Recovering Body and Soul from Post-Traumatic Stress Disorder

Traumatic events, such as fire, earthquake, bombing, and hurricane, occur daily. Such devastatingcircumstances often cause an acute reaction of fear and terror for individuals who experience them. War, rape, and physical assault or abuse, whether of a child or an adult, produce equally frightening results, known as post-traumatic stress. It occurs when traumatized individuals cannot safely assign to the past what has happened in their life. The experience of trauma undermines one's expectations of safety and security in the world. Traumatized individuals continue to be aware of what others know to be true but tend to keep hidden from their consciousness: That life is fragile and can be gone or forever changed in an instant, and that our expectation of control in the world is often an illusion.

As they struggle to make sense of what has happened to them, the majority of individuals who experience severe trauma develop such acute, short-term symptoms as sleep disturbances and physical pain. Others, unfortunately, develop chronic symptoms related to their experience of trauma. These symptoms, when they occur together, are indicative of Post-Traumatic Stress Disorder, or PTSD. The impact of such symptoms has a neurobiological basis and crosses physical, emotional, and spiritual boundaries. Such clients present significant challenges to the massage therapist's skills and knowledge in the treatment room.

This article examines the signs and symptoms of chronic PTSD and the role of the massage therapist in dealing with them. The overall goal in the massage treatment of PTSD is to help the client to become safely "embodied within the self." Massage therapists can teach clients safe and effective ways of self-soothing and stress management. People who have been traumatized are no longer at home in their bodies. Talk therapy alone does not always adequately address the fear and mistrust that has been encoded into their bodies. In a multidisciplinary context, massage therapy can help bring clients back into themselves by increasing their ability to feel safety and mastery in the world, to be freely curious without fear, to feel comfortable with their body, and to experience boundaried intimacy with another human being.

Clinical Manifestations

It is important for massage therapists to understand the clinical manifestations and neurobiology of trauma, in order to understand the risks and benefits which massage therapy treatment offers to clients with PTSD. Many clients have traumatic histories and exhibit the signs and symptoms of PTSD, whether or not the massage therapist is aware. In a national comorbidity survey of more than eight thousand subjects, Kessler, et al,2 found that 6.5 percent of the subjects studied had a lifetime prevalence of PTSD and another 2.8 percent had a 30-day prevalence of PTSD. Women were at twice the risk of men in developing PTSD, and those with PTSD were at increased risk of developing other psychiatric disorders, such as anxiety and mood disorders.3 Given that approximately 75 percent of massage therapy clients are women,4 and given that a large majority come into massage therapy treatment for what is generally described as "stress," the percentage of clients presenting with PTSD may likely be much higher than the 9.3 percent suggested by these figures.

Saakvitne and Pearlman5postulate that the experience of trauma undermines five basic human needs:

1. The need to be safe.
2. The need to trust.
3. The need to feel some control over one's life.
4. The need to feel of value.
5. The need to feel close to others.

Nowhere is this more evident than in the extraordinarily intimate surroundings of the massage therapy treatment room. Clients who, from time to time, experience emotional reactions to being touched often respond to simple human soothing. Crying, being held, being reassured by the massage therapist-"There, there. It's over now. You are safe with me"-most often brings the client back from the terror of remembered trauma and sadness to present reality. The world and the massage proceed as before.

Those who have experienced a deeply traumatic event may not be so easily soothed by simple words or touch. For them, trauma continues to live on in their body and spirit, as if it were still happening in the here and now. Soothing seems hollow, not to be trusted. The loss of confidence in the body's ability to keep them safe is experienced as the ultimate betrayal of all that they have come to know and trust about the world and other people. The longing for safety remains but is buried very deeply under the guard of perpetual mistrust and fear.

Clinical Definition

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV)6, a client must meet the following criteria to be classified as having PTSD:

Criterion A: Has been exposed to a traumatic event involving actual or threatened death or injury, during which the individual responded with panic, horror, and feelings of helplessness.

Criterion B: Reexperiences the trauma in the form of dreams, flashbacks, intrusive memories, or unrest at being in situations that remind the individual of the original trauma.

Criterion C: Shows evidence of avoidance behavior-numbing of emotions and reduced interest in other persons and the outside world.

Criterion D: Experiences physiological hyperarousal, as evidenced by insomnia, agitation, irritability, or outbursts of rage.

Criterion E: The symptoms in Criteria B, C, and D persist for at least one month.

Criterion F: The symptoms have significantly affected the personÕs social or vocational abilities or other important areas of life.

PTSD may be either acute or delayed in onset. Acute PTSD occurs within 6 monthsof a traumatic event. Delayed onset may occur any time later than 6 months after the traumatic event. This may be a year, 20 years, or even 40 years after the event.

Signs and Symptoms

In addition to a history of trauma, there are certain signs and symptoms to watch for when assessing a client for PTSD. Singly, the symptoms are not diagnostic; however, when observed as a cluster of signs and symptoms, the therapist should consider the possibility of PTSD.7

1. Hypervigilance (wariness of others) and hyperarousal (fight or flight response).
2. Emotional absence and/or unresponsiveness.
3. Avoidance of triggers that spring up memories of the trauma.
4. Dreams, nightmares, insomnia.
5. Difficulty in concentration.
6. Irritability or outbursts of anger.
7. Depression.
8. Suicidal thoughts or gestures of self-destructive behavior.
9. Exaggerated startle response or extreme ticklishness.
10. Numbness or hypersensitivity to touch over parts or all of the body.
11. Overwhelming feelings of anger, sadness, fear, despair, shame, guilt, or self-hatred.
12. Migrating symptoms of physical pain.
13. Migraines, fibromyalgia, extreme myofascial tension.
14. Disassociation from self, actions, or parts of the body.
15. Loss of connection with spiritual aspects of life or the ability to imagine a positive future.
16. Distorted relations with the perpetrator or others who remind the client of the perpetrator.

Massage therapists should be aware that there are many clients who may have experienced significant trauma, but their symptoms will appear more consistent with depression. For a concise description and delineation of responses other than PTSD to trauma, refer to Trauma and Recoveryby Judith Herman.8 As with all medical and psychiatric conditions, it is extremely important that the client be diagnosed by an appropriate healthcare practitioner. Massage therapists are advised to develop a reliable list of practitioners to whom they can refer clients for diagnosis and with whom they can work to coordinate an effective multidisciplinary, client-centered treatment plan.Trauma continues to live on in their body and spirit, as if it were still happening in the here and now.

Neurobiology

Individuals experience traumatic events differently. For example, one individual who experiences being mugged at knife point may respond in the moment by complying with the mugger, handing over her wallet while memorizing the mugger's face. She thinks that when she gets out of this situation she will go to the police station, identify the perpetrator, and have him charged. Another individual may become frozen with fear and go to a place inside herself that is often described as a place of "speechless terror." She cannot communicate rationally with herself, or reassure herself about a course of action she will take in the future. At the time of the traumatic event she is convinced that she will die.

 How individuals respond to traumatic events may partially come down to the differences between how they process information and feeling.

Those individuals who are able to keep talking to themselves while a traumatic event is occurring, and who keep planning for a possible future, are engaging the left side of their brain. These persons process sequentially and logically. They still feel intense fear, but their left-brain approach to understanding prevents them from being overridden with terror.

Those individuals who process from the right side of their brain experience the world from a more sensory, emotion-laden place. They receive the whole image of the event all at once, with emotion, sensation, and perception heightened. They cannot, in the instant of terror, manage a sequential understanding of the event, nor can they decide in a rational or logical manner what to do next in order to protect themselves. They no longer experience the world through the filters of their cerebral cortex and are entirely, at the moment of trauma, in the right side of the brain. They are, in other words, in a place of "speechless terror." Individuals who experience this are far more likely to develop PTSD.9

The brain is exquisitely organized into three basic and highly interrelated parts and functions. The brain stem and hypothalamus monitor regulation of one's internal environment and the fight or flight mechanisms. The limbic system balances the internal and external worlds and processes raw emotion. The neocortex analyzes and solves problems and is the part of the brain through which we largely interact with the external world. Together these parts of the brain coordinate the unconscious and conscious functions of feelings, thoughts, memories, communication, and actions.Massage therapists should be aware that many clients may have experienced significant trauma, but their symptoms will appear more consistent with depression.

One of the functions of the limbic system, the center of emotions, is to store fear-based experiences. Rapid and accurate access to experiences of fear and its associations is highly necessary for survival. For example, if a person walks down a forest path and sees a long cylindrical object lying across the path, he may gasp, stop quickly, or run away. The reaction to the object happens before the neocortex gives any information about what that object might be.

Part of the limbic system, the amygdala, records fearful experiences and feelings in intense sensory detail, and alerts the person to the possibility that the object is a snake, long before the word "snake" occurs in the person's left-sided cortex. The amygdala also sends messages to the hypothalamus to activate the hypothalamus-pituatary-adrenal (HPA) axis, the fight or flight mechanisms, so that the person will stop, look, and get ready to run, if necessary, before even knowing what the object is.

1. The HPA axis  is triggered by fear (among other emotions):
2. Hypothalamus secretes CRH (corticotropin-releasing hormone).
3. CRH activates the pituitary gland to release ACTH (adrenocorticotropic hormone).
4. ACTH activates the adrenal glands to release cortisol.
5. Cortisol stimulates heart, brain, glands, and skeletal muscle for the fight or flight response.
6. Cortisol suppresses the immune system.
7. The presence of cortisol in the blood eventually signals the hypothalamus to stop secreting CRH and the hypothalamus-pituitary-adrenal axis slows.

Under ordinary circumstances, high levels of cortisol in the bloodstream, an indicator of stress, will activate the process of homeostasis in the body. From the Greek meaning "to keep things the same," homeostasis is a complex process wherein the body maintains a finely tuned balance between all the systems that it needs to survive. After the danger (real or perceived, external or internal) has passed, the neurohormonal system will usually right itself. However, the neurohormonal systems of persons who experience PTSD are often stuck in the fight or flight mode, remaining hypervigilant or hyperalert. Clinically high levels of the hormones cortisol and norepinephrine result in hypervigilance and its related wariness and neural hyperreactivity. Another way that this break in the neurohormonal cycle manifests is as a cortisol and norepinephrine burnout. In this type of stress hormone burnout, clients may experience numbness in parts of their bodies, lethargy, and depression. PTSD clients may present with one or both of these conditions.Part of the limbic system, the amygdala, records fearful experiences and feelings in intense sensory detail, and alerts the person

Time Heals Not

PTSD has been described as the failure of time to heal all wounds, because the experience of trauma, for some individuals, is encoded entirely in the amygdala without reference to time and space. The cerebral cortex, which helps to shut off the floods or cascades of hormones, cannot be accessed. For people with PTSD, flashbacks of the traumatic experience occur when the flood gates of the amygdala are triggered to open. Then sights, sounds, smells, and feelings of the trauma return unexpectedly and intrusively, causing the person to experience yet again aspects of the original trauma as if it were happening in the here and now.10

For example, a woman survives a severe car accident that occurs during a storm. She develops intrusive flashbacks of the pressure of the seatbelt on her chest at the time of the accident, symptoms which have persisted long after the physiological damage to her chest muscles has healed. She comes to massage therapy complaining of chest pain for which she has no clear explanation. She also is baffled by the fact that the chest pain gets worse when it rains. At the time of the accident it was raining heavily. The intense fear and pain experienced and encoded in the amygdala was encoded with the accompanying sensory awareness of rain.

Now she has a conditioned response: A sensory stimulation (especially rain) reminds her (however subtly and unconsciously) of the car accident and triggers chest pain. In addition, at the moment she is flooded with the memory, she again experiences many of the sensations that occurred during the accident: sweating, racing heart, intense fear, and shallow breathing. This woman may now actively find ways to avoid stimulus that triggers these floods of stress hormones, such as staying indoors when it rains, or self-medicating with drugs and alcohol. It is not uncommon for individuals with PTSD to develop addictions to alcohol or drugs, to work extremely long hours, or find other ways to reduce or ignore the unwanted and frightening sensations.

Bessel van der Kolk11 refers to the normal neural encoding of experiences as narrative memory (located in space and time, without the intrusive neurohormonal cascade) and the kind of memory that people with PTSD suffer from as traumatic memory. He theorizes that the fundamental task of therapy-whether it is psychotherapy or massage therapy-is to help clients regain a sense of safety in their bodies, free of the flooding of stress hormones. Perhaps Freud was right when he said, "The task of therapy is to transform neurotic misery into ordinary unhappiness."

In talk therapy, or psychotherapy, intrusive neural symptoms are transformed, in the context of a safe, boundaried, therapeutic relationship. By encouraging the client to talk about the traumatic event, the unpleasant memories get reencoded from traumatic memory into narrative memory. In other words, people learn to use their left brains (cortex) to coordinate their right-brained feelings. This prevents the discharge of stress hormone from the amygdala. Once talk therapy has helped the client establish some degree of narrative memory and experience of safety, clients may face intrusive body sensations with a massage therapist. Massage therapy can help clients to reframe their experience of trauma from a kinesthetic perspective.

Seratonin, along with the body's natural painkillers or opiates, is produced in the brain. Since PTSD clients cannot easily access the seratonin needed to soothe the fight or flight response, medications such as Prozac, Zoloft, and Paxil (known as SSRIs, or selective seratonin reuptake inhibitors) are often used to help control inappropriate reactivity to internal stimuli such as impulsivity, aggression, and involuntary preoccupation with traumatic memories.12

Some clients may, with such therapy, be able to enhance their bodies' seratonin pump. Other clients, who have severe PTSD, may require SSRI medication on an ongoing basis in order to balance their reactions to general life stressors. Massage therapy in the hands of a skilled practitioner also can aid the coordination of the left and right hemispheres of the brain, thereby reducing intrusive symptoms and inducing the creation of self-soothing strategies for clients with PTSD.The fundamental task of therapy-whether it is psychotherapy or massage therapy-is to help clients regain a sense of safety in their bodies.

Benefits of Touch

There are no specific physical manipulation techniques for working with trauma clients. Swedish massage can be as effective and enlightening to a client as the most advanced fascial mobilization. No matter the technique, massage therapy can inadvertently trigger traumatic memory, which, as massage therapists know, also can be a powerful tool for healing and growth.13For example, there is ample documentation that touch stimulation is essential for babies to thrive. The results of Tiffany Field's research on preterm infants is most compelling, where each was given 15-minute massages three times a day for 10 days while still in incubators.14 The treated infants gained 47 percent more weight and were hospitalized for 6 days less. They performed better on the Brazelton Neonatal Behavior Assessment Scale.15 The babies averaged 12 points higher on the mental scale and 13 points higher on the motor scale than the control group. In another experiment,16 rat pups were stimulated with tiny wet paintbrushes, a procedure designed to mimic the licking of newborn litters by their mothers. The rat pups which were "licked" with the paintbrushes thrived similarly to those which had received normal care by mothers. Those that received no stimulation became ill, had small growth rates, and failed in many instances to thrive.

In 1958, Harry F. Harlow demonstrated that artificial or surrogate mothers made of wire mesh and terrycloth and which offered no food, were preferable to either infant rhesus monkeys or wire-mesh structures providing milk. Rhesus monkeys spend most of their infancy in close contact with the ventral portion of their mother. Harlow postulated that the monkeys needed contact and nurturing as much if not more than food in order to thrive.17

These findings may be compared with the reports of emaciated, touch-deprived infants found in Romanian orphanages after the overthrow of Ceausescu. The Romanian orphans had difficulty relating to other humans, exhibited little or no language skills and showed little or no emotional response or affect.18 Follow-up of the orphans indicated a number of attachment disorders. A 1997 study by Kim Chisholm, of St. Francis Xavier University, examined adopted Romanian orphans and evaluated their degrees of attachment. On parent questionnaires, the later-adopted children scored much higher on "indiscriminate friendliness," a behavior recently described as a criterion for attachment disorder.19 Chisholm found that the children "...tried to cuddle and kiss strange adults without the caution one might expect from young children."

"The behavior is as a result of not having a primary caregiver to form an identity in relation to; to fill the void, these children will grab at anyone who seems friendly."20 There are a large number of studies which examined attachment and nurturance. Their findings seem to suggest that healthy nurturance and loving touch are essential for human beings to develop and thrive.

Response to Massage

Many therapists express frustration with clients who are unable to receive a massage treatment. Indeed, in some circumstances a powerful battle of wills ensues when the client appears to put up barriers against each of the therapist's efforts to encourage the client's relaxation. Experience indicates that when the therapist demonstrates close attention, acknowledgment, and respect for such survival mechanisms, his client will eventually come to trust the process of massage as a safe way to receive the soothing she so deeply craves. With soothing comes a thawing from long-standing fear and the opportunity to reacquaint the client with her normal body signals.

In the ordinary course of events, massage therapy can offer a profound sense of peace to those who are able to feel strong enough at their core to let go and relax. For those who carry the effects of trauma, however, the world does not feel safe and they cannot trust their bodies to give the appropriate signals of safety. Alarm bells are always being rung by the flood of stress hormones. They either remain on full alert or alternate between numbness and hypervigilance.

If the trauma relates to sexual abuse, the intimacy of the massage treatment room may increase the sense of fear. Touch of any kind may trigger memories of both desired and unwanted information. Ways that a client manages to live with the memory of a traumatic event is simply not to think about it, to deny its existence, or, at the very least, never to allow herself to consciously dwell on the horrible event. The client may not think too much about what really happened, yet is plagued by extraordinary levels of tension. The touch of the therapist may open the floodgates of sensation which she had carefully kept closed, in order to avoid reliving the traumatic memory. If traumatic memory, stored in the amygdala of the limbic system, is triggered, then flashbacks, speechless terror, numbing, hyperarousal and/or disassociation may result. Witnessing this may be alarming and frightening to therapists who do not expect such occurrences or who are unaware of the signs and symptoms of PTSD.

Clients who, when babies and small children, were coddled, held, stroked, and nurtured, are likely to have grown up with strong senses of self and safety in the world.21If, on the other hand, touch had been forbidden or abusive, laced with malevolence or manipulation, they may not have developed ways of appreciating healthy, boundaried, and safe touch. As Judith Hermann suggests, three major forms of adaptation permit a child to survive in an environment of chronic abuse:

• Elaboration of disassociation defenses;
• The development of a fragmented identity;
• The pathological regulation of emotional states.

Inevitably, when the child grows up, the systems for coping that helped her to tolerate and survive an abusive situation, create great difficulty for her when faced with adult relationships and intimacy.22

When clients lay on a massage table without clothes and between two sheets, the very act of lying down nude may evoke sensorial and historic responses that are deeply attached to how they perceive themselves in the world. If gentle touch was historically associated with a subsequent beating or assault, then the gentle touch of a massage therapist may have surprising and unpleasant associations for the client. If, in addition, the client was constantly criticized for the size and shape of her body, she may feel a deep sense of shame, disgust, and vulnerability at exposing herself to anyone, and especially to the massage therapist.

Massage therapists may feel frustrated at the noncompliance of clients and their seeming inability to allow the therapist to work deeply when trying to alleviate tension and muscle pain. A more helpful approach may be to look closely at the reactions of clients, observing these reactions as the client's courageous efforts to keep herself together in the face of overwhelming fear. A massage therapist can assist the client to "climb back into herself." This requires consciously working with her strengths. The massage therapist must repeatedly offer her the opportunity to experience her body in the present in a respectful, nonjudgmental environment, to put the memory of trauma in context and live more fully in the present.Look closely at the reactions of clients, observing these reactions as the client's courageous efforts to keep herself together in the face of overwhelming fear.

Treatment Considerations

Establishing trust is essential when working with clients with PTSD. In order to treat them successfully, the massage therapist must understand the nature and essence of the therapeutic relationship and behave at all times in a trustworthy manner. It is the therapist's role to create a safe place in which the client can regain confidence in herself and in her body.

As van der Kolk wrote, "Treatment of PTSD needs to address the twin issues of helping patients: Regain a sense of safety in their bodies, and complete the unfinished past. It is likely, though not proven, that attention to these two elements of treatment will alleviate most traumatic sequelae."23

Philosophically, engaging in massage therapy represents a commitment to wellness on the part of the client and the therapist. It is a caring, safe way for individuals to experience touch and receive release from pain. It offers intimacy that is nonsexual, thereby providing an opportunity for clients who are fearful of intimacy to experience it safely. Massage therapy communicates support, acceptance, positive regard, and pleasure, through the modality of the therapist's hands, and it empowers the client to take charge of how she wants her body to be touched. Respectful touch can be healing. Massage therapists offer a safe place to clients, who in turn, may learn to trust that touch does not have to be associated with pain, fear, or anger. Massage therapists offer a safe place to clients, who in turn, may learn to trust that touch does not have to be associated with pain, fear, or anger.

In a healthy therapeutic massage relationship, the client participates in creating accomplishable treatment plans. Decisions for her care are widely discussed, and the process is one of consensus and cooperation. This approach is critical for the successful treatment of the client with PTSD. For her, safety needs to be paramount. She needs to know unequivocally that she has the power to stop, change, or modify a treatment at any time. By having choice over how she wants her body to be touched, the client with PTSD discovers in both a kinesthetic and cognitive way that the trauma is in the past and that here, in the present, she is in charge.

Intention

Technique is far less important than the therapist's intention. For the sake of both the client and therapist, it is imperative for the massage therapist to know at all times what her role is and what her intention is in the therapeutic process. Intention is the term used to describe the therapist's purpose and intent under any given circumstance during treatment. While the therapist intends to do no harm, she can do harm unintentionally unless she is aware of the potential traps and pitfalls of the therapeutic process.

It is imperative that the therapist consider exactly how far he is willing to journey with each client, to assess her level of commitment, and to know what his boundaries are before embarking on any therapeutic relationship. Devastating consequences may arise for the client if a therapist discovers that he is unwilling, unable, or too inexperienced to complete a course of therapy. Few therapists have the capacity to be clear about such things without the aid of supervision. Most therapists benefit from either consulting a more experienced therapist or from peer supervision as a means of becoming clear about their intent, including unconscious motivations that may surface for the therapist during treatment.

The massage therapist takes the role of listener, teacher, coach, and surrogate caregiver. As such, he will likely play an exceptionally important role in the life of the client. Occasionally, a client will want the massage therapist to respond in ways that would be counterproductive to the therapy. She may desire friendship or other access to the therapist outside clinic hours. The client may test the established boundaries of the therapeutic encounter by asking for more intimate touch than is appropriate. The responsibility for clarity, intention, and understanding of therapeutic role is not to be taken lightly. It always falls upon the therapist.

The Treatment Continuum

Whether embarking on the first treatment, or considering how the overall treatment plan is going, the massage therapist must be able to articulate to himself and to the client where she is in the treatment continuum. This helps to ensure the safety of the client, increases the effectiveness of the treatment, and reduces the potential for conflict and inadvertent retraumatization by the massage therapist.

Predictability and routine can be a great solace and comfort for clients with PTSD. It is important for the massage therapy treatment hour to include a well-understood beginning, middle, and end. Beginnings and endings should have familiar, repetitious aspects that signal to the client where they are in the treatment hour. The beginning of the treatment hour establishes safety, boundaries, and goals for the day. The middle part of the treatment hour is primarily experiential, and builds on the client's capacity to sustain safe touch. The ending of the clinic hour provides an opportunity for the client to articulate some of what has occurred during the treatment hour, to acknowledge what may need to be processed in her psychotherapy, and to take home strategies for healthy self-care and self-soothing.

Likewise, the overall treatment plan follows a predictable course where there is a definitive beginning phase, an exploratory midphase, and a concluding phase. Judith Hermann calls these stages: "Safety, Remembrance and Mourning, and Reconnection." 24 The initial stage of massage therapy treatment may take anywhere from one month to several months before the client feels genuinely safe in the treatment room. Emphasis at this stage of the treatment plan is on offering choices and establishing ways of contracting the ways in which the client wishes to be massaged. When she feels confident enough and ready for whatever sensory and emotional material may surface, the client generally expresses a wish to explore sensation in parts of her body that have previously not been touched, or have been either hypersensitive or numb during the massage.

The middle phase can be intense, sometimes emotionally painful, and often liberating as the client receives validation from her body that she has not made all of it up, and that she can experience her body as it really is in the here and now without being overwhelmed by sensations that originate in the past. It is extremely important to note that it is not the massage therapist's role to analyze or interpret what the client is saying or feeling. In massage therapy, clients may be very vulnerable to accepting the massage therapist's interpretations as literal truth. It is always the client's right to define for herself what she is experiencing. The massage therapist must remain in the role of compassionate witness, and never suggest to clients any literal explanations of their sensations, musings, and experiences.

As treatment shifts to the final phase, the therapist begins to notice subtle changes in the client's reactions to being touched. The client may begin talking about simple and inconsequential topics during the massage-such as what she is planning to have for dinner-that do not relate to the treatment. While she is being touched, she may talk about the ordinary events of her life and yet remain relaxed and present. There are no more ghosts of negative forces, people, and events who hurt her in the past in the treatment room. The therapist should take this as a cue that the third phase has begun. Good closure is just as important for this client as is a good beginning. In the final phase, the client reviews what has happened over the course of therapy, embraces whatever changes the massage therapy has given, taking her learning out of the treatment room and into everyday life-a life that is now more enhanced by the possibilities of a more embodied self.Great care must be taken by the massage therapist during this stage, to abstain from overindulging herself 

Great care must be taken by the massage therapist during this stage, to abstain from overindulging herself by encouraging the client to stay on in therapy. For many clients, the massage therapist is a surrogate caregiver, a stand-in for those who did not or could not protect her in the past. There is often a parent-child quality to the relationship. As with all children, there comes a time when they must leave the nest and fly on their own. In many ways, the safe, boundaried intimacy achieved with the massage therapist is simply practice for clients in order to enhance their capacity to go back out into the real world, and develop new and more satisfying relationships with friends and family. At this point, as throughout the treatment process, it is most helpful for the therapist to have supervision, peer support, and a commitment to her own self-care.

Self-Care Importance

Self-care is one of the most important preservatives and strengtheners for those who work with clients who have experienced trauma. Without good self-care for the therapist, commitment and compassion weaken, interest wanes, and integrity may be challenged. If the therapist is in an unhealthy frame of mind, a client with PTSD, potentially so attuned to the will and interest of others, will often perceive the shift immediately. Clients may then hide aspects of pain and confusion so as to protect the massage therapist, harkening back perhaps to earlier situations in their lives where their needs may have been distorted or ignored. The massage therapist can then be lulled into a false sense of comfort with the client.

It has been said many times: Before one attempts to guide another, one should be very sure of one's own ability to tell up from down and left from right. A massage therapist who cannot budget adequate time for her own relaxation, rest, and fun may be a poor example for a client who struggles with over commitment and poor self-care. It is not enough to say, "Do as I say, not do as I do." A massage therapist must be a model of healthy choices regarding self-care. When the massage therapist lets the client know that she does not have to take care of the therapist, and that the therapist can genuinely take care of herself, a burden is lifted from the client. She may proceed with the work of healing herself, and not having to worry about pleasing the massage therapist.

On the other hand, if a massage therapist suggests that she can take care of herself and then is discovered by the client to be overly committed, exhausted, and unable to concentrate, the client may become overly concerned to the detriment of the therapy, and her sense of the therapist's integrity will be shaken. She may think, "If I cannot trust my massage therapist to do what is necessary to take care of herself, then how will she take care of me and how will I ever learn to take care of myself?"The ABC's of Self-Care

Saakvitne and Pearlman25 eloquently outline the ABC's of self-care as follows:

• Awareness. Be attuned to one's needs, limits, emotions, and resources. Heed all levels of awareness and sources of information, cognitive, intuitive, and somatic. Practice mindfulness and acceptance.
• Balance. Maintain balance among activities, especially work, play, and rest. Inner balance allows attention to all aspects of oneself.
• Connection. Connect to oneself, to others, and to something larger. Communication is part of connection and breaks the silence of unacknowledged pain. These connections offset isolation and increase validation and hope.

Supervision or Support

In order to help ensure that the best interests of the client are always at the forefront of massage therapy, the therapist should engage in regular, ongoing supervision or peer support. Supervision describes the process where a massage therapist consults on cases and questions with a more experienced therapist. The confidential conversation is usually focused on the therapist's feelings and responses rather than the client's. It is a strong means of keeping the client's therapeutic process on track by gently and truthfully assessing the therapist's clinical decisions and intention. A good rule of thumb might be that when a massage therapist is uncomfortable with a client, she needs to describe the events of this therapy session to another therapist. There may be events occurring which are outside the bounds of safe therapeutic interaction and which need attention and adjustment.

Peer support is another way to provide checks and balances to one's therapeutic approach. In peer-support groups, two to six therapists agree to meet confidentially and to share the joys, burdens, and confusions of their work with each other. This can be an immensely rewarding and enriching experience, which strengthens each therapist, challenges questionable practices, and explores difficult ethical dilemmas.

When the massage therapist has both professional support and a balanced personal life, the challenges of work are less likely to lead to professional burnout. When she is confident and solidly based, then she can provide the necessary emotional shelter and support for her client. When the client feels the strength and support of the therapist, the client is able to make choices and question old beliefs in her own life. When the beliefs evolve into new ways of thinking and behaving, the client shifts towards more healthy choices and the therapeutic process moves into a new and affirming dimension for the client.

Conclusions

The experience of trauma assaults a person's sense of safety in the world, and can destroy her ability to control what happens to herself. Post-Traumatic Stress Disorder, a noxious presence, can demolish confidence, enhance shame, and have terrible consequences on social relationships. Yet it is considered to be one of the most treatable causes of psychic pain. The massage therapy treatment of PTSD must take into consideration the neurobiological consequences of this human experience. Massage therapists must offer choices in treatment, ways of being massaged that help to restore safety and control.

This is client-centered care at its best. In the hands of a skilled therapist, massage therapy for clients with PTSD acknowledges and helps to restore the most basic of human needs-for safety, trust, control, self-worth, and intimacy. When the ability to satisfy these fundamental needs is damaged, an individual may be unable to function easily or happily in the world. When these needs are satisfied in the context of a healthy therapeutic relationship, an individual may not only survive but relearn or discover for the first time how to thrive. If a client with PTSD has the courage to transform her speechless terror into narrative memory, the traumatic memories become woven into the ordinary fabric of her life. She is given the opportunity to learn that she can be touched safely and with compassion by another human being. This enhances her ability to reconnect with others in her real life and to rekindle her hope and belief in the future.

Trish Dryden, M.Ed., R.M.T., director and co-owner of the Sutherland-Chan School and Teaching Clinic and a professor in Applied Arts and Health Sciences at Centennial College at Toronto, Ontario, Canada, experienced workshop facilitator and lecturer, international consultant, and author of numerous articles and papers, maintains a private practice.

Pamela Fitch, B.A., R.M.T., in private practice since graduating from Sutherland-Chan in 1988, specializes in treating trauma and body image, has written extensively on ethics, professional boundaries, and breast massage ( Winter 1998), served as president of the Ontario Massage Therapist Association, and is a consultant, facilitator, writer, and practitioner in Hong Kong.

They have collaborated on running PTSD workshops, and are writing a book about massage therapy, trauma, and the body-mind connection.

RESOURCES

Books

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington, D.C.: American Psychiatric Association: 1994.

Bass, Ellen, and Davis, Laura, The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse. New York: Harper and Row, 1988.

Bass, Ellen, and Thornton, Louise (Eds), I Never Told Anyone: Writings by Women Survivors of Child Sexual Abuse. New York: Harper Perennial, 1983.

Briere, John, Child Abuse Trauma: Theory and Treatment of the Lasting Effects. California: Sage Publications, 1992.

Herman, Judith Lewis, Trauma and Recovery. New York: HarperCollins, 1992.

Laidlaw, Toni Ann, Malmo, Cheryl and Associates, Healing Voices. Feminist Approaches to Therapy with Women. California: Jossey-Bass, 1990.

Linehan, Marsha, Skills Training Manual for Borderline Personality Disorder. New York: The Guilford Press, 1993.

Matsakis, Aphrodite, I Cannot Get Over It: A Handbook for Trauma Survivors. California: Harbinger Press, 1996.

Montagu, Ashley, Touching. The Human Significance of Skin. New York: Harper and Row, 1986 (3rd ed.).

Northrup, Christiane, Women's Bodies, Women's Wisdom: Creating Physical and Emotional Health and Healing. New York: Bantam, 1998. (Rev).

Pert, Candace, Molecules of Emotion. New York: Touchstone, Simon & Schuster, 1997.

Rosenbloom, Dena, and Williams, Mary Beth, Life After Trauma. New York: The Guilford Press, 1999.

Saakvitne, Karen, and Laurie Anne Pearlman, Transforming the Pain: AWorkbook on Vicarious Traumatization. New York: W.W. Norton, 1996.

Salter, Anna, Transforming Trauma. A Guide to Understanding and Treating Adult Survivorsof Child Sexual Abuse. California: Sage Publications, 1995.

Shaef, Ann Wilson, Beyond Therapy, Beyond Science: A New Model for Healing the Whole Person. New York: HarperCollins, 1992.

Siegel, Daniel, The Developing Mind. New York: The Guilford Press, 1999.

Terr, Leonore, Too Scared to Cry. How Trauma Affects Children-and Ultimately Us All. New York: Basic Books, 1990.

Timms, Robert, and Connors, Patrick, Embodying Healing: Integrating Bodywork and Psychotherapy in Recovery from Childhood Sexual Abuse. Vermont: Safer Society Press, 1992.

van der Kolk, Bessel, Alexander McFarlane, and Lars Weisaeth (Eds.), Traumatic Stress. The Effects of Overwhelming Experience on Mind, Body and Society. New York: The Guilford Press, 1996.

Journal Articles

Loewenstein, Richard, J., "Disassociation, Development and the Psychobiology of Trauma."Journal of the American Academy of Psychoanalysis, 21(4), 1993.

McCann, I.L., and Pearlman, L.A., "Vicarious Traumatization: The Emotional Costs of Working With Survivors." The Advisor: Newsletter of the American Professional Society on the Abuse of Children, 3(4) (Fall), 1990.

Rothschild, Babette, "Defining Shock and Trauma in Bodypsychotherapy." Energy and Character,26(2) (September) 1995

"Post-Traumatic Stress Disorder." The Harvard Mental Health Letter, Part I: June, 1996, Part II: July, 1996.

Web sites and Other Resources

National Center for PTSD
Department of Veteran Affairs, VA Medical Center, White River Junction, VT 05009,802.296.5132.www.sover.net/~schwcof/ptsd.htm/

Internet Mental Health
www.mentalhealth.com

CIVITAS Child Trauma Programs
Dr. Bruce Perry, a noted neurobiologist, explains how many disorders such as Post-Traumatic Stress Syndrome begin with childhood  trauma. http://www.bcm.tmc.edu/civitas/

David Baldwin's Trauma Information Pages
A huge volume on emotional trauma and traumatic stress, including PTSD. http://www.trauma-pages.com/index.phtml

Measures of Traumatic Stress
For clinicians and researchers, this site by Dr. B. Hudnall Stamm, formerly at the National Center for Posttraumatic Stress Disorder, carries recognized tests and clinical instruments.http://www.isu.edu/~bhstamm/tests.htm

The Traumatology Institute
Brings together health, mental health, and emergency-service professionals from around the world to develop cutting edge research, treatment approaches, and training programs.http://www.cpd.fsu.edu/pet/TRAUMA.htm

About Medications for Combat PTSD
A large index of links to information about Post-Traumatic Stress Disorder and related medications. http://uhs.bsd.uchicago.edu/~bhsiung/tips/ptsd.htm

International Society for Traumatic Stress Studies
About the organization, annual conferences, publications, and an index of traumatic stress links.http://www.istss.com/

Internet Mental Health Resources
An extensive index of educational and commercial reference.http://www.med.nyu.edu/Psych/src.psych.html

Post-Traumatic Stress Resources
Scientific and research information on traumatic stress caused by war, disaster or other trauma.http://www.long-beach.va.gov/ptsd/stress.html

Post-Traumatic Stress Disorder
Information about the disorder: an overview, diagnosis, treatments, booklets, magazine articles, and other resources. http://www.mentalhealth.com/dis/p20-an06.html

Post-Traumatic Stress Disorder Bibliography
An annotated list of books and articles about the emotional aftershocks of rape, incest, child abuse, street crime, family violence, war, and other forms of trauma.http://www.sover.net/~schwcof/ptsd.html

Traumatic Incident Reduction: Trauma, PTSD
Literature, workshops, links, practitioners, and more. http://www.healing-arts.org/tir/

Crisis Fact Sheet: Ten Ways to Recognize Post-Traumatic Stress Disorder
A list of symptoms from the American Counseling Association.http://www.counseling.org/consumers_media/facts_pt

Post-Traumatic Stress Disorder (PTSD)
Background and treatment information with a bibliography and list of support organizations.http://www.psych.org/public_info/PTSD~1.HTM

PTSD.Com
Post-Traumatic Stress Disorder Resources www.ptsd.com/

References

1. Barnard, Katheryn and Brazelton, T. Berry, Touch: the Foundation of Experience. Madison: International University Press, 1990, front flap.
2. MacFarlane, Alexander C., and Giovanni De Girolamo, "The Nature of Traumatic Stressors and the Epidemiology of Post-Traumatic Reactions" in: van der Kolk, Bessel A., Alexander C. McFarlane, and Lars Weisaeth, (Eds), Traumatic Stress, The Effects of Overwhelming Experience on Mind, Body and Society, New York: Guilford Press, 1996, p. 141.
3. Ibid.
4. The Collis and Reed Report. Massage Therapy in Ontario: Anticipated Changes Needs, and Predictions for the Future. Toronto: College of Massage Therapists of Ontario, 1998.
5. Saakvitne, Karen W., and Laurie Anne Pearlman, Transforming the Pain: A Workbook on Vicarious Traumatization. New York: W.W. Norton & Co., 1996, p. 33.
6. Diagnostic and Statistical Manual of Mental Disorders, (DSM IV). Washington, D.C.:American Psychiatric Association: 1994 (4th ed.), pp. 424-429.
7. Herman, Judith Lewis, Trauma and Recovery. Ne