By Rachel Fairweather
Many clinically oriented massage therapists believe that emotional pain is literally “none of their business”. Isn’t our job to work with physical pain, not to be delving around in the messy arena of peoples’ feelings?
Yet massage has a long tradition of working not just with the body but the mind and emotions. The two are inseparable and chronic physical problems often go hand in hand with emotional pain and stress. So every time you touch your client you are making an intervention not only with muscles, fascia and joints, but the delicate mind-body balance of the spirit and psyche.
Feeling comfortable with the emotional side of bodywork is important as there is also a strong probability that a significant proportion of your clients have experienced severe trauma during their lifetime – and many of them won’t tell you about it. There are a disturbing number of adults who have experienced the horrors of sexual, physical abuse or domestic violence. The statistics speak for themselves:
Nearly a quarter of young adults have experienced sexual abuse during childhood at the hands of an adult
One in nine young adults has experienced severe physical violence
1 in 4 women experience domestic violence over their lifetimes, and between 6-10% of women suffer domestic violence in a given year.
And this is only the tip of the iceberg of distressing incidents that can affect physical and emotional health. Add to the litany the ongoing trauma of living with an alcoholic partner, the parent with mental health problems, the chronic illness of relatives, the grief of bereavement, and the nightmare of life threatening accidents. The hard fact is that the anguish of severe trauma is omnipresent. Understanding how this might affect our clients is vitally important to massage therapists everywhere.
Many of the conditions that we treat in clinic are clearly inextricably linked with the effects of stress and trauma in the body. There is extensive literature documenting how chronic pain is linked to a range of traumatic experiences including child and adult abuse, abuse-related injury, violence from a partner and post traumatic stress disorder.
Whether you realise it or not, emotional pain is your business. Literally.
Fight, flight and freeze
Both ancient and modern wisdom unite in the assertion that trauma can affect both physical and mental health. The ancient healing practices have recognised the mind and body as indivisible for centuries – trauma affects the balance of our energetic life field that in turn affects our physical and mental wellbeing.
Long before Western psychology and the fields of psycho neuro-immunology caught on, most ancient systems of healing were clear about the role of stress and imbalance as a fundamental factor in pain and disease. Traditional Chinese medicine views imbalance as a primary causal factor in disease, identifying a particular emotion with each organ – joy for the heart, anger for the liver, worry for the spleen, sadness for the lung, and fear for the kidney. Excess or insufficiency in emotions can cause imbalance and therefore ill health and pain.
Likewise, the shamanic approach sees all sickness to be self generated as an effect of stress. The source of stress is seen as resistance – our desire for things to be different than they are.
More recently, bodyworkers interested in the somatic understanding of trauma are indebted to the work of Peter Levine and his theory of how extreme distress may become encoded in the body (Levine 1997). Just like animals, our reptilian brain (brain stem) still responds to perceived life threatening situations by adrenalising the body into flight or flight mode. However, as humans, often our rational brain prevents us from taking action as we are unable to decide between these two choices. This can lead to a third response – the freeze response – also seen in animals when fight or flight are not possible.
The animal literally ‘plays dead’ decreasing metabolic activity and collapsing into immobility. Like having the foot on the accelerator and the brake pedal at the same time. the animal appears lifeless yet there is an inner racing of the nervous system. Do any of the fight, flight or freeze reactions seem familiar? Years ago I was mugged in central London and remember literally feeling rooted to the ground with fear, like everything inside had frozen. Not quite as brave as a friend of mine who in a similar situation chased her attackers down an alleyway and beat them with her handbag! In many cases of trauma, the freeze reaction may be the only viable option. Children who are sexually or physically abused by carers have no choice but to remain in the situation, shutting down their emotions and natural reactions. Fleeing or fighting are impossible.
Creatures who have adopted the freeze response will literally shake off the energy following the freezing period and then go happily about their business with apparently no ill effects. However for a number of reasons humans have lost the instinctual ability to discharge this residual energy leading to a wide variety of symptoms following trauma; i.e: anxiety, depression, and in extreme cases, post traumatic stress disorder or PTSD. The ensuing psychological responses to trauma can also cause neuropathic, endocrine and immune system changes that lead to an increased risk of chronic pain problems. Studies have shown that individuals with PTSD have excess inflammatory immune activity similar to that associated with chronic pain. (Gill et al., 2009)
Moreover, following trauma, as the system is now stuck in hyperarousal, any situation which in any way looks or feels like the original trauma will lead to a re- experiencing of symptoms. This is vital to understand as there is a high possibility that bodywork can recreate the effects of the traumatic situation unless we understand the fundamentals of how to create a safe space for our clients. As you are unlikely to always know which of your clients have experienced sexual or physical abuse, it is vital that this is part of good practice for ALL clients.
Creating a safe space for all clients – “First do no harm”
Given the strong link between trauma and chronic pain. what do we need to know to help us treat effectively? It is not uncommon for powerful bodywork to evoke emotional release or memories of previous trauma. This process can either be helpful or harmful depending on your knowledge and confidence in dealing with the situation.
The first rule of good bodywork is to create a psychologically safe space for your clients. This is well known in talk therapies but is often overlooked in bodywork. A safe space involves factors such as:
Good communication. Adopt an open listening style when taking a case history; be non judgmental, maintain good eye contact and ask questions that enable your client to give answers in their own words. In your assessment, be comfortable with asking about stress and emotional factors in addition to physical issues– this can help to give you an all round picture of the person you are dealing with.
Letting the client know they are in control: Clients who have been physically or sexually abused have had their boundaries completely violated. Their bodies will be hypersensitive to any perceived re-creation of this. They need to know that you are trustworthy and that you will do what you say. Explain exactly what is going to happen in the session; how they should position themselves and how they will be draped. Ensure a safe space emotionally and physically by letting the client know that everything that happens during treatment is confidential. Let them know they are in control and if anything doesn’t feel right in any way you will back off and change what you are doing. Remind them that pain does not lead to gain during therapeutic massage and to let you know if you are doing anything that is making them grit their teeth or clench their fists.
Explain what will happen at the end of the session so your client is not left feeling anxious about what they should do. For example say something like “At the end of the session, I will leave the room and let you get dressed in your own time. When you are ready, just wait in the chair and I’ll come back after a few minutes. It is really great for me to get feedback on how you found the session as that will help us in future sessions to design a treatment plan that is most appropriate for you”
Professional draping: Draping is there for a reason. It lets the client know where they will be touched and which areas are private. NEVER work under a drape unless you have a really good reason and have explained to your client why you are doing this and gained their permission. Keep your draping clear and tight and remain mindful of any potential exposure during the session.
NO means NO – Always respect your client if they ask you to stop or not to work an area! This may seem obvious but I have seen excellent and well- meaning bodyworkers overrule something a client has said because “your body needs it”. This is the quickest route to re-traumatising a client or allegations of misconduct. If you feel an area needs work but your client has asked you not to, you will need to gain trust over several sessions, months or years and work towards this with full permission.
As part of the feedback, ask them if anything didn’t feel OK (emotionally or physically) and respect that in the next session
Maintain good boundaries: You are a massage therapist. Do not slip into role of counsellor, friend or spiritual guru for any client. Be clear about who you are and what you provide. Be precise about your timing and do not give extra time for sessions unless this has been asked for and paid appropriately.
All of this helps your clients to feel safe and that you are trustworthy – you will do what you say and say what you do.
Dealing with emotional release or re-traumatisation during a session
It is extremely important to be able to recognise the signs of re-traumatisation during a session as this can be damaging and distressing to the client. There is a distinct difference between someone having a healthy and manageable emotional release on the table and the client who is becoming re-traumatised. Red flags to watch out for which means that you need to intervene are:
Rapid body movements that are becoming uncontrollable
Feeling uneasy in your own body
A feeling that the client ‘isn’t there’
Client refusing to engage with you verbally – not answering questions or staring blankly
Uncontrollable crying, shaking, laughing
Sudden change in breathing pattern
Client putting hands over eyes or refusing to look at you
In these cases it is vital that you re-orient your client back to reality and the ‘here and now’ as it is very easy to disappear into a literal black hole of trauma where they are unable to think, feel or react to you clearly.
Use the following steps as a guide to deal with the situation:
Ground yourself- take a deep breath, feel your feet against the ground and breathe out any anxiety or helplessness you are feeling
Orient your client to the here and now by directing her to current sensory experiences. A good start is to ask her to wiggle her toes and wiggle her nose. Then get her to open her eyes and look at something neutral - ask her to describe the colour or count how many ceiling tiles there are or something similar.
If your client is not doing as you ask you will need to keep asking and be very firm until you get an appropriate response. This point cannot be over-emphasised - if your client is covering their eyes, refusing to answer or staring blankly they could be in a dissociated state. Keep gently but firmly repeating what you need the client to do in a neutral and safe tone of voice ie: “Everything’s fine. You are here with me in the clinic and you are safe. I just need you to wiggle your toes for me so I know you are with me.”
Do not get involved in conversation about recounting the traumatic event. Your job is to bring the client back to the here and now.
If your client is crying or upset do not ask them “what’s wrong?” Just maintain a grounded, comforting presence and say something like “its fine to feel what you are feeling –just be aware of the feeling of your body against the couch at the same time”. In this way the trauma does not become overwhelming.
When your client is clearly back in the here and now you can discuss whether it is appropriate to continue the session or not. If you decide to continue the session, make sure your client stays in a position where they are able to feel in control of any cathartic energy release ie: telling them to feel what they feel but noticing the feeling of their body at the same time.
At the end of the session discuss ways forward together – unless you have been appropriately trained in bodywork and trauma you may need to suggest additional support such as talk therapy or another appropriately trained bodyworker
A more scientific explanation for transfer of physical and emotional sensations could be the role of mirror neurons. These fire both when you perform an action (ie: monkey picking up ball in A) and when you see another person doing the same action (monkey seeing someone else pick up the ball in B)
Energetic boundaries: Protecting yourself as a therapist
Without a doubt, a true connection with your client is a key component to the therapeutic relationship. In bodywork, our empathy for the client is expressed largely through our sense of touch when we are working on the body. Just as with talk therapy, our touch, focus and positive therapeutic intent can enable our clients to feel heard and accepted.
Working with presence, sensitivity and listening touch while being really tuned into your client can be profoundly healing but can bring it’s own challenges for the therapist. Clinical experience and our teaching careers have shown time and time again that it is common for massage therapists to be influenced by their client’s conscious or unconscious emotional state while they are working on the body. Therapists will often describe “picking up” client issues and this can manifest in dizziness, light-headedness, changes in breathing patterns, distress or sensing the physical or emotional pain that the client is experiencing. This phenomenon is also well documented in psychotherapy and dance therapy where it is known as body centred countertransference - “the spontaneous arousal of physical feelings in the therapist” (Field 1989). A large percentage of therapists working with people in trauma have reported physical sensations ranging from yawning, sleepiness, nausea, headaches, becoming tearful, raising of a therapist’s voice, unexpectedly shifting of the body, genital pain, muscle tension, losing voice, aches in joints, stomach disturbance, and numbness (Booth, Trimble & Egan 2010). Why this happens is unclear. Energy based explanations centre on the role of auras or electromagnetic fields around the body that can be sensed by the practitioner (Brennan 1987).(FIG 2) Another scientific rationale could be the potential involvement of mirror neurons - a neurone that fires both when you perform an action and when you see another person doing the same action. (FIG 3) These neurones are believed to be the basis of empathy - if you see someone crying you feel that distress within yourself. (Blakeslee 2006)
Whatever the mechanism of action, it is important to know how to deal with these feelings when they arise. Some therapists find the sensations overwhelming and treating clients can end up being an emotionally and physically exhausting experience. However it is important to recognise that these sensations are a way of your client unconsciously communicating with you about their internal state which often cannot be expressed verbally. The following guidelines will help you manage these feelings when you are treating:
Grounding: Firstly it is important to be able to distinguish your own energetic field from that of your client and the key to this (as ever) lies in grounding. At the start of a session make sure you are grounded, calm and still. We always recommend starting each session with some still work so both you and your client can enter a state of mindfulness. If your body feels like a calm still pond then you know that if you start to feel any unusual feelings then these are probably your clients and not your own. However if you start the session feeling anxious, irritated, or in a rush then it will be impossible to ascertain what feelings are your own and which ones you are picking up from the client.
If you find yourself experiencing unusual physical sensations (such as anxiety, dizziness, nausea), just visualise breathing the sensations out of your body back down through your legs to the floor and through your grounding roots to the earth. (FIG 4A and 4B)
If you find the sensations overwhelming every time you treat then there are certain visualisations or rituals that can help you feel energetically ‘protected’. For example, you can imagine that you are putting on an invisible purple cloak before treatment. Some therapists find that cleansing rituals such as rinsing the hands in cold water or smudging the room with herbs after treatment are helpful.
Be aware of the energetic interface - the invisible but perceptible boundary where you end and your client begins. You need to be energetically at the point where you are aware of your client but still mindful of your own body. This is a bit like trying to help someone out of a hole in the ground. If you are too close they will pull you in. If you are too far away you won’t be able to help them climb out. Bodywork is the same - always be aware of your own solid base of support; close enough to connect but not so close you become overwhelmed.
If there are unresolved issues within yourself it will be much more likely that you will feel overwhelmed by similar issues in your clients. Always work on yourself through receiving appropriate therapeutic intervention- this could be through supportive bodywork or talk therapy.
This article is an excerpt from “ ‘Massage Fusion: The Jing Method for the treatment of chronic pain” published by Handspring publishing.