vulnerability of our patients who are living with the effects of trauma. This approach requires a deep understanding of empathy and its processes as a way of ensuring TIC.


  1. Bath H. The three pillars of trauma wise care: healing in the other 23 hours. Reclaiming J 2015;23(4):5–11.
  2. Van Ameringen M, Mancini C, Patterson B, Boyle M. Post-traumatic stress disorder in Canada. CNS Neurosci Ther 2008;14(3)171–181. doi: 10.1111/j.1755-5949.2008.00049.x.
  3. Kreber C. Courage and compassion in the striving for authenticity: states of complacency, compliance, and contestation. Adult Educ Quarterly 2010;60(2):177–198.
  4. Federation of Massage Therapy Regulatory Authorities of Canada (2016) Inter-Jurisdictional Practice Competencies and Performance Indicators for Massage Therapists at Entry-to-Practice.
  5. Decety J. Human empathy. Jpn J Neuropsychol 2006;22:11–33.
  6. Singer T, Snozzi R, Bird G, et al. Effects of oxytocin and prosocial behaviour on brain responses to direct and vicariously experienced pain. Emotion 2008;8(6):781–791.

Further reading

  • Decety J, Jackson P. The functional architecture of human empathy. Behav Cogn Neurosci Rev 2004; 3(2)L71–100.
  • Fitch P (2019) Talking Body, Listening Hands: A Guide to Professionalism, Communication and the Therapeutic Relationship, 2nd edition. Ottawa: Algonquin College Press.
  • Lawrence RL. Coming full circle: reclaiming the body. N Direc Adult and Cont Ed 2012;134:71–78.
  • Zebrowitz LA, Montepare J (2006) The ecological approach to person perception: Evolutionary roots and contemporary offshoots. In: Schaller M, Simpson JA, Kenrick DT, editors. Evolution and Social Psychology (pp. 81–113). Madison, CT: Psychosocial Press.

This story originally appeared in the Spring 2021 edition of Massage Therapy Today. Reprinted with permission from the RMTAO and the author.

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