Posttraumatic stress disorder (PTSD) is not normally mentioned or discussed day to day, let alone on our massage table. Mostly associated with veterans, there are many different traumatic events which can bring on PTSD. There are many actions we can take as massage and bodywork practitioners help care and comfort these clients, from reassuring privacy to teaching loved ones how to perform massage. 

Acute stress disorder (ASD) is the development of severe anxiety, intense fear, helplessness, or horror felt immediately after or within 1 month of experiencing or witnessing a terrifying or traumatic event. People who have ASD have a high risk of developing posttraumatic stress disorder, a later-stage anxiety disorder characterized by symptoms of distress and difficulty coping with the aftermath of trauma. Only after ASD symptoms have been present for longer than a month can diagnosis of PTSD can be determined. But, unlike ASD, symptoms of PTSD may develop months or even years after the original traumatic event. PTSD may follow ASD, but it also may develop much later even if ASD never occurred initially. PTSD is often accompanied by substance use.

PTSD was initially called shell shock to refer to the anxiety of combat situations. PTSD frequently occurs after violent personal assaults such as rape, mugging, or domestic violence; acts of terrorism; natural or human-caused disasters; and accidents. Childhood sexual abuse and rape are strong predictors of PTSD development later in life. Eighty-five percent of men and 46% of women who are raped will develop PTSD. PTSD also can develop in physically abused children.

The affected person may reexperience the traumatic event, and may avoid stimuli associated with the event, and/or detaches emotionally from the event; the latter can produce a generalized numbing effect and subsequent lack of emotional responsiveness. Reminders of the event or cues associated with the event may trigger anxiety. Anniversaries of the event may be extremely difficult to handle. The person may experience a flash-back, a sudden and disturbing vivid memory of a past event that produces extreme anxiety or a panic attack.

1 2eKFqJMH34Jgi2vDE_HfMADissociation is a coping strategy which allows a person with PTSD to deal with psychological stress and continue to function after the traumatic event. Examples of dissociative strategies are depersonalization, derealization, and compartmentalization. Several studies have indicated between 15% and 30% of military veterans diagnosed with PTSD reported symptoms of depersonalization and derealization.

  • Depersonalization. Disconnection from one’s own body, thoughts, or emotions. During depersonalization, people report they are detached from their body and mental or emotional processes or they have lost control over them. In some cases of depersonalization in which the traumatic event recurs, such as in cases of continued physical or sexual abuse, people may have an out-of-body experience, in which they see themselves from the sidelines or from above, creating the perception the abuse is happening to someone else.
  • Derealization. Disconnection from one’s surroundings. During derealization, individuals report the world around them is surreal, foggy, or distorted. The person who derealizes may think the traumatic event did not occur but was a dream.
  • Compartmentalization. Suppression of memories, either consciously or subconsciously, because they produce anxiety as a result of conflicting personal values and beliefs. For example, if a soldier shot an enemy soldier, he or she might compartmentalize the act of shooting. This allows the affected person to place feelings and thoughts about the traumatic event in a compartment in the back of the mind for the conflicting ideas to coexist.

Beside dissociative behaviors, the person may experience insomnia or parasomnia (night terrors and nightmares) related to the posttraumatic event. Affected people often lose interest in things they once enjoyed, have difficulty feeling or showing affection, or experience avoidance behaviors such as not participating in social events or not watching movies associated with the traumatic event. Some people report feeling irritable, having trouble concentrating, becoming startled by loud noises or when surprised, or sitting or standing with their back to the wall while in public places such as restaurants. The person may experience significant memory loss of specific times, people, and events; out-of-body experiences such as feeling as though you are watching a movie of yourself; depression; anxiety; lack of self-identity; and thoughts of suicide. Individuals who have PTSD from sexual assault may have a rare specific phobia related to touch.

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Massage and Posttraumatic Stress Disorder: The overall effect should be nurturing and relaxing which involves the frequent use of effleurage applied slowly with moderate pressure. Schachter et al (2009) recommend nine principles of sensitive practice to help foster feeling of safety specifically for PTSD cases resulting from sexual abuse.

  1. Respect. Acknowledge the inherent value of each individual with empathy and compassion while suspending judgement.
  2. Take time. Be fully present, unrushed, and less task-oriented.
  3. Develop rapport. Develop and maintain a demeanor that conveys genuine caring and balances professionalism with warmth and friendliness.
  4. Share information. Tell the client what you are doing and why you are doing it, which helps ally fears and anxiety triggered by unanticipated events.
  5. Share control. Enable clients to be active participants rather than passive recipients by sharing control of what happens in the massage room (more on this later).
  6. Respect boundaries. Respect and model healthy boundaries to validate and reinforce the client’s inherit worth and autonomy as sexual abuse involves the blatant disregard of personal boundaries.
  7. Foster mutual learning. Encourage clients to assert their autonomy, to ask questions, and to speak up when they are uncomfortable.
  8. Understand nonlinear healing. The degree to which a client is able to tolerate or participate in treatment varies from session-to-session and from one moment to the next within a session. In recognition of this reality, check in with clients during these times and adjust treatment according to the client’s comments.
  9. Demonstrate awareness of interpersonal violence. Demonstrate awareness of sexual abuse issues by displaying a poster or pamphlets from local organizations who serve these populations. This may serve to help clients overcome their hesitancy in disclosing the issue with their massage practitioners.

PTSD-CRMHFAlthough these principles are appropriate for all clients, these are vital for clients who have undergone trauma. Ask clients how they are feeling during each visit. The practitioner must be able to recognize when a client does not want to talk and when the client needs to talk, honoring and respecting the client’s wishes at all times. Before each massage, reiterate the importance of feedback and encourage clients to speak up when they are uncomfortable. During the massage, observe clients carefully. Is the client grimacing? Holding his or her breath? Breathing rapidly? Flinching? Tightening muscles? Communicate your observations and make appropriate adjustments to pressure and administration of techniques when needed.

Explain all massage procedures and why they are done, allowing clients to be in control of certain aspects. This includes how much clothing is removed before lying on the table and covering with a drape, how they are positioned on the table, aspects of the treatment such as areas worked on, areas avoided, and depth of pressure. Additionally, clients may feel more relaxed and in control if they can “see” what you are doing; this may require raised lighting and avoiding the prone position or face rest to expand their vision. Identify and avoid triggers and what may cause hyperarousal, including loud noises or types of music and specific smells, or aspects of the treatment mentioned previously. Offer clients a choice of gender of the practitioner, especially in cases of past abuse. Remind clients their body will be draped during the entire session and you will be out of the room with the door closed while they undress and re-dress. Consider using techniques that do not require disrobing. Drape a client who remains clothed.

If clients indicate they would rather you not massage an area of their body, honor this request even if prior consent was given. For example, if clients initially request deep massage on the lower back but suddenly becomes uncomfortable and asks you to move on to another area, comply without asking for explanation. If needed, give clients the option of having a trusted friend or family member in the treatment room, having the door ajar, or both, during the massage.

In some cases, the client may experience the surfacing and releasing of powerful emotions. Be prepared to take a comfort break or stop before the scheduled time if the client begins to cry during the massage.

Suggest the use of stress management techniques such as diaphragmatic breathing or progressive muscle relaxation as home care to help clients maintain or improve their treatment goals. Progressive muscle relaxation is based upon the practice of tightening one muscle group at a time for 5-10 seconds followed by a relaxation phase of 10-20 seconds before tensing another muscle group. 

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Research: Grade-school children who displayed PTSD-like classroom behaviors reported being happier and less anxious and had lower salivary cortisol levels after 8 days of massage compared with a video attention control group. In addition, the massage group showed lower anxiety and depression, and were observed to be more relaxed. The massages began one month after a natural disaster (Field et al, 1996). Cortisol is a stress hormone.

After returning from Iraq and Afghanistan, National Guard personnel and significant relationship partners were given instruction in simple massage techniques (via a DVD) to promote stress reduction and interpersonal connectedness. Substantial improvements were noted in posttraumatic stress disorder, depression, and self-compassion in both veterans and partners, and in stress for partners (Collinge et al, 2012). Veterans also reported significant reductions in physical pain, physical tension, irritability, anxiety/worry, and depression after massage. Eight weekly 1-hour sessions of body-oriented therapy (which included massage) decreased pain and pain medication use as well as increased relaxation, body/mind connection, and feelings of trust and safety in female veterans with posttraumatic stress disorder taking prescription analgesics for chronic pain (Price et al, 2007b). Longacre et al (2012) reviewed scientific medical literature for the efficacy and use of complementary therapies (including massage) for refugees and survivors of torture and found limited, but promising reports. Somali women refugees with chronic pain and suffering from military and/or sexual trauma found relief from distressing physical and psychological symptoms with massage (Price & Abdullahi, 2013).

Field et al (1997) found 30-minutes of massage and relaxation therapy administered twice a week for 1 month reduced depression and anxiety in women who had experienced sexual abuse. However, the relaxation group reported an increase in negative attitudes toward touch; this effect did not occur in the massage group. Individuals undergoing psychotherapy for trauma, including sexual abuse, had better mental health outcomes (self-report and reports made by their mental health professionals) when massage and energy-based therapies such as Reiki and healing touch were added to their treatment plan (Collinge et al, 2005). Eight 1-hour weekly sessions of body-oriented therapy, which included massage through clothing, had a positive impact on a sense of inner security among women in sexual abuse recovery (Price, 2006). Price (2007a) found women in therapy for childhood sexual abuse who received 8 1-hour body therapy sessions that included massage experienced increased psychological and physical well-being and decreased dissociation.

Picture Credits:

http://www.medium.com/the-break-down-wake-up-journal/complex-ptsd-and-the-realm-of-dissociation-87e57049d18a

http://www.neurosciencenews.com/ptsd-memory-target-14270/

http://www.crmhs.org/ptsd-symptoms/

References: 

Collinge, W., Kahn, J., Soltysik, R. (2012). Promoting reintegration of National Guard veterans and their partners using a self-directed program of integrative therapies: a pilot study. Mil Med, 177(12), 1477-1485.

Collinge, W., Wentworth, R., Sabo, S. (2005). Integrating complementary therapies into community mental health practice: an exploration. J Altern Complement Med, 11(3), 569-574.

Field, T., Hernandez-Reif, M., Hart, S. Quintino, O., Drose, L.A., Field, T., Kuhn, C., Schanberg, S. (1997). Sexual abuse effects are lessened by massage therapy. J Bodyw Mov Ther, 1(2), 65-69.

Field, T., Seligman, S., Scafidi, F., Schanberg, S. (1996). Alleviating posttraumatic stress in children following hurricane Andrew. J Appl Dev Psychol, 17(1), 37-50.

Longacre, M., Silver-Highfield, E., Lama, P., Grodin, M. (2012). Complementary and alternative medicine in the treatment of refugees and survivors of torture: a review and proposal for action. Torture, 22(1), 38-57.

Price, C.J. (2006). Body-oriented therapy in sexual abuse recovery: A pilot-test comparison. J Bodyw Mov Ther, 10(1), 58-64.

Price, C.J. (2007a). Dissociation reduction in body therapy during sexual abuse recovery. Complement Ther Clin Pract, 13(2), 116-128.

Price, C.J. Abdullahi, A. (2013). Community Massage Program for Somali Women Immigrants: podium presentation. International Massage Therapy Research Conference, Boston, Mass.

Price, C.J., McBride, B., Hyerle, L., Kivlahan, D.R. (2007b). Mindful awareness in body-oriented therapy for female veterans with post-traumatic stress disorder taking prescription analgesics for chronic pain: a feasibility study. Altern Ther Health Med, 13(6), 32-40.

Schachter, C.L., Stalker, C.A., Teram, E., Lasiuk, G.C., Danilkewichet, A. (2009). Handbook on sensitive practice for health professionals: lessons from adult survivors of childhood sexual abuse. 2nd ed. Ottawa: Public Health Agency of Canada; 2009. Retrieved from: http://www.integration.samhsa.gov/clinical-practice/handbook-sensitivve-practices4healthcare.pdf.

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Dr. Susan Salvo is a massage practitioner, author, educator, researcher, explorer, and perpetual student. To learn more about Susan, check out the “About Susan” tab. You can contact Susan at susansalvo@hotmail.com.