Emotionality

Emotional Release: A Grey Area in Massage

1.   How do we as therapists actually handle emotional releasing?
2.  What are the benefits and problems for the therapist and the client in doing so?
3.   What ethical questions do we need to consider?
4.   Is it appropriate for massage therapists to facilitate release?
5.   If so, what are our guidelines or parameters in doing so?

I have found that as manual soft-tissue specialists we have a great deal of skill in the clinical and technical aspects of massage therapy as befits are training, but have been woefully trained in dealing with the fundamentals of emotional discharge as Micheal Shea describes, “the often colourful displays of feeling, temperament and personality”. We find ourselves on a daily basis in the delivery of our ‘duty of care, the need to have skills that tests our empathy and compassion, and still reside within our scope of practice.

Unless you have a counselling background or are currently training in an advanced course of somatic psychotherapy or transpersonal psychology, or concurrently taking basic counselling classes, the parameters for dealing with a clients emotional upset can be daunting.

I have searched high and low in massage literature for help in navigating what I have always considered a grey area in our professional training.  Granted that many more contemporary massage training programs are recognizing the absolute need to equip students with these essential interpersonal skills, there seems to my mind still to be a huge gap in this training and scarce information in the general domain concerning it.

Clearly much of the skills needed to handle an emotional upset are commonsense like, compassion and empathy, good listening skills and a calm presence can be all that is needed to calm an emotional storm. But their also needs to a context about why the storm is appearing.  And yet we are not meant to be counselling clients, or are we?

Although it is not within the scope of this discussion to cover the many diverse schools of thought that constitute areas that contribute to how emotions constellate in the first place.  I will however attempt to allude to concepts that underpin emotional releasing.

Psychology has within it many substrata that reflect divergent views about how to approach conditions that affect the integrity of the mind and body.  Be it cognitive therapy or body-centred experiential psychotherapy, the concept and idea that the body and mind are one is widely held.  Body Mind has become a catch phrase word to describe the interconnectedness and inter-relatedness of the mind and body.

Stanley Keleman wrote a seminal work in the mid 1980’s that looked at Emotional Anatomy as a form of body mapping. He was an instrumental contributor in the 1960’s somatic psychology movement that evolved out of collaborative efforts at Esalen in Northern California.

Keleman’s underlying premise is their “exists a one to one correspondence between specific locales of pain and specific emotional states or purported physiological malfunctions. ´1

Keleman was fond of a Freudian quote, “that anatomy is destiny”.  “That anatomical process is a deep and powerful wisdom giving rise to internal feeling images. Outer body and inner organ shapes speak to us of cellular motility, as the organization and movement of the psyche and soul.  The feelings these shapes generate are the ground floor of brain programs, (of) consciousness, the way we think and feel.  Feeling is the glue that hold us together, yet they are based on anatomy.” 2.

There is another widely held belief system that the attitudinal and habitual sensory habits along with long held emotional states of consciousness form and determine body shape and tension. And established modalities such as Alexander Technique, Feldenkrais or Thomas Hanna’s Somatics long realized an important connection between sensory habits, posture and emotionality.

Micheal Shea an advanced certified rolfer, craniosacral therapist and Ph.D. in Somatic Psychology wrote a series of essays that constituted his myofascial release textbook.  One such article is on Working with Shock Psychology. Shea’s premise is often stated throughout his literature of how important it is as ‘body workers’ to recognize the huge contribution the autonomic nervous system plays in regulating the organism. Shea states, ‘what is often missing is observing the non-mechanical components of structure”. The way you in which you look at the non mechanical components of structure is by looking at the arousal states in the autonomic nervous system, and in particular how the sympathetic and parasympathetic nervous system discharge in rhythm with each other.  You look at how this ANS goes into flux and how it has balanced itself sympathetic dominance and parasympathetic depression.  You seek to see how the body can handle this charge or arousal.”

Shea believes that instead of observing the ANS we are always tracking the nervous system in any hands-on work that we do. You could facilitate the process through which the ANS contributes to self-healing and self-regulation of the organism.  How you do this is how you pace your work in terms of the level of input to your client.  Pacing means slowing down and taking a break every few minutes.  You cannot keep up constant input to the organism because you will overload the ANS. Most clients arrive already overloaded in their autonomic nervous system.  You can drive trauma deeper-first into the cardiovascular, and then the digestive system.  You may irritate pathology.  Shea believes you should allow two to three cycles of respiration between each application of a technique. Respiration is the glue between physical and emotional responsiveness of the organism. In this way of pacing we avoid re-traumatizing the patient and dissociating them. Shea conviction based on thirty years of experience is that trauma does not come out of the body.  You do not get rid of trauma. Shea believes trauma gets integrated. It gets integrated, organized and renegotiated to a higher or lower level of functioning depending on a number of factors. These factors are usually the environment the client comes from, the constellated aggregate of all the social and emotional experiences a person brings to the table. 3.

“We have a shunting mechanism in our autonomics. The level of input you give to the system reaches a given capacity and then the shunting moves into other systems of the body. We have a hierarchy within our systems, be them myofascial or any other system within the body can handle only so much energy.  Each system takes so much input and then places it somewhere else.  Using from the neuromuscular to the cardiovascular to the alimentary.  This is where stress goes.  Stress response goes into the visceral digestive system.  Then it shunts into the hypothalamus and into endocrine with elevated cortisol or adrenal. There is also a chronic disturbance of thermoregulatory and homeostatic mechanisms.

Emotional release becomes a complex phenomenon.

Although there is scant little information written by massage therapists about emotional releasing I found an article on Emotional Release During Bodywork Sessions by Micheal Santengelo, PhD, in the AMTA USA Massage Therapy Journal of Spring 1995.

His is the prevalent view I was taught when I went through my massage education in the United States in the mid 1980”s.

Santengelo posed a question to open his article, “bartenders, hair dressers and body workers.  What do those groups have in common?  Their clients share unsolicited details of their personal lives with them.  And of the three, body workers engage their clients on a most intimate level, the level of the body.  This contact can lead to revelations and often-traumatic secrets and events.  The responsibility of the client is that this material must be handled in such a way that does not compound the patient’s pain and that we offer a safe environment.

Santengelo contends that the soft-tissue specialist either tries to hard or enters areas for which he or she is not properly trained and prepared, can do more harm than good.

Clearly the concept of “cellular memory” and body memory are topics that engender discussion. We all hold to some degree an assumption that the body stores emotional conflict.  Often the patient is unaware of the connection between a bodily complaint and its emotional component.  So it comes as no surprise when emotional content comes unbidden when we are doing “routine” bodywork.  When this happens, our response can become very important.

There can be appropriate or inappropriate response to this event.  The first inappropriate response is any that carries anxiety or an overly reassuring tone.  Why?

Any discomfort you might feel about what is going on needs to be yours alone. When a patient is in a vulnerable position such as when emotional release is occurring, an accepting and non-judgemental atmosphere is essential.  The patients can construe any anxiety or discomfort you have as disapproval of their own experience.  It can also be seen as a lack of confidence or control.  And believe me when some is in an emotional storm the practitioner needs to hold the space.

The other inappropriate response, is an overly assured “It’s OK”.  The “it’s ok” response can be construed as dismissive as if you are not taking their experience seriously.  Any of these responses can lead the patient to repress the event or experience, feel guilty, or feel the need to care take the practitioner.

Another inappropriate response that may be just as damaging to the patient and is a more subtle and seductive response is the urge to do psychotherapy with the patient.  The urge is to explore the trauma or conflict, to help resolve the issues.  While this is often motivated by good intentions, it is fraught with problems.

For one you might need to ask the following questions.  Am I qualified to do this?  Do I want this responsibility?  Do I want the legal liability?  Whose needs am I serving here?  Shouldn’t we try to help when are help is needed?  Is it in the patient’s best interest for me to take this on?

Psychotherapy is more than just talking back and fort, offering solutions or making psychological interpretations.  It carries heavy responsibility and should not be taken lightly.  Those who have become mental health professionals have trod a long and hard road of training and experience.  Attempting to enter another’s psychological landscape without proper preparation invites trouble both for the manual therapist and the patient.

Nevertheless emotional release in the bodywork session does call for some response.  Santengelo coined his response a “psychological first aid”.

He quotes the AMA, American Medical Association definition of first aid as, “the immediate basic care given to someone who is injured or ill until professional help is available.”  Psychological first aid is exactly the same only in an emotional sense.  The aim is to provide immediate intervention to ease the crisis and get the individual to a qualified professional as soon as possible or reasonable.

Santengelo says, “Many emotional releases will require referral, while some will not.”  He believes any significant life event, such as rape child sexual or physical abuse, or severe guilt, grief, anxiety or depression, should be processed by the patient with a professional who specializes in working with peoples emotional problems.

Any emotional release should be met with caring, support and empathy.  It is important to let the situation run its course within a structure that the massage therapist provides.  He uses statements that are simply, ‘It looks or sounds like your crying.” This gives the patient an opportunity to respond or not.

Communication of caring and empathy through the tone of voice and touch establishes a safe place in which the patient can have the experience.  Do not force verbal interaction. Leave it up to the patient the choice whether to verbalize it or not.

When emotions surface and a client chooses to talk about or process them, be reflective, not interpretive.  Reflection involves extracting emotional content of a person’s statement and phrasing back a response.

Therapist: You sound like your crying

Patient: When you worked my lower back, my mother’s death flashed through my mind.  But that happened 17 years ago.
T: That must have been an upsetting time.
P: It happen so suddenly
T: You were taken by surprise
P: One day she was there, and the next day she was gone…. (Sobs)
T: There seems to be some grief still there.
P: Yes.  (Cries softly and gradually become silent.)

At a time like this resist the urge to pull more from a person.  We do not try to interpret the association between the mother and the lower back, nor is the timing of 17 years queried.

These are simple non-judgmental response.  Straightforward interactions like these can help the patient navigate through the experience.

Always give careful thought to whose needs are being served in the situation of emotional release.  Do not fall prey to the need to handle everything yourself, or to foster dependency in your patient.  No one can be expected to be competent in everything.

Usually calmness and support will be sufficient first aid when confronted with a patient emotional discharge.  However, marked disturbances should be addressed with a suggestion that the patient seek help from a mental health professional.

Santengelo emphatically stated that serious psychological problems are true ailments in themselves, as serious as physical ailments.  Ethical massage practitioners wouldn’t attempt to treat physical ills that they were not trained to treat, and so it must be for emotional problems.  If you have not been specifically trained and supervised in psychotherapy, attempting to resolve a patients problems is a betrayal of trust placed in you by those you work with, and can open you up to legal liability, among other problems.  Santengelo says these are very strong words and meant to be so.

He finishes with points for stimulating discussion:

• Refer whenever you encounter anything out of the ordinary. Don’t assume you can handle every situation alone
• Be reflective when emotions surface.  Spare interpretations and psychobabble
• Take responsibility regarding your patient emotional health seriously.
• You can show that you are caring and concerned by allowing honest ventilation of feelings, and by being present with the patient in their time of need.  It is a mistake to try to solve a patient problem for them.Remain calm when emotional material arises.  Don’t overstep your expertise, but don’t under rate either.  We are important people to our patients, they trust with their bodies as well as their emotions and spirits. This builds a position of trust from which to work from, and their state of mind will be influenced by our reactions to their emotional pain.  If you feel you are facing a true emotional emergency, let the authorities know immediately.
• Don’t diagnose unless you are qualified to do so.
• Be aware of patterns that certain patients display. Especially those who have cathartic experiences in most, but not all session are either practicing they’re acting talents or are seriously disturbed psychologically, or both.  Massage may be contra-indicated until the patient has some context of realization about those patterns.
• Obviously we get a certain amount of our needs met by our practice.  But beware that you wind up serving less noble needs in yourself such as the need to foster dependency or self-aggrandizement at the expense of your patient.  This betrays their trust, even if you are unaware of it.
• Seek consultations and liaisons with other mental health professionals.  You may need support in dealing with problem patients or about getting advice when to refer a patient to another professional.
• Know the differences between what the different mental health profession do and how to refer accordingly.

Get knowledgeable.  Take an introductory course in clinical psychology or basic counselling skills if you’re interested.  This gives you more skills and confidence in how to handle the emotional storms. 4.

I would like to take the rest of time to review an article you have in your hands by the founder of the Hakomi method, Ron Kurtz who has authored an important book called Body-Centred Psychotherapy.

You will see a similarity of information about how to handle emotional release when it spontaneously occurs in a session.  Interestingly enough, Santengelo did not use Kurtz as a reference.

Kurtz believes that whenever we touch a body, as does Micheal Shea, we are reorganizing structure and self-image of the patient.  Kurtz postulates that body and image are intimately connected and both are shaped by experience, and in the process of working with the body, especially deeper tissue work, you will evoke emotionally painful material.  There is no way to avoid it.

Kurtz follows four principles: first acknowledge the emotional issue.  Often a person’s self image is fixated in some way because emotions involved were not acknowledged.  They are buried…if you also do not acknowledge a person’s feelings, if you go on without noticing, without commenting, the silence can mean that they are unimportant, no good or unacceptable.  What happens if feelings are not acknowledged it leaves the patient with the choices of either burying the feelings or attempting to deal with them on their own.  Kurtz believes when people bury feelings, either the body structure drifts back to the position it was before you worked on them or the person compensates in some other way, psychologically or in behaviour.

So often you can make a statement that doesn’t analyse or interpret:  “Your sad”, “you sound like your crying”.  Your goal is to accept and notice what is going on.  Noticing and accepting makes people feel safe.  With safety and acknowledgement, the process can continue.  Kurtz states, “feeling emerge in small ways.  A little wetness around the eyes, a little redness around the nose, a little catches in the voice. These are important indicators that continue to allow acceptance.

Kurtz’s second principle he believes the most important, “Feelings aren’t problems to be solved.” Feelings are just simply to be understood.  Kurtz believes if you try to solve problems, you are going off into the wrong direction, in fact, the same direction in which defence mechanisms tend. That is, the feeling is defended against because it is considered to be a problem and defence is the solution.  Essentially feelings are not accepted, they are handled.  If you get into problem solving, you get caught up in an active role, and lose the capacity to see and hear clearly. Problem solving can block intuitive kind of listening that would allow you to understand the person’s feelings. If you understand, then you can help the patient to understand.  You have to drop any problem-oriented way of thinking when you start working with people’s feelings. Help people process their emotions in such a way that they come to an understanding that is, they come to recognize some meaning in experience.

Kurtz’s third principle is for processing feelings is support spontaneous behaviour.  As Kurtz’s sees it, that’s all you have to do.  You’re just watching.  You notice spontaneous reactions to feelings and you support them.  Kurtz gives an example in his handout.

If someone starts crying on your table, they will either want to role away from you, so the head will start to turn away or they’ll start to manage the flow of feeling by tightening certain muscles.  The shoulders will come forward and up, the diaphragm and abdomen will tighten.  The person may try to close their knees.  All you have to do is to take over and help them do what their doing.  And since your only one person and can only do a few functions, you might for instance, put some towels or a pillow under their shoulders.  Take the effort out of any tightening their getting into, even if it’s defensive.  We’re not working against the defence system, were offering the kind of support they seem to spontaneously need.

The moment a person relaxes the muscles involved in managing the emotional expression, the feelings get more intense.  Kurtz believes that it is in this deeper experience that the meaning of the process can be found.  An example of how the head slumps forward with sadness, this puts the weight of the head on the back muscles and tends to restrict breathing in the upper chest.  As soon as you cradle the head and take it’s weight, the breathing deepens. With this relaxation more feeling comes into consciousness and the sadness is more clearly felt.  All this happens quite naturally.

The fourth and final principle that Kurtz examines is: go for meaning.  It’s not about attempting to get a bucket of tears out the person; it is a matter of how people organize their experience and how they organize the emotional flow of that experience.  Kurtz’s approach is to help the person stay with it long enough to examine where it comes from and what does it mean to them.  Sometimes, but not always, the experience involved something that happen a long time ago, even into childhood, and that something was beyond the understanding of the individual.  It is buried, the adult who could understand, never gets to.  If you never get a glimpse of it, you don’t discover in many ways, it is different from what you believed it was.  The emotional process may involve experiences that happened over and over again to a child, these, in turn, might have led the child to mobilize a particular self-image and to use the muscle system to express and maintain that self-image.  The way to meaning is, first to deep experience and, second, a questioning of that experience.  “What are you saying with your body when you tighten your chest and feel sad?”  Go for questions that ask a mind body interface.  “What does my hand seem to be saying to you?  Go for meaning of felt touch.  Meaning is in feelings and bodily experience.  Your questions aren’t invitations to speculate.  They direct the search for information about present experience. Even if the client doesn’t answer you, they may still realize something.

This concludes my presentation and I would like to open the floor up to discussion.

References

1.      Body mapping and Somatic Pain, Ray Bishop Ph.D. Advanced Certified Rolfer, and Website).
2.      Emotional Anatomy, Keleman, Stanley 1985, Centre Press, Berkeley, Calif, introduction xii.
3.      Working with Shock Psychology, Myofascial Release Textbook, Michael Shea, self published, Shea Educational Group 1995, pp. 77-78
4.      Emotional Release During Bodywork Sessions, Michael Santengelo, Massage Therapy Journal, Spring 1995 Vol. 34 No. 2 pp 83-91
5.      Dealing With Emotions, Ron Kurtz, lecture delivered to European Rolfing Association, Website www.somatics.de