- vivid flashbacks (feeling like the trauma is happening right now)
- intrusive thoughts or images.
- intense distress at real or symbolic reminders of the trauma.
- physical sensations such as pain, sweating, nausea, or trembling.
Criteria for Diagnosis
To receive a diagnosis of PTSD, a person must have at least one re-experiencing symptom, at least three avoidance symptoms, at least two negative alterations in mood and cognition, and at least two hyperarousal symptoms for a minimum of one month.
Symptoms of intrusive memories may include:
- Recurrent, unwanted distressing memories of the traumatic event
- Reliving the traumatic event as if it were happening again (flashbacks)
- Upsetting dreams or nightmares about the traumatic event
- Severe emotional distress or physical reactions to something that reminds you of the traumatic event
Symptoms of avoidance may include:
- Trying to avoid thinking or talking about the traumatic event
- Avoiding places, activities, or people that remind you of the traumatic event
Negative changes in thinking and mood
Symptoms of negative changes in thinking and mood may include:
- Negative thoughts about yourself, other people, or the world
- Hopelessness about the future
- Memory problems, including not remembering important aspects of the traumatic event
- Difficulty maintaining close relationships
- Feeling detached from family and friends
- Lack of interest in activities you once enjoyed
- Difficulty experiencing positive emotions
- Feeling emotionally numb
Changes in physical and emotional reactions
Symptoms of changes in physical and emotional reactions (also called arousal symptoms) may include:
- Being easily startled or frightened
- Always being on guard for danger
- Self-destructive behavior, such as drinking too much or driving too fast
- Trouble sleeping
- Trouble concentrating
- Irritability, angry outbursts, or aggressive behavior
- Overwhelming guilt or shame
For children 6 years old and younger, signs and symptoms may also include:
- Re-enacting the traumatic event or aspects of the traumatic event through play
- Frightening dreams that may or may not include aspects of the traumatic event
Intensity of symptoms
PTSD symptoms can vary in intensity over time. You may have more PTSD symptoms when you’re stressed in general, or when you come across reminders of what you went through. For example, you may hear a car backfire and relive combat experiences. Or you may see a report on the news about a sexual assault and feel overcome by memories of your own assault.
When to see a doctor
If you have disturbing thoughts and feelings about a traumatic event for more than a month, if they’re severe, or if you feel you’re having trouble getting your life back under control, talk to your doctor or mental health professional. Getting treatment as soon as possible can help prevent PTSD symptoms from getting worse.
If you have suicidal thoughts
If you or someone you know has suicidal thoughts, get help right away through one or more of these resources:
- Reach out to a close friend or loved one.
- Contact a minister, a spiritual leader, or someone in your faith community.
- Call a suicide hotline number — in the United States, call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) to reach a trained counselor. Use that same number and press 1 to reach the Veterans Crisis Line.
- Make an appointment with your doctor or mental health professional.
When to get emergency help
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.
If you know someone who’s in danger of attempting suicide or has made a suicide attempt, make sure someone stays with that person to keep him or her safe. Call 911 or your local emergency number immediately. Or, if you can do so safely, take the person to the nearest hospital emergency room.
Benefits of Massage for PTSD
Studies suggest massage therapy (MT) may be able to reduce some symptoms of PTSD such as irritability, anxiety, depression, and tension.
Sometimes you have to be dangerously close to a problem to see the solution. Chris Smith understands this.
A survivor of abuse as a child, Smith found bodywork to be a bastion in uneasy waters as she began seeking means for self-care as an adult. “I discovered early on that the hands-on aspect was very healing to my own history of trauma,” Smith said. “Massage offered a sense of healthy touch and a healthy sense of self.” She said the experience was not just about working sore muscles and relieving tension. “There was something very core about the touch and what it meant to me as someone with a history of sexual abuse.”
When she later became a massage educator and saw half her students coming in with their own histories of violence and abuse, Smith wondered how to help. “They were sometimes aware, sometimes not; and they were working through these issues in the classroom,” Smith said. “I realized something had to be done so they could deal with this on a conscious level.”
At the same time, the majority of massage clients Smith was seeing were survivors of abuse. “I guess we get those clients who are there to teach us,” she said. “It wasn’t unusual for clients to have enormous emotional releases on my table, and I knew I needed to get more information to deal with this.”
Between the need, she had identified among her students and clients, and her personal knowledge that bodywork comforted traumatic wounds, Smith found the inspiration for Trauma Touch Therapy in 1993.
Trauma Touch Therapy Defined
Trauma is something we’ve all experienced. For some, trauma can be as significant as death, or as maddening as driving a rush hour-packed interstate. “Trauma touches us all,” said Smith. Unfortunately, to the detriment of our physical and emotional health, many of us minimize trauma’s effect and many more don’t understand the value of very goal-oriented trauma work.
Trauma Touch bridges the gap. This unassuming, hands-on modality helps therapists work with trauma and abuse. It’s a simple approach for working with people who’ve forgotten what it means to be in the here and now; people who’ve forgotten what it feels like to “feel.”
Numb from dissociative survival skills learned during the traumatic event(s), numb from drugs or alcohol, or numb from other distractions created to hide behind, survivors of trauma often can’t feel their bodies or have parsed apart their various pieces of being. “Many people might ask why numbing out is a bad thing, especially if you’re numbing out all the pain, the horror, and discomfort. The numbing process is not selective,” said Smith. “They numb out everything – their joy, their capacity to feel alive, and their ability to feel safe in the world. It’s frustrating. Their capacity to experience life is greatly diminished. This is what brings people into the therapy.”
Trauma Touch Therapy works to integrate the pieces again. It provides a slow application of touch that helps bring the client back to themselves – to take residence, if you will, back in their bodies. The work is led by the needs of the client, actually asking them to think through their own somatic needs. Where is the pain? Where is the tension? What does it feel like? Is it okay to touch? Trauma Touch Therapy is a process of integration weaving itself through the course of 10 sessions with the client typically clothed. Work can be done on a massage table, in a chair, or position most comfortable for the client.
The one requirement for entering a Trauma Touch program? Clients are required to be in active psychotherapy, and many naturally come from that field via healthcare referrals. Smith said instead of incorporating psychotherapy directly into the bodywork like some therapies, simultaneous but separate counseling and bodywork sessions keep the two fields distinct. “That way there’s no confusion in the therapist’s role,” she said.
While the Trauma Touch therapist might help emotions and wounds come to the surface, it is the psychotherapist who helps the client find meaning. The bodyworker remains just that, a bodyworker, not venturing outside their scope of practice.
No Blurred Lines
It was a melding of mind and body therapies that initially concerned Smith as she learned how to work with clients of trauma and abuse. Though she highly regards other body therapies which incorporate psychotherapy and has even completed a two-year Hakomi Integrative Somatics program, she believes melding the two fields of work so seamlessly, and without extensive training, could be quite harmful.
“It’s hard to know where clear boundaries begin and end when you do this,” said Smith. Where on the one hand a massage therapist’s instinct is to offer whatever help possible, it’s ethically responsible for them to refer a client to other professionals when that client’s needs exceed the therapist’s scope of practice. “That’s one of the things I realized in developing this course: bodyworkers were getting stuck asking, ‘Who am I to give the client advice?’ It’s confusing for therapists.”
Smith began seeing the issue as a dichotomy of career and spirit. “One of the crucial things I realized was that massage therapists want to help everyone.” The fact is, regardless of how much you think you might be helping the situation, if you are untrained in this area and attempt to psychologically “treat” or advise a massage client who has a history of abuse, you may do much more damage than good.
A common mistake for concerned, but untrained, therapists is assuming too much or projecting their own feelings about the client’s history onto the client.
Smith explained it this way. “A sense of empowerment is one of the first things to go away for a victim of abuse. If we project onto our clients, we’re promoting that sense of helplessness and hopelessness.” The client needs, instead, to be supported in finding their own answers.
“Most of the time I’m teaching massage therapists how to back off,” she said. “I remind them it’s okay if they don’t have all the answers.” Smith said therapists, in their attempt to bring relief, are often befuddled when “nothing is happening” for the client. Instead of letting the process happen, this therapist wants to be helpful and make the answers obvious. With Trauma Touch Therapy work, the client is “in charge,” directing traffic when it comes to their own issues while finding support and comfort via their massage therapist.
Letting It Happen Naturally
Abuse is a complicated reality. Therapists often reflect that complication onto the work, instead of letting the process happen naturally. “Often the best thing to do,” said Smith, “is very simple and let it come from the client organically.” That, she said, is what Trauma Touch Therapy does so effortlessly.
She describes Trauma Touch Therapy as the Zen in working with trauma clients. She gives it that moniker because of the simple and innate nature of the therapy.
It’s all about collaborating with the client. Instead of thinking, “Nothing is happening, they’re going to think I’m a bad therapist. I don’t know what to do next,” Smith said the answer is simple: “Ask the client.” They will tell you what they need.
It may be nothing more than a simple holding of a spot. It may be no touch at all. An entire session of Trauma Touch Therapy work might focus exclusively on how the client feels in their body or getting them to sit still long enough to feel anything at all.
Smith said it’s important to stay within your scope of practice, and don’t try to provoke a response or an emotional release. “Just be as simple as possible in your response. Stay present with them. What do they need? And be sure not to push your own agenda.”
In her early, personal study of other types of bodywork, Smith watched and experienced the encouragement of cathartic release on the massage table. “These releases involved the client reliving the trauma,” Smith said, complete with primal screams, uncontrollable sobbing, etc. “I believe it did nothing but increase the traumatization.”
Smith admits a release of this kind feels beneficial initially. “It’s a huge release of endorphins, but what happens is you’re so dissociative at the time of the release, there’s no time to integrate the shift that has occurred. What happens instead is people get retraumatized,” she said.
“In Trauma Touch Therapy, I teach that there are a number of different stages of emotional release clients can experience. We want them to stay in a range where they are still very aware and present of what’s going on. Even though it may be intense and they may be in a high state of emotionality, they need to be very present.” Smith explained that oftentimes a victim of abuse can find themselves wrapped tightly in a cathartic release and actually confuse the past and the present. “They can easily mistake the massage therapist for the perpetrator and it can be completely regressive.”
A release of this kind often happens when people’s resources are overwhelmed. “It’s akin to reinstating the original trauma, or even creating a new one,” Smith said.
“What Trauma Touch Therapy does very well allows the clients to experience larger and fuller states of feeling without getting overwhelmed. No matter what state they’re in, we want Trauma Touch Therapy clients to experience stronger levels of feeling and aliveness without seeing that as being traumatizing,” said Smith. “The key to that is keeping the client present.” To do so means the client understands you’re there as a compassionate witness and that you’ll be in this place with them. Feeling alone in the world is a hallmark of trauma – no one to help, no one to understand. Having a willing therapist there is a huge acknowledgment of self for the client/survivor.
Smith based her philosophy on the work of Carl Rogers. “He had this notion of unconditional, positive regard and he felt it was the most potent element of change we have. We don’t have to say anything profound or do anything other than just be very present for the client.” The simplicity of this philosophy permeates through all aspects of Trauma Touch Therapy.
What a Session Entails
Trauma Touch Therapy is designed to address each individual’s needs. As such, there is no set protocol for “treating” a client, and each session is very different from the next. A primary difference between Trauma Touch Therapy and other body therapies is the thorough intake during the first session. In addition to a lengthy physical and emotional health segment, the intake also deals with what work the client is ready to undertake.
“It’s really a time for the therapist to get a sense of what the client wants to share,” said Smith. “We don’t need to know the details, but we do ask if they know of any triggers they react to if they have witnessed any violent crimes, if they’ve any history of suicide, and we establish whether or not this client is ready for the work. It also gives the client a sense of who we are as a therapist and if they’re comfortable with us.” Smith said a simple approach is to ask, “Is there any of your histories you would feel comfortable sharing with me today?”
After the intake, a Trauma Touch Therapy session usually begins with some sort of awareness exercise. One example is asking the client to take a moment and scan their body. Ask if there’s a place they’d like to work today. It can be a place that feels pain, that feels hollow, or a place that can be happy and light – a feeling they want to expand.”
It’s critical to let the client steer the course of action in the therapy, said Smith. “You don’t presume anything with Trauma Touch Therapy. Always ask permission to touch and let the client lead the way. It may be the therapist, however, who holds the negotiation on whether or not we stay with that area.”
Even up to this point, there may be no touch involved. If a client identifies an area they want to work with, the therapist should ask if they would like some contact in that area. Another option is to ask the client if they want to provide the touch for themselves (i.e., “Would you like to place your hand on your stomach for a bit?”).
When addressing any of the client’s self-chosen areas, the therapist needs to continuously check in and ask about any feelings taking shape. The purpose is to awaken the numbed client and integrate their mind back with their body.
The Goals of TTT
The goals of Trauma Touch Therapy are as simple as the work itself. “We want the client to experience their body and all the feelings, emotions, and sensations that come with that, all the while staying present with the experience,” Smith said. “We want to get them back into their bodies.”
Smith said the client having an intellectual understanding of what they’ve been through is but one piece of the puzzle. “I used to think that was the only thing. But, the body has its own story to tell; it’s own healing to do.”
Integration is the end goal, said Smith. By putting the pieces back together, the client can live again. “Trauma narrows one’s life. When we numb out the pain, the numbing is not selective. It also numbs out joy and aliveness.”
Smith said sometimes the process is excruciatingly slow. Asking a client to take a moment and feel how her blouse feels on her arm is an example of the little things you can do to make them aware of feelings. “It’s very much like working on stroke clients. It’s this miraculous thing when they get their movement back, small as it may be.”
Those are the same small moment’s Trauma Touch Therapy therapists long for. “When the client finally feels an aliveness and joy by being in their bodies, it’s almost like a midwife watching a birth,” Smith said. “We have something beautiful after all the pain.” Afterward, the client is more empowered, has found her voice, is able to take better care of herself, and can finally ask for what she needs. “The client finally gets to see the body as a safe place, and that’s an extraordinary process.”
Unlike many massage therapists, Smith is excited for the day when her client walks away for the last time. “I want my clients to get to the point that they don’t need me anymore,” she said. Until that time, the client and therapist take “baby” steps. “I want them to walk away from each session saying, ‘Look at what I did for myself today. I experienced myself in a new way. I can deal with these emotions and not be washed away. I can do this by myself.’ ”
There are two important elements in Trauma Touch Therapy that rest solely in the therapist’s hands – their self-care and the condition of their client while in session.
Smith said vicarious traumatization is a big risk with this kind of work. “You need to recognize the signs, like nightmares, hypervigilance, increased startle response, inability to sleep, heightened anxiety, and lack of self-care.” In addition, it’s imperative Trauma Touch Therapy therapists work with a support facilitator who has experience counseling with vicarious traumatization; someone who can support the massage therapist personally so things stay clear for everyone.
Just as being aware is important for avoiding vicarious traumatization, awareness is critical in keeping the client safe. “A big thing for massage therapists is thinking they can connect with their client more deeply if they close their eyes,” said Smith. “This isn’t advised for Trauma Touch Therapy therapists. We need to watch the client’s body more fully to get a sense of how our touch reacts to them. If we’re not watching, we may not see that their hands are clenched, their jaw is clenched or their breathing has shifted. You’ve got to open your eyes and watch what happens to the client.”
Smith said attentiveness is critical regardless of what modality you use. “You could be doing sports massage and if you’re not really watching the client fully, their whole body, you’re going to miss something and usually do.”
The Shift – The Results
What started as an uncomplicated means to address trauma is now finding its place in the world of massage and bodywork. And it’s working for clients.
“Extremely successful” is how Smith described the work. “I would really say it’s 100 percent successful because clients get to do the work they think they need to do,” she said. “It’s based on what goals the client comes in with. Do clients leave feeling more empowered? Yes. Do they have more autonomy and a sense of self-sufficiency? Absolutely. Can they experience their body more fully without dissociating? Yes.”
Smith said many of the clients she sees will report to her their 20 years of psychotherapy. “They’ll say, ‘I get it in my brain, but…’ That’s where Trauma Touch Therapy comes in.” By working with their traumas and by having the client identify how they’ve shut down and become numb, an “aliveness” begins to seep through all the armoring that’s taken place. That “aliveness” is a magic pill of sorts, which begins waking the client into a new paradigm where they can begin living life again. It may sound simple, but that’s what Trauma Touch Therapy is all about.
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