Trauma-informed Bodywork and Scope of Practice

Over the last two decades, the topic of trauma has become commonplace and PTSD, complex PTSD, and the impact of Adverse Childhood Events on the physical and psychological health of adults has also grown.

As awareness of trauma grows, the question arises of how to integrate this awareness into personal and professional contexts. This article examines the importance of integrating the latest understanding of trauma into one’s massage therapy practice while staying within one’s scope of practice.

Trauma-informed Definition

In the United States, the Substance Abuse and Mental Health Services Administration defines a trauma-informed approach by emphasizing “the 4 Rs”:

A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization. (SAMHS, 2014)

In a bodywork setting, trauma can show up in numerous ways:

“Sometimes it shows up as a strong reaction (e.g. panic attack) in response to a sound outside or in response to something the therapist says or does. Other times it shows up as a client that is “checked out” and unavailable. Most of the time trauma shows up in more subtle ways, embedded in the client’s personality in every way possible, from wanting the therapist to fix them, to their postural and movement and pain patterns, to their way of relating to the therapist and themselves. The latter includes a higher incidence of both transference with the practitioner and/or shaming themselves.” (Olson, 2020)

Shock vs. Developmental Trauma

There are many different types of trauma and many different ways to categorize them. The type that most people equate with the term “trauma” is shock trauma, which may occur after a single event, such as an act of violence or a car accident. Shock trauma survivors are sometimes diagnosed with PTSD. Shock trauma engages the Autonomic Nervous System, creating fight, flight, and freeze responses (van der Kolk, 2015). Most people are aware of these responses because most people are aware of shock trauma.

The most common form of trauma is developmental trauma (DT), which refers to trauma that occurs during childhood in response to abuse and neglect and results in disruption of the attachment relationship with one’s primary caregiver. While PTSD is characterized by relatively simple ANS responses, DT affects the development of complex psychosocial functions related to the self and personality, including most counter/transference phenomena. A thorough explanation of this cannot be provided here other than to say that a child will develop relational strategies that foreclose its own desires and impulses in order to preserve its attachment bond with its primary caregiver upon whom the child depends for survival, and then those relational strategies get carried forward into adulthood (Kernberg, 1975; Kohut, 1977; Mahler et al, 1975; Masterson, 1993).

Trauma-informed Care vs Trauma Treatment

Due to the important line that is drawn between massage therapy and psychotherapy, as manual therapists it can be tempting to relegate all discussion about trauma to psychotherapy and avoid the trauma topic. But massage therapy has a number of general qualities that are trauma-relevant, including the application of touch (including affective/sensual/hedonic touch), the offering of care and support, the focus on one’s health (particularly one’s pain and anxiety), the safety concerns of not being fully clothed, the power dynamics between client and therapist, and the navigation of boundaries, needs, and requests. It’s important to acknowledge this and know how to best respond in a manner that remains within one’s scope of practice.

A key distinction to make is the difference between trauma-informed care/services and trauma treatment. Trauma treatment is something that only mental health professionals can provide and is thus out of scope for massage therapists, whereas providing trauma-informed care and services is something that every individual, institution, and business can (or should) do (SAMHSA, 2014).

Being trauma-informed is analogous to being compliant with the Human Rights Act. Any business can be HRA-compliant. A bank, grocery store, or amusement park may install wheelchair ramps to be compliant, for example, but they are not performing procedures that might assist a person in walking. Furthermore, everyone would agree that those businesses should be compliant. The same is true for being trauma-informed, particularly if the business offers educational or health services.

Trauma First-Aid

Being trauma-informed is also comparable to being trained in First Aid and CPR, which everyone understands is not out-of-scope since they both provide the necessary skills to work with whatever might happen until a medical professional can take over (as well as being required for MNZ membership). The same is true for being trauma-informed. If a client hears a loud noise outside and this creates a “flashback” to events they experienced during military service, it would be negligent to just leave them to suffer on their own, just as it would be negligent to wait for an EMT to arrive before starting CPR.

Trauma-informed bodywork requires, at minimum, the ability to recognize and respond to PTSD symptoms when they arise by providing a sort of “Trauma First Aid (TFA)” so they can “get off the battlefield” and “get back into the room”. Two examples of TFA would include guiding the client’s attention to objects in the room or having the client touch their own skin. Knowing how to perform TFA before referring to a mental health professional is not only an ethical thing to do, but it may allow the client to continue with a massage session that they wouldn’t otherwise be able to continue. Again, one is not providing trauma-treatment, just TFA, as part of providing trauma-informed care.

Being able to recognize and respond to PTSD episodes constitutes a first step towards being trauma-informed, but alone is not sufficient. Ideally it would involve an equal amount of education about attachment and developmental trauma to allow for a better grasp of how relational skill habits are formed and maintained and a better grasp of what sorts of things can be re-traumatizing.

Informed vs Non-informed Responses

In addition to the general ways that trauma is relevant in massage therapy, there are a number of trauma-based phenomena in massage therapy that are likely to be missed or overlooked without a trauma-informed lens. Because of the complex ways our relational strategies form in childhood, many of these trauma-based phenomena are rather counter-intuitive, and they show up more often in massage because of the way it mimicks a parent-child context, where one person is providing unilateral care to another who has less power.

For instance, while increased calmness and body awareness both seem like positive effects of massage, both can make a client aware of difficult feelings that they normally keep themselves distracted from. In such instances, the positive experience on the table can counterintuitively lead to unpleasant experiences during the session or on subsequent days. (Heller & LaPierre, 2012)

In such instances, a non-informed therapist may think the client is calm and relaxed, but a trauma-informed therapist would, using the 4Rs, be able to recognize if the client has moved into an autonomic freeze state, would realize what the freeze state is and the purpose that it serves, would respond effectively by implementing Trauma First Aid, and would resist re-traumatization by not doing anything that would likely reengage a fight, flight, or freeze response.

Second, while asking a client what they want from their session seems very simple and straightforward, for some clients, acknowledging that they have needs and making requests is challenging on a subconscious level and can lead to a non-optimal dynamic with the practitioner.

So in a case where a client consistently doesn’t ask for what s/he wants or give feedback during the session and then complains later that s/he didn’t get what s/he wanted, a non-informed therapist may think their client is just “being difficult” and re-traumatize them by shaming them for not expressing their needs. In contrast, a trauma-informed therapist is going to recognize the signs of developmental trauma in the client’s seemingly contradictory behavior (and in one’s own tendency to pathologize the client), realize how developmental trauma can make it difficult for a client to say what they are wanting, and respond to the client in an accepting manner that allows the client to get the massage session better tailored to his/her individual needs.

Third, while the application of “deep tissue” is often proudly hailed as a gift to be given to any client that asks, a client’s hyper-focus on deep tissue can often be a sign that a client has reduced interoceptive awareness (Heller & LaPierre, 2012), which may be an adaptive strategy to not feel unpleasant feelings. Once a trauma-informed perspective illuminates a phenomenon like this, the complexity of seemingly simple scenarios can be seen more clearly, allowing for the possibility for the client to be met more fully.

In such a case where a client consistently asks for “very deep tissue”, a non-informed therapist may think in terms of “fixing” the client with outdated ideas of manipulating connective tissue, but a trauma-informed therapist is going to recognize that this request may be a sign of early developmental trauma, realize why trauma can block interoception and lead to clients seeking strong sensations, and respond to the client in a manner that broadens the set of treatment options beyond the requested option, which might have caused more harm than good. In addition, the therapist would not take on an agenda of trying to promote interoceptive awareness, thus resisting re-traumatization of the client.

These are but a few examples of the benefits for a massage therapist of incorporating a trauma-informed perspective into one’s practice.

What Could Go Wrong?

Could there be a down-side to incorporating a trauma-informed perspective into massage therapy? One could argue that it’s all too easy for a well-meaning therapist to overestimate his/her knowledge level and prematurely label oneself as trauma-informed. This often happens when a practitioner learns about trauma from sources that are incomplete, outdated, or false. For instance, not being educated enough about developmental trauma or applying harmful ideas from positive psychology and new age philosophy are common. It’s also common for popular outdated ideas in the culture about psychological healing to intentionally or unintentionally impact the session. These usually include a lack of awareness about how a focus on body awareness can be retraumatizing. Others may improperly and naively cross the line by implying that they offer trauma treatment, offering popular, outdated ideas about emotional expression, unaware of how this can be re-traumatizing. In most of these cases, clients won’t be aware that re-traumatization is occurring and may continue to schedule sessions despite their harmful impacts.

All of these scenarios are already happening and will likely always happen, unfortunately. Certainly a trauma-abstinence approach may avoid such pitfalls, but as outlined earlier, it leaves other problems unaddressed. Instead of steering clear of the trauma topic, the solution to these concerns is to address them directly by promoting quality education on trauma that goes beyond the obvious and intuitive and being outspoken about the dangers that these concerns point to.

NeuroAffective Relational Model (NARM)®

One way to acquire an adequate understanding of trauma and develop effective trauma-informed communication skills is through education in programs that specialize in trauma and don’t attempt to apply skills designed for one form of trauma onto another (e.g. shock trauma techniques for developmental trauma). One such program is NARM®, which is an approach that was developed for psychotherapists working specifically with developmental and relational trauma (Heller & LaPierre, 2012). Combining ideas from Attachment Theory, Object Relations Theory, and Somatic Psychology, NARM® is both a bottom-up (somatic) and top-down (cognitive insight) model that doesn’t focus on the past and doesn’t view clients in terms of pathologies. Instead, it focuses on how the formation of early relational strategies (the foreclosure of the true self) become mistaken for one’s identity and affect one’s life in the present, and it works with the organized, coherent part of the self to build greater capacity for self-regulation (What is NARM, 2021).

Though NARM® was developed for psychotherapists, NARM® principles are relevant to communicating with anyone, and the NARM® Training Institute offers courses specifically designed for health practitioners who are not psychotherapists.

Applying NARM® principles to massage therapy sessions improves the quality of the client-therapist relationship, which makes the whole session more effective. It’s not psychotherapy—it’s effective “bedside manner”. As a result the improved client-therapist relationship, clients will feel safer, which means that their muscles will have fewer reasons to guard, their pain relief will be greater, and they are more likely to be a returning client.

Summary

“Given the pervasiveness of trauma in our society, a massage therapist is going to be more effective with more people if taking a trauma-informed approach. This means realizing what the different forms of trauma are and how they impact the lives of trauma survivors. It means being able to recognize signs of trauma and being skillful in responding effectively to them. It means resisting re-traumatization of trauma survivors. And while a trauma-informed approach is essential for working with trauma survivors, the whole-person approach and the skills associated with it are valuable to apply with all clients.” (Olson, 2020)

Being trauma-informed and applying NARM® principles to any helping profession is a positive step that is not outside of that profession’s scope. Rather, it’s enhancing the quality of the relationships that form therein and it’s helping the client to feel more safe, which allows for the emergence of a more effective session and increases the likelihood that the client will return and recommend that practitioner to others.

Citations

Heller, L., & LaPierre, A. (2012). Healing developmental trauma: How early trauma affects self-regulation, self-image, and the capacity for relationship. North Atlantic Books.

Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. J. Aronson.

Kohut, H. (1977). The restoration of the self. International Universities Press.

Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant: Symbiosis and individuation. Basic Books.

Masterson, J. F. (1993). The emerging self: A developmental, self, and object relations approach to the treatment of the closet narcissistic disorder of the self. Brunner/Mazel.

Olson, Mark. (2020). Why massage therapy needs to be trauma-informed. Massage and Fitness. https://massagefitnessmag.com/massage/why-massage-therapy-needs-to-be-trauma-informed/

Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Substance Abuse and Mental Health Services Administration.

Van der Kolk, B. A. (2015). The Body keeps the score: Brain, mind and body in the healing of trauma. Penguin Books.

What is NARM? (2021). NARM Training Institute. www.narmtraining.com/what-is-narm/

Originally published in Massage New Zealand, Issue 1, 2022.

Author

Dr. Mark Olson holds an M.A. in Education and a Ph.D. in Neuroscience from the University of Illinois, specializing in Cognitive and Behavioral Neuropsychology and Neuroanatomy. His research focused on memory, attention, eye movements, and aesthetic preferences. Dr. Olson is also a NARM® practitioner, aquatic therapist, and published author on chronic pain and trauma-informed care.  He offers a variety of courses at Dr-Olson.com that provide neuroscientific insights into the human experience and relational skill training for professionals and curious laypersons.