Addressing PTSD with Esalen® Massage

By Robin Fann-Costanzo, LMBT, RYT500

In 2010, a client, “Jan,” walked into my office. While we spoke about what she was looking for in her massage, I noticed she had a difficult time making eye contact with me. Her body language was closed, she was slightly turned away from me, and expressed her fear of what might “come up” during her massage. Jan briefly shared that she had survived a severe bike accident two years earlier and as a result, had to have extensive reconstructive surgery to her face. She was experiencing pain in her neck, shoulders and right knee, as well as anxiety, depression and insomnia. Jan had recently been diagnosed with PTSD by her therapist. With this knowledge I was able to approach the session with extra sensitivity to how physical and emotional challenges associated with PTSD can manifest in the body.

What is PTSD?

PTSD, Post Traumatic Stress Disorder, is defined as a set of long term symptoms experienced by someone after a traumatic event. These events could include: exposure to death or threatened death, actual or threatened serious injury, or actual or threatened sexual violence. These events could be experienced by the individual, by witnessing another experiencing the trauma, or by learning that a loved one has experienced a trauma. To be diagnosed with PTSD, someone needs to have at least three types of symptoms: a re-experiencing symptom, an avoidance symptom, and an arousal symptom. These are some potential symptoms:

• Intrusive thoughts 

• Nightmares

• Flashbacks 

• Panic attacks

• Emotional stress

• Physical reactivity 

• Inability to recall key features of the trauma

• Overly negative thoughts and assumptions about one’s self or the world

• Exaggerated blame of self or others for causing the trauma

• Negative affect (emotional expression)

• Decreased interest in activities

• Feeling isolated

• Difficulty experiencing positive affect

PTSD is also defined by trauma-related arousal and reactivity that began or worsened after the trauma. Symptoms manifest in the following ways:

• Irritability or aggression

• Risky or destructive behavior

• Hypervigilance

• Heightened startle reaction

• Difficulty concentrating

• Difficulty sleeping

Those with PTSD, never feel safe.  Depending on the trauma, anything can be a trigger that reminds them of their experience: touch, the presence of another human being, a sound, a smell.  So as a massage therapist I asked myself “how do I let my clients feel that it’s safe to trust me and relax?”   

Understanding the Nervous System

Understanding how the nervous system works is key to understanding how to approach a client experiencing symptoms of PTSD. The human body is wired with an incredible built-in protection, the nervous system. Our brain is the master controller—signals get sent in a split second from our senses: sight, sound, smell, touch, back to the brain, which then reacts with signals back to the nerves and muscles. There are two branches of the autonomic nervous system, the sympathetic and parasympathetic, and they do opposite, yet complementary actions in the body. The sympathetic nervous system signals the body into action. When our senses detect danger or perceived danger, this is the part of the nervous system that makes you pull your hand from a hot pan, jump out of the way of an oncoming car, run or fight the bully that is about to pounce, or curl into a ball and protect when the ball comes flying out of nowhere. The parasympathetic branch of the nervous system signals the body into relaxation.  This is the part of your nervous system that says, “You are safe,” and allows you to take a deep breath, nap on the beach, enjoy a good meal, or relax during a massage.  

Peter Levine, leading expert in trauma, describes PTSD as a condition where the nervous system gets overwhelmed, which can impact victims in many ways, subtle, and not so subtle.  It’s as if the sympathetic nervous system gets stuck in the “on” position, and a client’s ability to “relax” cannot fully function.  

Esalen Massage

Esalen massage is my number one approach with clients who suffer from PTSD because it has some wonderful built-in qualities that naturally create a sense of safety for clients and can be extremely beneficial for those suffering from PTSD.  

1. Communication/ awareness:
   Esalen massage incorporates the teachings of Fritz Perls, founder of Gestalt therapy, which is a type of therapy that encourages the client to observe and be curious about their experience in the moment, and take ownership of their thoughts, feelings and emotions. Helping clients to identify what they are experiencing can be a powerful tool and step toward taking back their power, especially since during a traumatic experience they feel so powerless. Before, during, and after each massage I invite my clients to track their experience with a body scan. I encourage them to be curious and observe without judgement. On a physiological level, this encourages them to move into the frontal cortex part of their brain where they observe and witness, and begins the process of moving out of the reptilian brain, the part that reacts to perceived danger.  

2. Working together: 
   Avoid “fixing” the problem. When I work together with my client, instead of on them, I change my perception, as do they. Esalen massage is a collaboration with the client—not a set routine that I do again and again. In terms of which techniques I use, I am always listening, watching and feeling for how my client is responding to the techniques I’m using.  I am looking for a “relaxation response” from my client. If I’m not getting that, then I get curious and try another approach, or pause and regroup. I approach the massage with an understanding that whatever has led up to this moment in a client’s life has been a lifetime of experiences, defenses, reactions, and their nervous system has done its best to protect and bounce back them from these life experiences. This lifetime of defending will not be “fixed” or “undone” typically in one massage. However, I can hope to cultivate an atmosphere of safety which may provide some awareness, and possibly some alternative strategies or perspectives for them.  

3. Moving Slowly: 
   Esalen massage is done slow, slower, and slowest. One way that trauma settles into the nervous system is by experiencing something too quickly for the nervous system to integrate. Moving slowly allows for the client to integrate their experience and to have the opportunity to say “stop” if they are feeling overwhelmed by my touch. By moving slowly I cultivate feelings of safety and trust. 

4. Pause: 
   Pausing is also an important technique in Esalen massage. Similar to moving slowly, it gives the client an opportunity to integrate their experience, feel their own body without movement, and gives space again for communication. I will pause four or five times during a massage with my hands, either on or off my client’s body.  

5. Rhythm: 
   The incorporation of long flowing strokes, rocking, and compressions create a soothing rhythmic movement to the massage which helps to settle and calm the nervous system. Much like a mother instinctually does when they rock their baby to sooth them, these techniques have a deep calming effect to an aroused nervous system. 

6. Breath: 
   Breath is the link between the mind and the body. I invite my clients to observe their breath to give them clues about their experience, and use their breath to direct their attention and focus on different parts of their body. The breath can be a very powerful tool to support the nervous system in settling, and gives a focus for the mind.  

Massage and therapy 

Massage is in no way a replacement for psychotherapy, especially after experiencing a traumatic incident. However, in conjunction with therapy, massage can be a wonderful complement to help support a client in experiencing their body in a new way. There are several cutting edge therapies that specifically address trauma, Somatic Experiencing (SE), Eye Movement Desensitization and Reprocessing (EMDR),Tension & Trauma Releasing Exercises (TRE®), and Behavioral or Cognitive Behavioral Therapy (CBT). If you have a client who has PTSD, and is not receiving therapy, having some therapy referrals on hand to give them is very beneficial.  

Having a Trauma-Informed Massage practice

Working with clients who have PTSD can be very rewarding, and challenging. It’s important to educate yourself as a massage therapist about some of the do’s and don’ts when providing care for these folks. I highly recommend getting some continuing education in this field. Here is a short list to help you begin: 

Do’s: 

• Do your own therapy around traumas you might have experienced

• Regulate your own nervous system—stay calm and grounded

• Explain everything that will happen before, during and after a session

• Use permission language: “Would you like me to..., Do I have your permission to…”

• Set clear and professional expectations and boundaries around timing, pricing, and the nature of the relationship

• Focus on building rapport and relationship through clear communication and listening skills

• Address what is working and appreciate your client for being there

• If it feels appropriate, get written permission to consult with your client’s therapist to give you a better understanding of how you can best support your client

Don'ts:

• Don’t surprise your client by cancelling, changing time, location, or treatment plan

• Don’t take it personally.  If your client experiences strong emotions or feelings, begins to blame, or misconstrue situations, listen compassionately and address their concerns.

• Don’t give advice. 

• Don’t work outside your scope of practice as a massage therapist.

• Don’t try to “fix” your client

• Don’t avoid.  If your client says or does something out of the norm, don’t ignore it.  Address any concerns you have head on. 

Like Jan, many of my clients who have been diagnosed with PTSD find a lot of relief in developing a new relationship with their bodies through touch. As massage therapists, we can have a significant impact on the nervous system to help these folks live a very productive and fulfilling life free from the debilitating symptoms associated with trauma. We can play such a fundamental role in that healing process with  some awareness, and a lot of compassion.