Be ready to expand your practice with massage for trauma clients. How the therapist shows up within the treatment room will make a world of difference in the effectiveness of the session.
When considering massage for trauma, examples of veterans of battle or crime survivors might come to mind. We forget that traumatization can occur when any individual — any client — experiences a very negative event that can create a lasting impact on the person’s emotional and mental stability.
This article will present two aspects of this topic. First, many facets of how trauma presents within the body will be examined. Second, considerations when creating massage treatment planning will be appraised.
How Trauma Expresses
Merriam-Webster’s medical dictionary defines trauma as “1. Injury; 2. Psychological or emotional damage.” All massage schools hold discussion in courses around healing the physical nature of trauma. Not every school discusses the psychological or emotional natures of trauma. Before working with trauma clients, a massage therapist needs to do an honest introspection on their level of training and understanding of trauma.
Everyone’s experience and comfort level with the subject will vary. As a massage therapist learns more about how trauma processes within the mind and expresses through the body, the nuances of the topic will demand heightened awareness and sensitivity.
Trauma is processed in the mind in a fascinating manner. Neuroscientist and psychiatrist Paul MacLean (1913–2007) described how the brain processes trauma via the Triune Brain Model.
This model devises three brain aspects at work to help the body process stress: the brain stem (primitive brain); the limbic system (paleomammalian complex); and the neocortex (neomammalian complex). Essentially, the brain stem activates the other two complex portions to facilitate a stress response. Primitive instincts and protective measures learned early in life will initiate to protect the person from the pain of trauma.1
The Stress Response Cycle
Trauma expresses through the body in many fashions. There are many manifestations of physical expression of trauma. Sympathetic responses, also referred to as fight, flight or freeze responses, can grip a person recalling trauma. Heart and breathing rates increase, nerves become hyperactive, eye pupils dilate, digestion shuts down and muscles activate.
The body’s HPA axis is involved within the trauma response. HPA stands for three glands communicating hormones in response to trauma: hypothalamus, pituitary and adrenal glands. The communication amongst these three glands is the same regardless of the type of trauma experienced.
When the body experiences stress, the hypothalamus sends corticotropin-releasing hormone to the pituitary gland. This induces the pituitary to release adrenocorticotropic hormone to the adrenal glands. This facilitates a release of adrenaline hormones (epinephrine and norepinephrine) as well as cortisol into the bloodstream to create a sympathetic stress response.
Elevated levels of cortisol indicate long-term stress experienced. Cortisol in significant quantity can signal to the hypothalamus and pituitary to continue producing corticotropin-releasing hormone and adrenocorticotropic hormone, perpetuating the stress response cycle. This constant positive feedback can create a condition called HPA axis dysfunction.2
This condition results in lessened cortisol levels in the long run, making the body rely on adrenaline hormones for stress response. Common symptoms of HPA axis dysfunction include waking up feeling tired, insomnia, cognitive challenges, weight gain and irritability.
Massage for Trauma: Emotional Release
On the massage table, the sympathetic response can present in many ways. The client’s breath rate may increase enough to make a session feel uncomfortable. Their body may twitch with many muscle spasms.
Their body may also become rigid. Muscles may be too difficult to apply pressure upon. When receiving massage for trauma, the client may ask you to avoid a certain region of the body. We must respect client requests and steer away from bodywork that overstimulates their body.
The client may also verbally recall events, sharing deeply personal and intimate information. The ability to listen without offering counseling is paramount. Remain within scope of practice which is to mindfully listen, hold professional space and refer the client to appropriate professionals.
The potential for somato-emotional releasing during massage for trauma is quite likely with trauma clients. Different schools describe varying methods and perspectives of interacting with clients experiencing these responses. What I present in my continuing education courses is a three-step approach:
1. Acknowledge the energetic shift in the room. When a somato-emotional response is occurring (or soon to occur), there can be a palpable shift in energetic feel of the client. When this occurs, immediately stop performing massage and check in with client. Their response will inform you of how to proceed next.
2. Validate the client’s feelings. Some clients may not want to share their feelings or allow feelings to be felt while lying upon the table. Saying statements to validate that feelings are valid such as “It’s OK to have this feeling” and “This is a safe space to feel what you need to feel” can provide permission for a client to feel appropriately.
3. Continue as directed by the client. We hold space for clients and wait for them to provide a directive on how to next proceed. Some clients may request a simple touch gesture such as holding their hand. Other clients may want you to back away or leave the room. Many clients may ask you to wait a few minutes before proceeding with the massage while others may end the session entirely. We simply respect their wishes for this step.
Massage for Trauma: Treatment Plans
There are many considerations for massage therapists to review as massage-for-trauma treatment plans are devised and a client is expressing their trauma upon the table. The first question to consider is if the therapist is able to maintain poise during a session. Poise refers to the ability to gracefully maintain focus and balance of a situation when it becomes uncomfortable. A therapist needs to refer a client to another practitioner if they cannot maintain poise with a client.
Also, deducing myofascial patterns of tension and determining where a client holds tension can be valuable. The Fascial Research Congress has confirmed in numerous studies that fascia possesses gray matter nerve tissue. This tissue stores memories and data.3 This explains why many clients experience a recollection of a memory when a person touches a certain region.4
Activating the neuronal tissue of fascia can literally activate memories stored within a body region. This will facilitate a physical response of myofascial tightening and restrictions.
A therapist can seek the patterns of tight and taut muscle tissue the body holds with this trauma response. Modalities to assist in the softening of these restrictions include myofascial release, cranial sacral therapy, reflexology and facilitated stretching. A classic Swedish-style approach can also be effective when performed mindfully.
When to End a Session
Right of refusal is an often overlooked aspect of the therapeutic relationship. Clients have the right to refuse services for any reason at any time. If they determine that the session should be stopped mid-session, their request must be respected. Allow the client grace and dignity in this decision.
This same right also applies to the practitioner. You can end a session at any time with just and reasonable cause. Consider the nature of the therapist-client relationship with these decisions.
Also, if the therapist feels the client’s trauma response upon the table is to an unmanageable point, ending a session and offering a referral to a medical professional is appropriate. Document any session that ends prematurely, either by the client or the therapist’s discretion.
A final note on massage for trauma is for massage therapists to seek additional resources for learning more about the effects and manifestations of trauma.
Our industry is quite limited in what is presented in schools; therefore, further training is imperative. The ability to hold professional space with someone experiencing trauma can be tricky, yet methods can be learned and practiced as we become cognizant of our communication tendencies and sensitivity of awareness.
Grounding Techniques for the Trauma Massage Therapist
The mental demand and energy to maintain poise can become taxing for a massage therapist working with this population. As massage therapists experience working with traumatized clients, it’s important to perform grounding and self-care techniques upon day’s end. Practicing healthy habits after seeing trauma clients will help avoid therapist burnout, either physically or emotionally.
Grounding techniques I’ve found effective include breath work. Here are two examples of easy breath work a therapist can do to maintain centeredness.
• Imagine three sections of your torso: the lower belly below the umbilicus, the upper belly between umbilicus and rib cage, and 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 color breath from chest, then upper belly, then lower belly squeezing your core tightly as you complete this breath.
• Beginner’s Note: Start with small interval of only 4–5 seconds per inhale / exhale to avoid becoming lightheaded. As you feel this breathing method become easier, strive for 10 seconds or more per inhale / exhale.
• Inhale through your nose, 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. Other self-care tips that can become healthy habits include being mindful of your dietary food choices, creating a stretching or yoga routine, taking a walk, unwinding your mind with a good book, taking baths to soothe your body and inhaling relaxing essential oil scents.
About the Author:
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 “To Succeed in Today’s Massage Market, You Can’t Make These 3 Mistakes” and “These 5 Keys Will Unlock the Door to Massage Session Re-Bookings.”
1. Rosenthal, Michell. The Science Behind PTSD Symptoms: How Trauma Changes the Brain. June 2019; psychcentral.com/blog/the-science-behind-ptsd-symptoms-how-trauma-changes-the-brain. Accessed July 2020.
2. Patel, Reshma. HPA Axis Dysfunction Explained: The Facts You Need to November 2019; webfmd.com/hpa-axis-dysfunction. Accessed July 2020.
3. Gunther, et al. Fascia as a Sensory Organ: A Literature Review of the Sensory Organ Innervation of Muscular Fascia. Fascia Research Congress, September 2012.
4. van der Kolk, Bessel. The Body Keeps the Score, Penguin Books. 2015.