Many Americans are struggling with challenges to their emotional and mental health, with COVID-19 and its economic and societal fallout a main driver of this problem.

Massage therapists, when in possession of knowledge of how to respond to clients’ mental health challenges and while working within scope of practice, can create an environment that is safe for both the client and themself, whether working on clients with serious mental health challenges or a client who present with or develop a state of melancholy or agitation during a session. (The author of this article assumes that the reader is aware of scope of practice and when to refer a client to another type of health professional.)

This article looks at the growing mental health crisis in the U.S., as well as how massage therapists can employ not only touch but breathwork, visualization and stretching techniques to help any client return to a parasympathetic state.

A Growing Crisis

As massage education ventures further into helping people with mental health challenges, there are several key aspects of client care to consider.

According to “COVID-19 and Mental Health: A Growing Crisis,” a spotlight report published by Mental Health America, a nonprofit that addresses needs of people living with mental illness:

• The number of people screening with moderate to severe symptoms of depression and anxiety increased during 2020 and is still higher than rates prior to COVID-19. “In September 2020, the rate of moderate to severe anxiety peaked, with over 8 in 10 people who took an anxiety screen scoring with moderate to severe symptoms. Over 8 in 10 people who took a depression screen have scored with symptoms of moderate to severe depression consistently since the beginning of the pandemic in March 2020.”

• A greater number of people are reporting frequent thoughts of suicide or self-harm than have ever been recorded in the Mental Health America screening program since its launch in 2014. “Since the COVID-19 pandemic began to spread rapidly in March 2020, over 178,000 people have reported frequent suicidal ideation. 37% of people reported having thoughts of suicide more than half or nearly every day in September 2020.”

• People screening at risk for mental health conditions are struggling most with isolation and loneliness. “From April to September 2020, among people who screened with moderate to severe symptoms of anxiety or depression, 70% reported that one of the top three things contributing to their mental health concerns was loneliness or isolation.”

“While the risk of contracting the disease itself is a population-wide traumatizing event, our physical and social environments have changed as well, leading to greater rates of isolation and loneliness, financial hardship, housing and food insecurity, and interpersonal violence,” the report notes.

“Further, the COVID-19 pandemic has highlighted and exacerbated existing inequities and injustices faced primarily by black, indigenous, and people of color (BIPOC) in the United States. Any of these factors by themselves can negatively affect the mental health of individuals, but in combination they have created a nationwide mental health crisis.”

Additionally, more Americans are engaging in drug and alcohol abuse, for example, with data reported in December 2020 by the Centers for Disease Control and Prevention showing that drug overdoses are at an all-time high, and with a CDC survey in June 2020 showing that “40.9% of 5,470 respondents who completed surveys during June reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder (30.9%), those with TSRD symptoms related to COVID-19 (26.3%), those who reported having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%), and those who reported having seriously considered suicide in the preceding 30 days (10.7%).”

MTs Can Create a Safe Environment

Knowing these trends, massage therapists can become better aware of communication and behavioral tendencies of their clients. How clients show up can determine the effectiveness of a massage and bodywork treatment.

First, it is wise to determine the client’s tolerance to touch. Sitting with the client prior to treatment to chat and determine how they feel today will be beneficial in determining their touch tolerance. Placing a hand upon their shoulder or holding their hand. I often begin with a breathwork exercise with a therapist placing their hand upon the client’s back. These are all ways to test how tolerant the client is to touch today.

If you are working on a psychiatric patient or other client in an altered state who is receiving massage as part of a health regimen, then speaking with another other adult (parent, caregiver) present within the room can also help determine touch tolerance. It is highly recommended to have another adult present if the client exhibiting mental health challenges is eroding in communication skills.

Helping a client return to a parasympathetic state during session can create a safe therapeutic environment in which to foster healing. As massage therapists, helping a client’s body return to a parasympathetic state becomes fundamental to our work.

Parasympathetic refers to the body in a state of ease in which the body moves toward relaxation and homeostasis. Heart rate drops, breathing rate slows down, eyes no longer dilate, digestion restores, blood sugar is not utilized as quickly and organ functions calm throughout the body.

The parasympathetic state is our ideal body condition. The opposite state, sympathetic, occurs when the body is agitated, excited, scared or forced to work hard, causing organs to function more and body systems to work faster and harder. Helping ease the body out of sympathetic mode into parasympathetic mode is a major aspect of how massage therapy brings ease and comfort.

Some ideas that can be employed by massage therapists to restore a parasympathetic state include breathwork, visualization, stretching and varying intensity of a massage session.

These may restore a sense of balance and well-being any client. Suggesting these ideas as self-care, when within scope of practice, and following up appropriately can help a client develop healthier coping means and life skills to support themselves.

Breathwork Helps

There are many ways to incorporate breathwork into massage and bodywork sessions.

At the beginning of a session, a therapist may place both hands upon the client and guide them through a breathing sequence. I often place one hand upon their heart and the other upon their head. Guiding them through breathwork with this hand placement can allow them to focus their breath anywhere through their body.

Examples of breathwork techniques include:

1. Three-Part Breath

Imagine three sections of your torso: the lower belly below the umbilicus, the upper belly between the umbilicus and rib cage, or the chest region. Imagine a color to your breath. As you inhale, draw this color to your lower belly, then upper belly, then chest. Pause briefly, exhale, emptying the color breath from your chest, then upper belly, then lower belly squeezing your core tight as you complete this breath.

*Beginner’s note: Start with small intervals of only four to five seconds per inhale/exhale to avoid becoming lightheaded. As you feel this, breathing methods become easier, strive for 10 seconds or more per inhale or exhale.

2. Ujjayi—Ocean’s Breath

Inhale through your nose and then slightly constrict your throat as you slowly exhale, creating an ocean’s wave sound to the exhaled air. Imagine a mirror in front of your face that your breath fogs upon exhalation. Continue with a slow rhythmic pace.

*Beginner’s Note: Make your exhale last longer than the inhale as you practice.

3. Kapalabhati Breath

Using only your abdomen, inhale as you fill your lower belly, then exhale quickly, with good force, as you bring your lower belly inwards. Alternate this sequence quickly, creating a pumping effect with the torso.

*Beginner’s Note: This breath is excellent to clear nasal and respiratory congestion. It can make you feel lightheaded, so stop when this occurs.

4. Bringing Ease Breath

Begin with slow inhales and exhales, about five to seven seconds per inhale or exhale. As you breathe, sense where in your body you hold tension. Place your hand or fingers at this location. Breath even slower at this point, visualizing oxygen entering this touched region.

*Beginner’s Note: Ensure you are comfortable when performing this breathing method. Lying down on your back on the floor may be the best option for many people.


Visualization exercises are techniques utilized by therapists to enhance mind-body wellness. Most include guided imagery of some form to create or enhance a therapeutic session. In the realm of massage therapy, guided imagery may be a useful tool to aid a client into deeper states of healing.

Visualization can be a powerful tool to aid a client towards a parasympathetic state. A visualization is an exercise to guide a client mentally to a state of relaxation. I have utilized these by dictating statements aloud while holding compressions upon muscular regions for 10 to 20 seconds. As I move onto a different region, I say aloud the next phrase of the visualization.

This slows down my efforts upon their body, allows their breathing to harmonize and their minds to relax into a pleasant mental state.

One way a massage therapist can employ a visualization is to perform this sequence: 

• Provide massage treatment to muscles within an area 

• Pause after your final massage strokes, hold with intention for 30 seconds 

• Apply a passive movement to this region walking the athlete through their sports related movement or activity.

• With this movement, speak a visualization with this athlete how this movement becomes easier, stronger and leads to a victory 

Visualization exercises can be employed before, during and after massage treatment sessions. Here are benefits to employing these exercises at the different intervals. 

Before the session: Employing visualization exercises before a session allows a client to quiet their mind to better receive treatment. It is difficult for a client to receive treatment with mental fatigue and anxiety as physical tissues will hold more tension within this mental state. Our efforts with massage will be easier when the physical tissue tension is eased along with the mental tension. I have performed visualization before session in one of two ways: client still fully dressed before they get upon the table or with client disrobed under the top sheet before physical manipulation occurs. 

Mid-session: If a client is beginning to talk much and becoming emotional during session, I will pause treatment to employ visualization techniques. This effort will refocus mental energy to the present healing treatment and calm the client. Talking may be a healthy release method for some clients, however if emotions arising are distracting the therapist and client from healing efforts, visualization techniques are quite beneficial to restore the healthy focus of treatment.

After the session: Some clients need additional grounding efforts at the end of sessions. Visualization exercises are excellent for these individuals to keep their minds quiet at session end. To allow the client to rest peacefully after receiving physical treatment can allow the body to more fully integrate what it received. I have discovered a mere five minutes at this point makes a huge difference in how someone walks away from treatment in terms of retaining their newly found healing.

Visualization exercises have helped me in my private practice with several populations of clients. In addition to athletes, I have utilized visualization with youth oncology, PTSD and collegiate student patients. 

When employing visualization exercises. ensure your environment is sufficient to conduct such exercises. Be sure to limit noise distractions as best possible. Use soft ambient lighting with lamps emitting a supple eminence. Ensure client comfort with bolstering for safe positioning. 

A relaxing mist of lavender, vetiver or other grounding scents may be appreciated by many clients. Ensure the tactile feel of linens and blankets is non-distracting. Creating a soothing environment will help ensure visualization exercises are well received. 

Chakra Alignment Visualization

• As you lie comfortably, begin with slow deep breathing 

• Feel your breath fill your body’s lower core, then upper core, then chest 

• Let each breathe fill the body’s core and chest, then empty completely 

• Imagine a red light gleaming at the base of your spine 

• See and feel this red light slowly getting larger with each breath taken 

• Keep your breathing slow and rhythmic 

• With your next breath, draw this red light to just below the belly button

• Watch this color transform 

• See and feel this new light color slowly getting larger with each breath taken 

• Keep your breathing slow and rhythmic 

• With your next breath, draw this colorful light to just below rib cage

• Watch this color transform 

• See and feel this new light color slowly getting larger with each breath taken 

• Keep your breathing slow and rhythmic 

• With your next breath, draw this colorful light to your heart 

• Watch this color transform 

• See and feel this new light color slowly getting larger with each breath taken 

• Keep your breathing slow and rhythmic 

• With your next breath, draw this colorful light to your throat

• Watch this color transform 

• See and feel this new light color slowly getting larger with each breath taken 

• Keep your breathing slow and rhythmic 

• With your next breath, draw this colorful light to your third eye 

• Watch this color transform 

• See and feel this new light color slowly getting larger with each breath taken 

• Keep your breathing slow and rhythmic 

• With your next breath, draw this colorful light to the crown of your head 

• Watch this color transform 

See and feel this new light color slowly getting larger with each breath taken 

Imagine this colorful light surrounding your entire body as your breathing softens 

Surround yourself with this healing colorful light 

Feel safe in this healing colorful light 

Sense warmth within this healing colorful light 

Rest peacefully within this healing colorful light 

Vary Intensity

Varying the intensity of a massage session may be important to ensure the body can enter a parasympathetic state and ease touch perception challenges. There are many ways to vary intensity:

• Decreasing the session duration

• Decreasing pressure application

• Slowing down stroke application

• Focusing on one body region primarily

• Incorporating bodywork methods into the massage session


Because clients exhibiting mental health challenges may have touch-perception challenges, stretching may benefit this client immensely. Stretching can restore length to chronically tight muscles and ease the body’s tension patterns to restore a parasympathetic state. Perform stretches slowly to allow the body time to fully receive the stretch.

Observe non-verbal feedback from their body such as twitching, breathing changes, head movements and tension within other regions.

For someone who never stretches on their own, holding a stretch 10 seconds will suffice. For people who stretch fairly often, holding their stretches 30 seconds. Adding stretches can add a safe element to touch that is perceived as comforting and therapeutic simultaneously.

Communication Matters

David Swink of Psychology Today online provides tips for communicating with people with mental illness. He raises awareness in his article to be aware of the negative stigmas attached to mental illness. He advises the following ideas for improved communication:

• Ensure you show the client proper respect and dignity.

• Any hallucinations experienced are their reality in the moment. Do not attempt to talk them out it, rather play along and guide both of you to safety.

• If a client presents paranoia, they may be frightened so back away to provide them space.

• Mental health has nothing to do with intelligence. Do not assume lesser intelligence.

• Have resources of local mental health providers and community resources available.

• People who get “passed around” due to fear of working with them may appear angry.

• Please be aware on how you can assist, even if not with massage directly.

• Utilize active listening skills such as repeating back what a client states and asking for interpretation of words.

• Set boundaries such as “We have this much time remaining” and “I can work on these body regions today.”

• Be sure to call police or related authority if you feel physically threatened. Have your cell phone easily accessible.

For anyone interested in furthering their studies within this topic realm, here are suggested sources to develop depth in one’s knowledge and perspectives of working with individuals with mental health challenges:

• Download the report, “COVID-19 and Mental Health: A Growing Crisis” from Mental Health America, an organization devoted to providing the general public resources and education regarding mental health disorders. This group provides an advocacy network to further support people in need of assistance with mental health.

Diagnostic and Statistical Manual of Mental Disorders (DSM—5). This resource clinically defines mental health disorders. Mental health workers such as psychiatrists and psychologists will employ this resource to establish a proper diagnosis. Even though massage therapists cannot diagnose clients, we can benefit from researching and understanding the subtle nuances and differentiations of mental health conditions.

Substance Abuse and Mental Health Services Administration (SAMHSA). This is governmental agency under the US Department of Health and Human Services. Grants and programs to assist organizations supporting mental health institutions on state and local government levels are provided by this administrative office.

National Institute of Mental Health (NIMH). Information, resources, research and outreach programs are offered by this federal agency. A branch of the National Institute of Health, this organization works to foster cures and remedies for mental health conditions. The National  Advisory Mental Health Council, Board of Scientific Counselors and peer review committees contribute to the mission of NIMH.

Psychology Today. A website on which anyone can locate local mental health providers of many varieties and niches.

• Attending continuing education pertaining to mental health conditions will be an important means to better understanding our clients with mental health needs. Collegiate level courses will provide rich knowledge and profound outlooks on traditionally challenging conditions.

Classes devoted to presenting the polyvagal theory and somato-emotional healing will be valuable to share bodyworker perspectives on facilitating a parasympathetic response.

Many Americans are struggling with emotional and mental health problems. Through education, employing greater presence and awareness during sessions and having tools at hand to guide the client into a parasympathetic state, the massage therapist plays a helpful role in mitigating the current crisis facing our nation.

Jimmy Gialelis, LMT, BCTMB, is owner of Advanced Massage Arts & Education in Tempe, Arizona. He is a National Certification Board for Therapeutic Massage & Bodywork-approved provider of continuing education, and teaches “Professional Ethics for LMTs” and many other CE classes. He is a regular contributor to MASSAGE Magazine, and his articles include “Diabetes and Massage: What Therapists Need to Know” and “Massage for Trauma: 3 Ways of Responding to an Emotional Release.”