I saw her expression change, and just as I was about to inquire as to her thoughts she stated, “Oh my goodness, I just realized that this is the first time I have been touched in over a year.
“I’m discovering my own body in ways I have not experienced for many months. You cannot fully experience yourself unless you are in relationship with another human being.”
In the moment of silence that followed, we both pondered the gravity of that statement. It is relevant to share that this person has been a client of mine for many years. She is a brilliant psychotherapist and someone with whom I have shared hours of very connected conversations. Many of those conversations have revolved around the parallels and overlaps of her profession and mine of over 40 years, massage therapy.
Breaking the silence, she continued. “I have not thought about it until now, but due to the pandemic, I have not had anyone touch me in well over a year. In the beginning, I was almost completely isolated from outside contact due to my age and the fact that I live alone. As restrictions eased, my daughter would visit, then over time, friends and family as well.
“In all that time, however,” she added, “there have been no affectionate hugs, no physical displays of affection. Think of the ramifications of that lack of touch, not just for me, but for society in general.”
Touch Deprivation
Ever since that session, I have thought about that conversation a tremendous amount. There are so many unknowns as to the ramifications from the isolation the pandemic created. Much like exploring any other topic, we can search research literature for precedents and parallels, learning from the past and from the experience of others.
All indications are that there, indeed, might be a tsunami of need. Depression, already one of the most common causes of disability due to mental disorders, has increased markedly during the pandemic, some studies showing as much as a three-fold increase1, while other studies estimate up to a seven-fold increase2.
A search of the literature shows the incidence of depression and anxiety increasing across multiple segments for the population. Younger populations seemed to have higher incidence rates of depression, anxiety, and stress3.
Health care workers have had an especially difficult time during the pandemic, with marked increases in stress, depression, anxiety, and sleep disorders4. In response to this the burden on health-care workers, I sent one of my staff to do on-site massage at our local health-care district for the nursing staff, who were exhausted from giving vaccinations at a relentless pace. I have talked to the head of the local hospital about treating the ICU staff next
In whatever population one explores, the incidence of anxiety and depression has increased at alarming rates. What role might massage therapy play in response?
Massage for Anxiety & Depression
Thinking about this took me back many years ago, when my office participated in a study with the University of Illinois on the application of massage for anxiety and depression. This project was part of Christopher Moyer’s dissertation and my first participation in a formal research study. (I did not recall until writing this article that the project was funded by the Massage Therapy Foundation.)
After going through multiple assessments for depression and anxiety, 30 participants were referred to my office for massage therapy sessions. We saw each participant for five one-hour sessions, one week apart.
There were essentially two questions addressed by the study. First, is massage therapy beneficial in the treatment of depression and anxiety? Is it effective? Second, if massage is shown to be helpful, is that benefit due to social engagement (the undivided attention and connection with the therapist) or was the power of human touch the most important variable?
To do that, clients (without their knowledge) were randomized into two groups. In one group, conversation with the therapist was permitted and the other group had conversation gently restricted.
For instance, if the client in a talk-restrictive group remarked how difficult the day had been, the therapist would respond in an acknowledging way that did not encourage further conversation. The talk-permissive group might have the therapist asking what made the day so challenging. All conversations were recorded and transcribed for review. (Putting microphones in the headrests was quite an experience.)
The results, as shared in a poster presentation for the Association for Psychological Science (formerly the American Psychological Society), not surprisingly showed that clients who felt the most therapeutic bond/therapeutic alliance (connection with the therapist) had better outcomes. The power of therapeutic alliance spans most all health care disciplines. What surprised us was that the best outcomes were from the subjects who had the highest therapeutic bond and were also in the talk-restrictive group.
Why would the talk-restrictive group have better results than the talk-permissive group? My staff and I incorrectly assumed that the talk-permissive group would have better outcomes. Having been wrong about the “what” question, we were understandably hesitant to guess why the opposite was true
I have, however, thought about that question for years and wondered if, somehow, the subjects undisturbed by extraneous conversation were able to experience themselves more deeply through the touch of another, as my client stated at the beginning of this article.
The Gift of Interoception
One of the greatest gifts of massage therapy might be its ability to reveal the nervous system to itself. Through the guided touch of the therapist, the recipients experience their inner reality, a process called interoception. With increased awareness comes interpretation of these sensations, followed by integration5. Simply stated, touch can possibly facilitate a “software update” for the brain as you cannot change that which you are unaware. The therapist’s hands become like mirrors, reflecting the nervous system to itself.
In exploring the research literature regarding massage for anxiety and depression, I found an article published in 2019 from researchers in Germany that explored the concept of massage therapy and interoception6. In this article, they proposed that a possible mechanism for the power of massage therapy to create interoception is through unmyelinated C tactile (CT) afferents, a specific touch receptor in the skin that is highly sensitive to slower and more rhythmic touch. These receptors have been shown to enhance activity in a part of the brain called the insula, where a great deal of interoception occurs. Activity in the insula has also been shown to be diminished in people who suffer with depression. Therefore, could massage therapy positively affect depression via stimulation of these CT fibers, which then encourage greater interoception and insular activity? It is an intriguing concept.
Another important point in the article is that increased interoceptive accuracy decreased Alexithymia, a condition where people struggle to identify the feelings they feel, especially the somatic aspects of those feelings. This is an important point because there seems to be a link between depression and alexithymia7.
Can massage therapy help the client more fully observe and identify their somatic life and feelings associated? If so, how can we therapists adapt our sessions to fully maximize this possibility?
You Need Time on the Table Too
At this point, it is unknown to what full- and long-term extent the pandemic will affect individual massage therapists and the profession at large. It will be interesting for us to see the results of Project COPE, which will shed some light on the emotional toll on this profession and others as well. While so many people are struggling because of the pandemic, all indications are that we massage therapists have undergone tremendous emotional stress and upheaval, both personally and professionally.
“This pandemic has underscored even further the importance of whole-person pain care in general,” said Amy Goldstein, MSW, the director of the Alliance to Advance Comprehensive Integrative Pain Management. “he foundation of bio-psycho-social plus self-care is vital when it comes to pain management. This pandemic clearly shows the need to more practically emphasize the bio-psycho-social-plus-self-care parts so that people with pain have an integrated experience and support to achieve what matters to them.”
As a profession, we could benefit by working toward building community, reaching out to each other to support and reaffirm the power and promise of massage therapy. In addition to creating a meaningful community, interoceptive experiences can be of enormous benefit.
We massage therapists need our time on the table as well. While massage therapy seems to be an excellent tool in interoceptive awareness, there are many other self-care approaches that can be used to great effect, from somatic therapies to mindfulness meditation practices. Now is the perfect time to embody the biopsychosocial model, reconnecting with our somatic life, our inner feelings, and savoring deep and meaningful connections with others.
About the Author
Douglas Nelson, BCTMB, LMT, is immediate past president of, and wrote this article on behalf of, the Massage Therapy Foundation. Nelson began his career in massage therapy in 1977 and maintains an active clinical practice. He has served as a neuromuscular consultant to NBA and NFL teams, as well as high-level musicians. His book, “The Mystery of Pain,” was published by Singing Dragon in 2013.
Footnotes:
1. Ettman CK, et al. “Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic.” JAMA network open 3.9 (2020); e2019686-e20119686.
2. Bueno-Notivol J,, et al. Prevalence of depression during the COVID-19 outbreak: A meta-analysis of community-based studies.” International Journal of Clinical and Health Psychology 21.1 (2021): 100196.
3. Varma, P, et al. “Younger people are more vulnerable to stress, anxiety and depression during COVID-19 pandemic: A global cross-sectional survey.” Progress in Neuro-Psychopharmacology and Biological Psychiatry 109 (2021) 110236.
4. Marvaldi M, et al. “Anxiety, depression, trauma-related, and sleep disorders among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis.” Neuroscience & Biobehavioral Reviews (2021).
5. Khalsa SS, Adolphs R, Cameron OG, Critchley HD, Davenport PW, Feinstein JS, et al. Interoception and mental health: a roadmap. Biol Psychiatry: Cogn Neurosci Neuroimag 2018;3(6):501–13.
6. Eggart M, Queri S, Müller-Oerlinghausen B. “Are the antidepressive effects of massage therapy mediated by restoration of impaired interceptive functioning? A novel hypothetical mechanism.” Medical hypotheses 128 (2019): 28-32.
7. Bornemann B, Singer T. “Taking time to feel our body: Steady increases in heartbeat perception accuracy and decreases in alexithymia over 9 months of contemplative mental training.” Psychophysiology 54.3 (2017): 469-482.