Originally published in Massage Bodywork magazine, February/March 2006. Copyright 2006. Associated Bodywork and Massage Professionals. All rights reserved.
With the growing evidence that massage and other forms of bodywork and energy therapies are beneficial complements to traditional healthcare, we've seen an exponential increase of integrative programs within conventional medical services. From doctor's offices to major hospitals, complementary and alternative medicine (CAM) is being used to attenuate symptoms in a variety of conditions, from cancer to everyday maladies such as headaches.
An interesting aspect of the research conducted in these areas is the relationship between bodywork and reduction of the mental health issues of depression and anxiety. And yet, CAM research has received little attention within the field of psychotherapy and mental health practice. In light of the body-mind connection and scientific validation of integrative approaches, a group of Maine researchers thought it a good fit to incorporate CAM in the treatment of mental health clients.
In 2000, Counseling Services, Inc., a community mental health center in Saco, Maine, established the Complementary Therapies Program, offering sessions of massage, energy healing, and acupuncture concurrently with psychotherapy for low-income clients who otherwise wouldn't have access to CAM. The impetus came from social worker Roberta Wentworth who was frustrated with the lack of progress in her clients, a majority of whom had experienced severe trauma. Three decades into her career, she says, "I saw how difficult it was to do this work because people's problems seemed to be beyond the cognitive work and medication. I didn't want to leave the work, but I needed a quick fix." So she went to massage school.
In the process of Wentworth's massage training, she witnessed the significant emotional releases her fellow classmates were experiencing with touch, one student even disclosing for the first time having been raped. While continuing her psychotherapy career, Wentworth also established a part-time practice in massage and healing touch. Seeing first-hand how much these complementary modalities contributed to the healing of her trauma clients, she approached the mental health center's executive director, Sherry Sabo, Ph.D., with the idea of providing complementary therapies within the agency.
Wentworth estimates more than 70 percent of people coming to the center were disclosing trauma; the staff found that most of these cases were progressing at a very slow rate. Added to this was a keen interest, on the part of some clients, in seeking CAM therapies, as well as the interest of staff members in pursuing training in these modalities. With this confluence of factors, Sabo was receptive to the idea and a plan was initiated.
Starting with just $1,500 in funding -- a combination of donor contributions and diverted funds from the center's annual budget -- the team initially anticipated serving only 10 people. Wentworth also found practitioners who agreed to reduce rates for their services. Early positive results brought more support through small local grants and by the end of the three-year study, the program had served 25 people. The team's preliminary results of the pilot group were only recently published (Collinge et al., 2005), but over the interim years, study participation has grown with more than 400 referrals and 300 subjects enrolled. According to Wentworth, this may be the only community mental health center in the country providing such a program, completely free of cost to low-income clients.
William Collinge, Ph.D., widely-published author and expert in the field of integrative healthcare, served as research consultant on the project. "For a publically-funded center to do this is really innovative," he says. In general, community mental health center clients are on Medicaid or state funding and don't have the financial resources to pay private massage practitioners. From another angle, he says, "The main thing is that integrative medicine is becoming widely understood, appreciated, and accepted with medical illness, but it's much newer with psychiatry." It lags behind the strides made in medicine, such as using massage or energy healing in treatment for cancer and heart disease. And some mental health practitioners might see it as controversial, particularly when touch is involved. The use of touch with someone with mental illness generates concern for several reasons, including "the possibility that physical touch could evoke emotional issues or stimulate emotional trauma." But according to Collinge, that's what this project takes head-on.
As an exploratory study, the initial pilot focused on gathering data, through scaled questionnaires and qualitative inquiry, to assess feasibility and benefits of the integration of complementary therapies with mental health practice. Not only did results show a high level of client satisfaction, but there was also feedback from both clients and psychotherapists regarding breakthroughs in resolution of trauma-related issues. "As they continue with psychotherapy," Collinge says, "they process what comes up in massage." He describes it as "getting them on a fast track." The Pilot Study
Referrals to the pilot program came directly from psychotherapy clinicians within the mental health center, with the requisite that potential participants be currently under treatment. As it turned out, treatment history with this particular agency for the final sample of 25 subjects ranged from one to 20 years, with a mean of 7.4 years. This coupled with a history of trauma for the entire group, with 10 subjects reporting sexual abuse. The 20 women and five men ranged in age from 26 to 60 years, and diagnoses included posttraumatic stress disorder (10), major depression (9), anxiety disorder (3), and dual diagnosis (3).
As the study progressed, the team had an opportunity to evaluate and categorize the participants' comments regarding their motivation to receive the complementary offerings. Psycho-emotional reasons included a desire for relaxation and peace, less depression and anxiety, and a reconnection with feelings, whether to express sadness, enjoyment, or positive sense of self. The somatic-related reasons had to do with reconnecting with a physical sense of the body, such as liking the body, experiencing non-hurtful touch, and regaining body control. While one type of motivation or the other was expressed predominately by some participants and appeared to be present in equal frequency overall, many participants' responses indicated simultaneous reasons covering both categories. "In our experience," authors say, "clients often show a clear intuitive understanding that psyche and soma are intertwined, and that intervention with the massage or energy therapies available can help them to overcome emotional issues associated with physical trauma or feelings about their bodies."
Assignment to treatment protocol was determined by a combination of client choice and willingness to receive a particular modality, a recommendation from both the psychotherapist and program director (Wentworth) based on clinical judgment, and the availability of practitioners for that modality. The majority of subjects (19) received Swedish massage with the remainder assigned to acupuncture (3), reiki (2), and healing touch (1). Despite the program's offering for up to 10 sessions of massage or energy therapy and five for acupuncture, the mean number of sessions completed by the group was five (range 2 to 10). Nonetheless, satisfaction ranked high on a rating scale in participants' feedback to open-ended questions about their experience. Response to the question, "How helpful was complementary therapy?" showed a mean rating of 8.6 on a 10-point Likert scale, with a range of 2 to 10, and was significantly correlated with the number of sessions completed.
Once the pilot was underway, the team notes, "... it became clear that for many clients this was the first time in years that they had allowed a significant level of intimate contact and vulnerability with another person." Based on this observation, researchers added another set of Likert-scaled questions to the survey, covering four basic concerns: "How safe did you feel during the session? How much sensation did you have of your physical self? How comfortable were you with telling your therapist where to work and where not to work on your body? How ashamed of your body did you feel?" From a sample of 10 participants, results showed increases in sense of interpersonal safety and comfort in setting interpersonal boundaries, increased sense of physical self as opposed to dissociation, and a decrease in sense of bodily shame.
An important aspect of this study is the interdisciplinary collaboration involved in the process. The client's psychotherapist was included in the first meeting between client and complementary practitioner, both to openly discuss the client's needs and to provide a sense of safety. Additionally, the two professionals maintained communication with each other between sessions to track progress and direction. For those participants who were anxious about starting treatment, the psychotherapist stayed with them during the first session and any subsequent sessions as needed.5
"It's a matter of people who are severely traumatized by touch in the past," Collinge says. "If they have a therapist they have developed a relationship with, they feel safe with the therapist." In addition to providing a sense of protection, the therapist can also help clients communicate their boundaries. "If they have been violated in the past in a traumatic way, they may be unable to assert boundaries." Having the psychotherapist in the treatment room "helps facilitate communication and helps the client stay true to their own healthy boundaries."
Although only an exploratory project, much was accomplished with this study. First, it established the feasibility of implementing such a program. The team notes the benefits for both mental health clinicians and complementary practitioners to collaborate and learn from each other's disciplinary approach and intervention with the impact of trauma. "Both groups have become more expansive in their thinking and their understanding of what kinds of interventions can benefit persons with mental health concerns," the authors write.6
For the participants, it provided a favorable experience with healthy touch. As reflected by responses on the questionnaire and by anecdotal comment, the complementary modalities not only gave participants an opportunity to receive safe, noninvasive touch, but also boosted confidence in their sense of self and ownership of their body. "In the first group of 25 people, we had no one who reacted negatively or refused or dropped out," Wentworth says. "Every one of them has progressed at least to a bathing suit and allowing their whole body to be worked on." Only two of the total 300 now enrolled have discontinued massage, with reasons given as discomfort or flashbacks.
Wentworth interviewed all of the 25 initial participants individually before CAM treatment, receiving comments such as "I had some wonderful work talking, but I didn't like myself," and "I didn't feel right." In contrast to these "before" perceptions are the self-rated scores on the questionnaire expressing increased sense of safety, comfort, and sensation of physical self, and the decrease in body shame following complementary treatment.
It would appear the complementary modalities, administered alongside continuing psychotherapy, provided that missing somatic link for body-mind integration in the healing process. "The study had long-term chronic patients who had been using mental health services for several years, some for decades," Collinge says. "It tells us the conventional community mental health system has failed. That's all the more reason to try this."
The team not only tried it, but they made it work. As enrollment and data collection continues, Wentworth has her eye on the future, pursuing a major grant to establish a solid, controlled trail. In the meantime, the program serves as a role model for other community mental health centers, providing "safe" therapeutic touch to low-income trauma clients. References
1 Collinge, William, Wentworth, Roberta, and Sabo, Sherry. Integrating complementary
therapies into community mental health practice: an exploration. Journal of Alternative and Complementary Medicine, 2005 June; 11(3):573.
2 Ibid., p. 572.
3 Ibid., p. 572-573.
4 Ibid. p. 573.
5 Ibid., p. 572.
6 Ibid., p. 573.