Originally published in Massage & Bodywork magazine, October/November 2004.
Copyright 2004. Associated Bodywork and Massage Professionals. All rights reserved.
Diagnosed with breast cancer, Mary Ellen Havard of St. Louis, Mo., was facing the known (a regimen of necessary, but painful and debilitating medical treatment), and the unknown (the outcome). "The doctors told me when they outlined my treatment that it was going to be rigorous," she says. "I knew I needed to do something to help myself feel better as much as I could while I was having chemotherapy, surgery, and radiation. Those are very demanding, unpleasant, painful treatments." With determination, she put together her own group of supporters that included not only friends, family, and a medical team, but also a psychologist she refers to as her coach and Trager practitioner Mary Openlander. Havard's request for weekly Trager sessions throughout the cancer treatment was a new venture for Openlander. As with many Trager practitioners, the breast cancer patients she normally treated were postsurgical, with the work focusing on releasing residual tightness and easing shoulder movement.
In addition to her 12 years as a certified Trager practitioner, Openlander is a physical therapist with 26 years of experience. Her first contact with Havard was for physical therapy following an arm fracture in an auto accident. At that time, Openlander introduced her client to Trager work, and their relationship continued with occasional sessions. Embarking on this new journey together, Havard and Openlander agreed to journal their thoughts, challenges, and successes along the way. The journey now completed with Havard cancer-free, they have collaborated on a book, Breast Cancer: One Illness, Two Women, Four Seasons,
based on their experience.
The mantras of Trager work -- What could be lighter? What could be softer? -- were just what Havard needed. The approach uses psychophysical integration to release deeply-held mind-body patterns, enhance relaxation, and bring the client into an awareness of ease within her body. For breast cancer patients in particular, Trager's gentle, noninvasive touch provides a safe space for healing from the trauma of medical invasion and its residual effects and the imbalance brought about by the disease state. Mentastics, a form of self-care for clients, allows them to reinforce and expand changes initiated by bodywork through daily practice of specific body movements.
In considering her plans and expectations for Havard at the outset, Openlander focused on addressing some of the difficulties associated with cancer treatment. "Sleep is often disrupted for all sorts of reasons, as well as the emotional upheaval," she says. "For many years I have come to appreciate how much Trager can help people sleep better."
Another aspect was the arduous treatment regimen. "What I could offer Mary Ellen is a breather, a little respite from all this discomfort -- the lengthy chemotherapy treatment, radiation, and surgery," Openlander says. "Along the same lines, when she had some anxious moments, Trager work would help her build skills to deal with anxiety. Trager brings you into your body and helps you be present at the moment. When using Trager and awareness of the body, what we look for is what's easier, softer, light, or comfortable in the body. That is a very effective approach to calming down or finding your center. It sounds like a mental thing you're doing. Mentastics and the hands-on work helps with that by giving them a movement to pay attention to instead of a still body. I didn't know a lot about her social support system, but I knew I could be reliable and have energy for her and her time."
Havard says the sessions with Openlander did, in fact, give her a reprieve from the impersonal, institutional medical care she was receiving. "Mary was just one person. There was no white coat. I was in a quiet, peaceful room. Her touch helped me to feel calm, reassured, and safe."
Learning to stay in the present was an important aspect of Havard's Trager work and a key to maintaining balance during her year of treatment. "I found myself either rewinding or fast-forwarding all the time," she says. Fast-forwarding to "Am I going to make it? What stage do I have?" or rewinding to equally distressing thoughts, "I probably gave myself the disease. I must have been a bad person." Realizing this rewinding/fast-forwarding process was of no benefit, she began changing her perspective, seeing the disease and treatment not only as "pathology" but also as an opportunity to establish balance in her life.
"A way to do that was to stay present," Havard says. "The movements we would do were very relaxing and calming and enabled me to go someplace else than being sick. It was difficult to sleep at night. I could put myself back on that table in her office. I could get my muscles to remember. I could go back to those feelings in my muscles that happened in the Trager session. It was also very helpful during chemotherapy or radiation. I could help myself relax by remembering. My body could remember what that was like and go there." Movement and Memory
The Trager approach was created and developed by Milton Trager, a physician whose unique work began in his youth and was expanded over a lifetime of practice and teaching. Earning his medical degree in his mid-40s was a calculated move, serving as a means of integrating this modality into the medical realm. After decades of practice, Trager's presentation of his bodywork at Esalen Institute in Big Sur, Calif., in the mid-'70s was received with great enthusiasm, leading to his retirement from medicine and the establishment of the Trager Institute. Known for his vitality and enthusiasm, he continued to practice and teach the work well into his 80s.
Trager's movement education is now embraced by a variety of holistic practitioners and physical therapists. Among those applying the modality to breast cancer clients is Cynthia Harada, a nurse and certified Trager practitioner in southern California. "The way I explain Trager," she says, "is that the movements -- rocking, fluffing of tissues, and movement of joints -- really help the body to soften from the outside in, to the core. As this work goes on, the mind, tissues, and the body gets that it's been holding onto, or protecting, and being guarded. Then when the movement happens, the body says it's OK to move, the mind gets it, and the body-mind connection is made.
"In breast cancer, with surgery and radiation, the tissues get really hard and tight. Some of it is mechanical, and a lot is psychological. There's a guarding against intrusions that have happened, and what Trager seems to do is allow that connection to be reframed. Positive adaptive patterns are reacquired. The result of a Trager session in general is that a body will move more freely." There's also a cumulative effect, with each treatment building on previous learning.
Movement in Trager bodywork involves three primary aspects of interaction, Openlander says. Weight is one, with the experience varying from person to person, depending on their ability to allow the holding of their weight. "It is being suggested (nonverbally) to allow me to have the weight of your arm," she says. This can convey support or being held. A second aspect is creating resonance by initiating waves of movement throughout the entire body. "This suggests connectedness, wholeness, integration," Openlander says. The third is playing with the elasticity of the tissues, such as in lengthening movements. "This may suggest opening or letting go," she adds.
Havard says the stored muscle memories and accompanying sense of being cared for was of great benefit. "When I was lying in bed and would move a certain way, it felt to me like my muscles remembered, and it brought the hope that my whole body would feel good again."
Adrienne Stone, a Trager practitioner and instructor in Katonah, N.Y., had a special relationship with Trager. She learned at his side when she lived in California. Describing him as an adopted grandfather, Stone says Trager allowed her to administer bodywork to him following a stroke, albeit with the occasional mentor's admonition about her technique. With breast cancer clients, she says, there is benefit to working with the scar tissue hardened from surgery or radiation, even if joint motion is not limited. "Trager brings softening and aliveness to that tissue. It happens because of the way we work, using soft hands and soft touch. By making contact with the hard tissue, it gives the person a feeling experience of what soft is. This is the way Dr. Trager talked about his work in general. The feeling goes from his mind to his hand to the person's tissue, and that feeling is picked up by their mind, and then their mind is what really changes the tissue because their mind picks up the feeling of softness. They become the therapist, in that we're doing the facilitating but they are the one actually making the change."
This key component of Trager work, called the "hook up," occurs when the practitioner enters a state of meditative connection with the universal force of energy. This could also be termed "mindfulness," or "being in the presence of the oneness of all." Thus the work -- that feeling of lightness and ease -- is flowing through the practitioner to reach the client's mind.
Under the guidance of Openlander's hands, Havard tapped into feelings of being supported. During a movement in which her shoulders were lifted by Openlander, she says, "There was a tremendous image there of all the people who were praying for me. They were lifting me and carrying me." There were also moments of unexplained tears. "It was as though my body remembered something from a movement -- that it evoked a memory." A particular positioning of arms and hands reminded her of being bathed by her mother as a little girl.
"Radiation was very frightening to me, thinking about what was happening to me in that room," Havard says. With her left arm up over her head and right arm at her side, Havard had to remain in this position within her body mould for the duration of the treatment. The minutes felt like hours. She found that by making a small movement with one finger of her right hand, she could find a part of herself that felt normal and concentrate on that experience. Knowing she was alone in the room with the door shut, she also used her imagination to picture a slight crack in the doorway, connecting her with those outside.
Havard's tiny finger movement brought her back to an awareness of what is light and easy. It is the same with Mentastics, the client's self-care portion of Trager work. Combining the words "mental" and "gymnastics," these simple movements can be performed by the client any time during daily activity. "It's different than regular exercise," Stone says. "There's initiation of motion, release, and then a pause just to feel the weight. It's subtleness of movement -- the more subtle we can be, the more likely we are to attract the attention of our own unconscious mind.
"If the upper arm feels tight or is painful, the client performs a releasing movement at whatever level is comfortable for them. The movement can be so small as to feel as though they're doing nothing. That's OK. It's a starting point, and what we're after is coming back to what is nothing. Sort of like a stillness where there's a total release and then there's nothing to do about it. It's like your arm hanging in space rather than a tense arm you're holding up in space." The client is guided toward particular movements depending on the location of her limitation. If the suggested movement isn't effective, another is tried. Movements play with weight, and the client is invited into an awareness of what could be lighter or easier or what could be half of that effort.
Another example given by Openlander is the shifting of weight from one foot to another. Through this movement the client "learns how to go inward to a kinesthetic sense and feel their own weight," she says. There's an awareness of how the pressure presents and how it disappears as weight is applied and removed from the foot. The client can also sense weight in other parts of the body and feel movement in the shifting. "In noticing movements, there's a feeling where it's effortless," she says. "It is bringing the client's awareness to the ease that's in the body."
Stone describes this mind-guided movement as an opportunity for a mini-vacation. "It's a moment to go back inside yourself and re-center and then to move from there."A Safe Space for Healing
As Havard points out, Trager's gentle touch brings about a wholeness that allows the client to recognize what feels normal and healthy, even when ravaged by disease. "The person who comes in the (treatment) room has received catastrophic news, is having very difficult treatments, and anything that the therapist can do to reassure them, to give them hope, is wonderful. In my own case, when I went to Mary I felt like I was in a body that was under siege. When I was with her, the touch and the movement of Trager was very reassuring to me. I felt hopeful."
Havard says with Openlander she also found peace and quiet from the frenetic pace of medical treatments and procedures. "I took a certain amount of time to process what was happening to me, not in front of doctors or my family -- they were very upset -- but it was OK with Mary. It was OK to process and to just let it wash over me what was going on. It allowed me to go someplace that I needed to go. If I cried it was fine."
Openlander emphasizes the importance of respecting and accepting the full range of Havard's emotional response. "There was often listening to what was so difficult today to deal with, as well as what went well." When Havard was overwhelmingly caught up in strong emotions, Openlander offered support and redirection, pulling her awareness back into the moment and the hands-on work. She'd emphasize to Havard: "Right now you're right here, and I'm listening to you." The sessions continued despite intrusions of drainage tubes, port-a-caths, fatigue, nausea, and hair loss. Openlander says, "I think experiencing firsthand the loss of hair, eyebrows, eyelashes -- to vicariously experience that was an eye-opener for me of how many things get affected by chemotherapy. I'd never seen skin burned by radiation." With the suggestion by physicians to apply vitamin E prior to radiation treatment, Openlander incorporated the cream into her session at Havard's request. This, she says, provided another challenge in learning how much pressure could be applied.
As a seasoned Trager practitioner and owner of a physical therapy clinic in Marina del Ray, Calif., Dianne Khebreh has treated many post-mastectomy and reconstruction clients. She was also involved, along with Stone and Harada, in a special breast cancer project sponsored by her regional Trager association group in conjunction with the Cordelia Knott Center for Wellness in Orange, Calif. After exploring the ways in which Trager could be beneficial for these clients, the group offered introductory sessions with free treatment. Response was enthusiastic, and the center has continued to offer Trager as part of its program.
Reflecting on her own clients, Khebreh says, "It's a very healing process for them to have somebody touch them. They're very guarded and have a lot of feelings about what their bodies look like after surgery." Trager helps to reacquaint them with their bodies, as well as gain back sensation lost through surgery. Protection of the abdomen and chest is common, causing rigidity and misalignment. Having the practitioner touch and move the rib cage lets the client know it's safe to move and helps her regain mobility throughout the area. But Khebreh cautions about being certain incisions have healed and doing the work within the person's comfort level. "As soon as you sense resistance there, our job is to back off and be more gentle."
The amount of dialogue surfacing in Trager work will depend in part on the client. There's a certain amount of checking in, using Trager's questions of what could feel lighter, how the movement could be easier. For Openlander and Havard, time was allotted prior to table work for "settling in" talk, with more interaction during the session according to Havard's need to express or reflect on her experiences.
"There's a lot of communication about how they're feeling," Khebreh says. "As with most bodywork and massage therapy or movement education, issues are going to come up for people that they want to talk about," whether an emotional release or feelings related to surgery or recovery. "Most Trager practitioners are used to having that happen, and you don't become a Trager person without being a very nurturing person anyway."Caring for the Caregiver
With breast cancer, as with any life-threatening condition, emotions can run the gamut, for both client and therapist. Practitioners are taught that their self-care reflects on their ability to offer care, but in these cases some added measures should be considered. Jack Blackburn of Seattle, Wash., combines Trager with massage, reiki, and craniosacral work in his practice. But it is his interest in the body-spirit connection that led him to a graduate degree in spiritual direction. With his counselor training and instructor experience in basic and specialty classes in Trager, Blackburn offers his expertise on the caregiving/caretaking aspect of bodywork. Caregiving, the normal state of affairs for practitioners, involves providing supportive care while being able to step back without attachment. Caretaking, on the other hand, is when the therapist crosses the line and assumes responsibility for the client's treatment and decisions. While this shift may happen at brief moments of time within the session, a trend toward a constant role of caretaking presents problems.
"The tricky thing is to be able to make that shift into caretaking when necessary without staying there," Blackburn says. "When you need to create that nurturing container where you're doing some of the client's decision-making, it's important to be able to do that without getting overly invested. The safest thing is to involve other people, and not just in terms of what is safe for the client but in terms of being able to last in this profession and feel good about what we do."
Blackburn is a staunch advocate of supervision for therapists, whether by a senior mentor or an associate with experience related to work in which the therapist is offering care. If sessions are triggering childhood patterns or memories of times when caregiving left the practitioner feeling helpless, Blackburn says, "It behooves the person to take that into their own therapy." Although caregiving may be somewhat automatic for practitioners, it's important to recognize the warning signs. "A feeling of helplessness is really the key," he says. At that point the therapist needs to step back and examine the situation.
Taking care of oneself includes the obvious -- receiving self-care -- sometimes overlooked due to busy schedules and commitments, Blackburn says. Another important piece is education. Learn about the actual disease itself, the type of cancer involved, and how it metastasizes. "It takes care of some of that fear that comes up. If the client is hurting in those areas where you know cancer is active, what do you know about what is actually occurring in the body?
"I've always thought self-care includes getting through those areas where we have doubts and fears. When we're working with these people, there's a very good chance they're going to die. When we sign on, it's important that we have looked at our own views about dying and actually being with people who are going through that process." Then there's transference and countertransference, issues generally addressed in bodywork training in terms of maintaining boundaries. It can become a problem if the therapist does not take them into awareness, but if accepted as inherent to the experience, it can also serve a positive purpose. "It's such a gift," Blackburn says, "an opportunity to become more mature about the subtle interactions going on with ourselves and our clients."The Mind-Body-Spirit of Cancer
It was more than teamwork that carried Havard through the tears and pain to a triumphant recovery. It was also her convictions about the spiritual side of life and the mind-body-spirit connection. "I don't think anymore there's any difference," she says. "I think it's all one. I have explored that a lot, and cancer really underlined for me that I can't tease them apart." Accepting cancer's challenge, she tackled it as an opportunity for inner growth.
Emphasizing the importance of being aware of the client's reality, Blackburn says, "People we work with are going through different phases of their life. Cancer can be a phase that really changes everything in a person's life and can be a phase where the person is caught up in fear and pain and the losses they're going through. It's a time where they have a ticket to open any door they want to if they see it that way, or they have a ticket to withdraw, to kind of go inward or remove themselves from the world."
Havard chose a proactive stance, but other clients might not be so motivated. Openlander outlines important points in determining cancer clients who can best benefit from Trager work. First, they must understand this is complementary care, and while it does not cure, it can help with side effects. In addition to overcoming sleep problems, Trager offers skill-building to clients having difficulty adhering to the treatment regimen. "Trager provides the actual time frame for them to practice the skills of letting go -- giving yourself time to do something that's positive for yourself," she says. In learning to redirect attention, the client can identify what feels right, what is feeling good. "It's part and parcel of the Trager session -- practicing skills for what to do when they're anxious." Trager also offers one-on-one contact for those lacking a support system. And finally, as in the case of Havard, "If the client wants to be an active participant in their own healing process and understands there's something they can do but just needs a little coaching, that's a very appropriate client."
A final consideration in applying bodywork during the course of cancer treatment is the safety of the client. Openlander cautions about vulnerability to infection, especially during chemotherapy. Restrictions on positioning will require adjustments, and care must be taken with pressure on hypersensitive or numb areas. And as with all serious illness, therapists should consult the client's physician before initiating bodywork.
Openlander's desire is that this experience will encourage other Trager practitioners to work with clients undergoing cancer treatment. "Living with cancer -- despite its challenges and difficulties -- can be a time of growth; experiencing cancer with openness can bring about positive life changes, renewed relationships, and insights into oneself that actually enhance life."Breast Cancer: One Illness, Two Women, Four Seasons,
by Mary Ellen Havard and Mary Openlander, is available for $15.95 through BookMasters at 800/247-6553 or www.atlasbooks.com
. Shirley Vanderbilt is a staff writer for Massage & Bodywork magazine.