by Kathrin Stauffer
Article published in Biodynamic Massage, the Journal of the Association of Holistic Biodynamic Massage Therapists Vol. 4 Issue 1, Winter 2000/2001
I have been asked to write something about how massage is useful with clients who are in states of shock, or who are suffering from the aftermath of a shock including post-traumatic stress. I have attempted to draw together the trauma training that I’ve had with Babette Rothschild and the sort of thinking that comes from biodynamic massage, because it seems to me that the two are very compatible
I will start by defining what I mean when I use the word trauma, and then move on to revise briefly what happens in the autonomic nervous system (ANS) in shock and trauma. This will lead me on to reflect that biodynamic massage, being as it is closely concerned with rebalancing the ANS, can be an ideal tool to address the difficulties that people experience as a result of a shock or trauma. I will talk about what I would choose to do on a physical level first, and then briefly address some of the more psychological issues and how I see massage fitting in there.
- Trauma and post-traumatic stress: definitions
The DSM-IV defines trauma as ‘a response to three types of events: (1) incidents that are, or are perceived as, threatening to one’s life or bodily integrity; (2) being a witness to acts of violence to others; or (3) hearing of violence to or the unexpected or violent death of close associates’.
I will follow Babette Rothschild and use the term shock more or less interchangeably with trauma, with an awareness that shock colloquially tends to refer to an experience that is more short-lived and less severe in its effects.
In a more phenomenological language such as we would use in massage, we can also define shock as a state where both the sympathetic and the parasympathetic branches of the autonomic nervous system (ANS) are highly active and fail to downregulate each other. Psychologically this amounts to the person being overwhelmed (usually with fear). The condition called posttraumatic stress is essentially a continuation of this state where both branches of the ANS are up and can’t come down on their own (more on this below).
- The role of the Autonomic Nervous System in shock and trauma
We have all been taught that the autonomic nervous system, the part of the motor system that is not or only partly under voluntary control, can be divided roughly into two branches, the sympathetic and the parasympathetic branch. The two act, again roughly, as a switchback. This means that they mutually suppress each other, so that generally one of them is much more active than the other. Moreover the system is organised so that when one of them gets overactive, there comes a point where that very overactivity triggers the other branch which then becomes more active and thereby dampens the activity of the first branch.
Let me illustrate this: say I get startled by the telephone ringing. Like all startles, this triggers a certain amount of activity in my sympathetic nervous system, and I get anxious. If I pick up the phone and there is a friend at the other end, this will quickly induce a parasympathetic response from my ANS, and it will make the sympathetic arousal disappear and resolve the startle because I feel happy about talking to my friend. But say it is the middle of the night, and I am a bit dubious about picking up the phone, and prefer to sit there and hope that the ringing will stop if I ignore it. With each ringing, I will get more anxious, and my degree of sympathetic arousal will continue to go up. There will come a point when this very sympathetic charge will trigger an activation of my parasympathetic nervous system. This means that after the twentieth ring or so I will become able to ignore the ringing and pipe down. Or I might get calm enough to revise my original decision and pick the phone up anyway.
Now suppose that I pick up the phone and it is a nuisance caller who threatens me over the phone. In that case, my sympathetic arousal is going to get worse despite all the efforts of my parasympathetic nervous system to tone it down. Of course, the parasympathetic branch will continue to try and try harder, so I will end up with both branches of my ANS way up. If this goes on beyond a certain point, I will become totally overwhelmed with panic. This would make it a traumatic experience, according to the definition of trauma as a state where both branches of the ANS are highly activated to a point where they no longer downregulate each other.
- How to recognise trauma and posttraumatic stress
I think it is good to be aware that a client with a trauma history may or may not be overwhelmed when they come for a massage. When they are overwhelmed, it is sometimes possible to pick up bodily signs of sympathetic hyperarousal such as extreme pallor, cold sweat, racing heartbeat; but sometimes they can be ‘masked’ by the parasympathetic hyperarousal, which may result in a sort of frozen, paralysed state called tonic immobility. I also think that most of us would recognise the peristaltic noises that often go with being overwhelmed: very watery, gushing, or ‘fizzy’ sounds. Alternatively, in a state of deep startle, there may be no peristalsis at all.
If the client is not acutely overwhelmed when they come to the session, we may not be able to pick up a trauma history purely by observing physical signs. We can often deduce the presence of trauma from the client’s history: any major surgery, life-threatening illness, recent bereavement, recent accident, assault, or abuse is likely to have left a certain amount of post-traumatic stress. More clinical symptoms could be extreme jumpiness and a tendency to startle very easily, panics, phobias, and flashbacks; but also things like depression or chronic pain (and indeed other ‘psychosomatic’ conditions) can beindicators of trauma.
- How can we work with trauma?
It is clear that a state of autonomic overload, if it persists, will profoundly affect the everyday functioning of a person, because their normal self-regulation is out of action. In biodynamic terms, their vasomotoric cycle has ceased to function; but it hasn’t just got stuck in a particular phase. It is no longer any kind of cycle because both upgoing and downgoing energies are maximal. This is what we are faced with when a client presents themselves with a trauma or a recent shock in their history. The treatment is, to a biodynamic massage therapist, rather obvious: reduce the sympathetic hyperarousal, and get the system back to a point where the switchback mechanism can operate normally, so that the person can go through vasomotoric cycles again.
I’d like to use a very basic piece of teaching that we’ve all had: think in terms of overbound and underbound. An overbound person needs to be more in touch with their inner life. We generally do this by using the more provocative techniques that will deepen a charge, such as provocative deep draining, encouraging the client to focus on a particular area of their body, using a touch that invites emotional deepening. An underbound person, on the other hand, is already too much at the mercy of their inner life, and needs to be calmed and have their boundaries strengthened and their emotions more contained. We will do this by using techniques that serve more to dilute a charge and strengthen the ego, such as packing, emptying, resistance work, using a more matter-of-fact touch. We can think of an acutely traumatised person as the extreme end of this scale, an extremely underbound person. What I find useful about this model is that it allows me to think in terms of accelerating or slowing down a process, and to be clear at any point what my intention is right now. Thus a client may need some charge in order to get near the traumatic experience they’ve suffered in the past, but once they start exhibiting signs of anxiety, I will have to switch to slowing down the process and helping them to contain the overwhelming feelings. Biodynamic massage is extremely useful for this type of work, consisting as it does of a wide repertoire of techniques that can be used to deepen or dilute charge in a very finely graded way.
When presented with a severely unbalanced ANS, I think most of us would intuitively do something useful to try and bring it back into kilter. A lot of techniques help, emptying being perhaps the most straightforward (and one of my personal favourites). Hearing the sort of fizzy peristalsis I referred to above, I would work to deepen the sounds, to help them become a bit more ‘earthy’. This I believe is what corresponds to decreasing the sympathetic charge and allowing the parasympathetic nervous system to re-establish normal balance. In other words, if we think in terms of the vasomotoric cycle with both sides maximally up, the way to balance is to work towards downgoing energy. This usually means to intend soothing and calming, and to avoid anything that is provocative.
A slightly special case is work on muscle. I’ve been taught that muscle work is generally provocative, and could therefore conclude that I shouldn’t do deep draining on a traumatised client; however it is also important to recognise that the voluntary musculature is one of our most efficient resources for containing a strong dynamic updrift. I would therefore usually attempt to work on muscle a bit, just to give the client a sense of their own strength. This could be a mild deep draining with careful distribution (certainly not ‘hard’, provocative deep draining without distributing and containing the energy!), or it could be encouraging the client to push against some resistance that I am providing. Exercises like that are a very good way of keeping the client in the here and now instead of letting them drop into some remembered terror. I believe that the important point here is the intention that I am holding: to strengthen the client’s motor ego and their defences, to bring their muscles to life, bring the client’s awareness to the fact that they have strength in their body. Stretches can also be brilliant for this.
With clients who feel very frightened and unsafe, I have found that it tends to be helpful to do things like packing and holding, and generally to work fairly slowly. This gives the client time to tune into feeling in their body and increases their sense of safety.
Sometimes we can have a client who is in such a profound state of shock that there is no peristalsis at all. I have come across this mostly in clients who have had a shock very recently – hours or just a day or two before the session. In this case the – again obvious – thing that they need is for the peristalsis to open. Gerda Boyesen recommends what she calls the shock position for these instances: lay the client on their left side, then just hold the 7th cervical vertebra (the ‘hump’ at the base of their neck) and the belly. After a while, if there is still no peristalsis, start to very gently move the tissues at the back of the neck slightly until you hear the peristalsis open up.
One of the characteristics of traumas like assault and abuse is a violation of the victim’s boundaries. Here we could consider packing – perhaps the aura if the person finds it difficult to be touched in the first place. We may have to underpin verbally that the threat is over and they are now safe, especially if they threaten to become overwhelmed again. It is also good to know that lying down can increase someone’s sense of being overwhelmed, especially lying on the back; we could consider working with the client lying on their side, or sitting up. If they keep their clothes on, they will have an extra boundary and thus extra safety.
In the worst case, we may be faced with someone who becomes hyperaroused just by lying down, or by being touched. It is important in these cases to remember that re-establishing safety and control is a key step in helping a person cope with posttraumatic stress and has to come first, so if someone cannot tolerate a massage, it will be more helpful and empowering for them not to be massaged. Always remember that the organism is not really in any state to process anything usefully when it is overwhelmed with fear, so bringing the sympathetic charge down is the first priority. What can be useful is to check if the client knows that they are overwhelmed and that they are suffering from shock or post-traumatic stress. Just naming that can help to contain the feelings.
- Psychological issues with traumatised clients
Sometimes the very presence of a biodynamic massage therapist can resolve the remnants of trauma in a client on a deep vegetative level; I do have a strong belief that we tend to hold that kind of deeply healing space at our best, but also recognise that it is by no means possible to expect this as the norm. In cases of a shock that has happened only a few days ago, but that the client is already coming out of, I have found that it is often very nice and easy to just empty the remains of the startle out of the tissues at all levels.
Psychological features common to all traumatic experiences are loss of control, overwhelming fear, boundary invasion. The first priority is always to re-establish safety. Massage can be extremely helpful for clients (not just traumatised ones) to discover that their body is a safe place to be. Resistance work, where the client is actively doing something, helps to get back a sense that they are in control of what’s happening. I would also be extra careful to keep checking out with the client what’s OK and what isn’t.
Unresolved trauma binds (or ‘hijacks’) tremendous amounts of life energy. Because the organism has had an experience that it cannot assimilate, it will bend all its efforts towards trying to do this. On a psychological level, this can look as though the person is almost obsessed with their traumatic experience and unable to think of themselves in any other terms. It can also lead to great difficulties letting go of that experience: because so much of someone’s life energy is bound up in the trauma, everything else just doesn’t quite feel alive. It can be an important part of the therapist’s attitude to be aware that the process of resolving a traumatic experience is a slow and gradual one (unlike the original experience of trauma which is likely to have been very sudden and all-at-once!) and has to be carefully paced according to what the client can cope with without becoming overwhelmed again.
A life-threatening experience can be very isolating. I have treated one cancer patient who verbalised this as a huge chasm that separated her from everybody else: others just didn’t have a clue what it had been like, and it felt almost impossible to communicate across this chasm. Massage played a big role in bridging the chasm, in that it provided her with good contact and a sense of being more connected to humanity. This client also needed to talk a lot with me. Her body was not a very safe place to be except in some places which I was able to help her establish, but I also felt that she used my hands, my body, as a safe place.
Studies have shown that one of the main factors influencing how severely someone is going to be affected by a traumatic experience seems to be the quality of their social network, their sense of being connected to other people. By teaching our clients what good contact is like, we thus not only help them cope with past trauma but also work to build an important resource for their future!
I think those massage therapists who have worked at IDT, and all those who have worked with people who have survived a major shock or trauma, will agree with me that massage is an invaluable resource to give our clients a sense of safety, containment, and being valued and loved. Most of all, I am always aware that one of the greatest helpers that we have to counteract fear is pleasure, and experiencing the pleasure of a massage is a resource that can go a long way to help combat the spectres of past and present fears.
I would like to thank Gill Westland and John Waterston for their helpful comments on the manuscript.
 Babette Rothschild: Defining Trauma and Shock in Body-Psychotherapy. Energy and Character 26, 61-65 (1995)
 Gerda Boyesen, Ueber den Körper die Seele heilen. Kösel Verlag Munich 1987, p. 164