Takeaway: Trauma-informed care is a collaborative approach to health care that focuses on helping clients safely reconnect with themselves and their physical experiences in ways that may be more effective than seen with other kinds of approaches to care. 

Author’s note: I am not, nor am I ever likely to be, deeply knowledgeable about massage therapy in the context of trauma-informed care (TIC). Many experts willingly share their knowledge on this important topic (several of whom I interviewed for this project), and massage therapists who want to learn more about how TIC can enrich their practice have ample opportunities to do so.

My purpose here is not to be comprehensive, but to provide some initial thoughts. I will offer some basic concepts, and I will make some interesting and important connections between trauma and other situations. I will show how massage therapists are well-positioned to be excellent providers of TIC, and I will point interested readers to many other resources and providers where they can pursue this topic at a much deeper level.

I undertake this with deep humility, with appreciation for others who have carved pathways in this difficult terrain, and with special reverence for the clients who put themselves, literally, in our hands.

Why This, Why Now?

I am writing this column in early spring of 2022. We are entering the third year of the pandemic, which impacts all aspects of life, sometimes to devastating effect. And the virus continues to mutate even as we struggle to find some way to emerge from this chaos.

In addition to COVID-19 itself, in the last two years our country has faced social polarization, with protests and counterprotests about COVID-related restrictions, gun violence, racism, the results of the last presidential election, voting rights, education, and more. To all this we can add the global effects of climate change, rising sea levels, worldwide natural disasters, and heartbreaking international conflicts that carry the threat of initiating a worldwide war. All these challenges continue to directly and indirectly take their toll on our well-being.

In short, ACK! We are all dealing with trauma!(Aren’t we?)

The word trauma gets thrown around a lot, sometimes in ways that may diminish its importance. But it’s not a stretch to say that for the last two years many of us have been under increased strain, with challenges to our emotional, mental, and physical health. Sometimes those challenges can overwhelm our normal resilience and equilibrium.

Our clients have always come to us to find some respite from the “outside world,” but at this moment, the oasis of peace and safety that massage therapists can offer seems more important than ever. To do this well means we must be conscientious about nurturing some skills that are likely to come naturally to us—many of the habits and attitudes that make excellent massage therapists are highly valued in the context of trauma-informed care. My hope is that we can hone these skills with purpose and intention, rather than just hoping for the best. Our clients need us to be good at this—now, more than ever.

Trauma Vocabulary

The definitions of trauma and related terms are open to wide interpretation, since “trauma” can refer to anything from a grazed knuckle to surviving torture. A manual titled Treatment Improvement Protocols: Trauma-Informed Care in Behavioral Health Services is produced by the Substance Abuse and Mental Health Services Administration (SAMHSA), and it serves as a reference point for many clinicians working with traumatized populations.

The SAMHSA document states, “Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being      . . . traumas can affect individuals, families, groups, communities, specific cultures, and generations. It generally overwhelms an individual’s or community’s resources to cope, and it often ignites the ‘fight, flight, or freeze’ reaction at the time of the event(s). It frequently produces a sense of fear, vulnerability, and helplessness.”¹

Clinicians who specialize in helping people injured by trauma make an important distinction: The event—whether it was being that target by violence, a natural disaster, or long-term abuse and neglect—is just the event. Resulting dysfunction depends on how the person is impacted by and responds to the event. In other words, it is the reoccurrence that creates the traumatization and all its consequences, not the event itself. In this way, two people may go through the same threatening incident but develop very different severities of ongoing dysfunction, depending on how each of them processes their experience.

The Physiologic Consequences of Trauma

When a person’s reactions to a traumatizing experience become ingrained, the autonomic nervous system may become locked into sympathetic flight/fight/freeze reactions. A person who lives with the aftermath of trauma is consciously or unconsciously hypervigilant: constantly scanning the environment for possible dangers. This is exhausting—mentally, emotionally, and physically. It may also lead people to filter out important information about their own physical experience. And it has negative repercussions on long-term health.

“Traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and, in an attempt to control these processes, they often become an expert at ignoring their gut feelings and in numbing awareness of what is played out inside. They learn to hide from their selves.”²

Signs and symptoms of trauma can look a lot like posttraumatic stress disorder (PTSD), with hypervigilance, troubling flashbacks, problems sleeping, and other specifically stress-related challenges. Or symptoms can be vague, unpredictable, and hard to pin down. Headaches, gastrointestinal pain, and muscle aches may be related to ongoing trauma reactions. Of course, these not-quite-sick-but-not-quite-well signs and symptoms are familiar to many massage therapists, because people who live in this limbo often struggle to find helpful answers within conventional medical options, so they turn to massage therapy for relief.

People who have been traumatized are vulnerable to many disorders and diseases related to long-term stress. Cardiovascular disease, autoimmune diseases, sleep and mood disorders, and even certain types of cancer are more likely to occur in people injured by trauma than in people whose challenges have been less severe or whose support systems have allowed them to deal with trauma more successfully. Further, traumatized people are often in a lower socioeconomic class (this is both a cause and effect of trauma), and they may have difficulty accessing adequate health care. Physicians and other clinicians who are not sensitive to the challenges of living with trauma can further alienate or even retraumatize these patients, which means they may be less likely to seek medical help unless it is a life-threatening emergency.

Trauma, Health, and Society: Everything Connects to Everything

The individual, community, and cultural impacts of trauma on health don’t easily fit into a typical outline format. Instead, it may help to think of the experience of trauma as the center of a web, with strands to many other issues—personal and societal—that create self-fulfilling cycles of dysfunction. On the opposite page is one version of a trauma web that demonstrates how trauma is both a cause and an effect, linking numerous life and health challenges—many of which are commonly seen in massage therapy settings (see “Trauma: Everything Connects to Everything”).

TIC: Connection and Collaboration

The SAMHSA definition of trauma-informed care (TIC) is: “TIC is a strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment. It also involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma, and it upholds the importance of consumer participation in the development, delivery, and evaluation of services.”³

This approach has been codified by some experts into the “Four Rs” of TIC:

• Realize what trauma is and how it can affect individuals, families, communities, and societies

• Recognize signs of trauma

• Respond to trauma in practice and in general policy

• Resist retraumatization by being sensitive and using good communication skills

A close reading of the SAMHSA statement shows that skilled massage therapists could be confident providers of trauma-informed care. We learn early on the importance of creating “physical, psychological, and emotional safety for both providers and survivors.” When we encourage our clients to make decisions for their sense of comfort and safety, we are “avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma.” And when we invite feedback about pressure, comfort, and technique, we promote “participation in the development, delivery, and evaluation of services.” None of this requires that we be deeply educated in principles of psychotherapy or that we know anything specific about our clients’ backgrounds.

“TIC does not require that clinicians know the exact nature of the trauma a patient has experienced. Instead, by promoting sensitivity and focusing on trust, TIC provides a set of principles to help clinicians create a safe environment in which survivors feel comfortable returning in the future.”⁴

In short, when we are present and invested in being client-centered with our work, we deliver trauma-informed care. TIC is about making deep and true connections, conveying that our clients are important and deserve our full attention. In that process, we can help safely reconnect our clients with themselves and their physical experiences in ways that other interventions may not be able to do. 

In addition, TIC is a collaborative process because it is based on a relationship where partners work together. It is a mutual journey: As we walk together, the practitioner offers support and guidance, but the client does the hard work of learning to understand why they have reoccurring traumatic experiences, and how to manage them in a way that promotes their health and well-being.

Trauma: Everything Connects to Everything

• Posttraumatic stress disorder and acute traumatic stress disorder (ATSD) are conditions connected to short- and long-term physical, mental, and emotional changes related to traumatic events. People who live with PTSD or ATSD may also perpetrate threatening or violent acts on others, furthering the cycle.

• Systemic racism, especially as it manifests in health-care access and treatment, causes trauma in people who are targets of racism, and is also associated with other negative health-related outcomes, including chronic conditions and substance abuse and misuse.

• Epigenetics is the study of how long-term trauma can impact inherited characteristics for multiple generations. In this way, the societal impacts of trauma resonate far further than any single person; they can affect whole communities and cultures for many decades.

• Chronic disorders like cardiovascular disease and autoimmune diseases have direct links to traumatic histories, as well as to epigenetics and systemic racism. Many conditions that have been considered a genetic predisposition in marginalized ethnic groups are now understood to be at least partially the result of generational stressors. Anxiety and depression fall into this category of health challenges as well.

• Chronic pain conditions such as fibromyalgia, migraines, irritable bowel syndrome, chronic fatigue syndrome, and others can be both the cause and effect of trauma. Interestingly, these all involve dysfunction in the hypothalamus-pituitary-adrenal axis, which determines the efficiency of the stress response system.

• Adverse childhood experiences (ACEs) are, as the label implies, negative events that happen in early life. When a person has multiple ACEs, it has been seen to lead to both the experience of trauma and predictably poorer health outcomes and shortened life spans compared to people who don’t have a history of multiple ACEs.

• Substance abuse and misuse are common but dangerous coping mechanisms many people with trauma-related histories may use to try to manage their pain and stress. And of course, the repercussions of substance abuse and misuse can include the risk of creating ACEs and other traumatizing events for people close by.

Many more connections can be made between trauma and other aspects of health and wellness. This map leaves out the trauma-related repercussions that are part of the experience of being other than cisgender and having a non-straight sexual orientation. Other marginalized populations (immigrants, people with disabilities, people over 65, etc.) could also be represented here—not to mention the people whose identities intersect, like gay elders of color, for instance. But this map provides a place to start thinking about how trauma and its aftermath affect every part of our society and culture.

Practical Steps

While the idea of TIC is widely accepted in the medical community, many health-care providers are unsure whether they can provide it skillfully. This is often attributed to the assumption that TIC takes more time than the clinician can offer, or to a lack of education, confusing information about TIC, or fears of inadvertently retraumatizing patients.⁵

When clinicians write about the practical differences between a trauma-informed encounter and one that is less sensitive, some interesting suggestions arise:

• Be prepared: Have the room ready for whatever activities are planned, so the patient doesn’t have to be there while a doctor or nurse searches for the correct equipment or unpacks the right tools.

• Make eye contact with your patient and try to keep your eyes on the same level as theirs—that is, avoid standing over your patient while you are having a conversation.

• Be transparent and get consent: Tell the patient what is going to happen and get their agreement as you go through each step together. If something is happening that the patient can’t see, inform the patient about what is going on.

• Offer suggestions rather than directions: “Some people find it easier to take a deep breath at this point” is better than “take a deep breath” when a patient is in obvious discomfort.

• Know grounding techniques: When clients or patients have an unexpected emotional reaction to some trigger that takes them out of the present, it is important to be able to reorient them to their surroundings in a safe and compassionate way.

• Work with patients, rather than on them. The therapeutic alliance in TIC is a partnership, not a one-way hierarchy. It is a collaboration with mutual goals, rather than a provider only giving something—instructions, a prescription, a referral—to the receiving patient.

I hope readers will resonate with these practical applications of TIC, because many of them are built into the ways we learn to interact with clients from the very beginnings of massage therapy education. But to be skilled in the field of TIC, these practices and the attitudes behind them must be conscientiously developed and nurtured.

What Does Healing Look Like?

Traumatization is not the result of an event; it is the result of a person’s responses to adverse or threatening situations. Those initial reactions to dangerous situations were probably appropriate and protective—there’s nothing wrong with them. But when those effects linger and interfere with being able to live a life of meaning and purpose, then more functional responses must be developed. Healing from trauma is not a matter of fixing anything—those initial sympathetic reactions were necessary. Rather, it’s a long road toward learning new ways of dealing with the repercussions of the initial event. The trek can be lengthy, and may involve many helpers: family and intimate, trusted friends, talk therapists, medical doctors, and sometimes bodywork practitioners who can help trauma survivors reconnect with their resilient, miraculous, physical selves. 

[People living with trauma] “. . . cannot recover until they become familiar with and befriend the sensations in their bodies. . . . In order to change, people need to become aware of their sensations and the way that their bodies interact with the world around them. Physical self-awareness is the first step in releasing the tyranny of the past.”⁶

Healing from trauma isn’t about flipping a neurochemical switch, or correcting misaligned perception, and then being done. A traumatized person may never wake up someday and say, “Wow, I’m glad I don’t have to deal with that anymore.” Healing from trauma is a process, an ongoing project, a journey through what can look like scary, uncharted territory. Progress isn’t always smooth, and momentum can stall. The path forward can seem to disappear, or the person can get mired in mud or tangled in brambles. That’s why it takes a community of helpers, working collaboratively with each other and with the traumatized person to walk the path (or blaze the trail) of healing together.

A person who has been injured by trauma will always carry that history. But they can set a course toward a different future—one in which they have the skills to deal with stressors, triggers, and other obstacles without being knocked off their path.  

We have seen how trauma can affect multiple generations—descendants of people who were enslaved deal with this every day, as do the children and grandchildren of ethnic groups decimated by genocide. And what will the aftermath of the pandemic look like? How do we go about healing trauma that affects whole communities and whole societies? That is a bigger question that goes beyond the scope of this article. But being a trauma-informed practitioner means we must be willing to be educated and sensitive to how this unseen force may influence us, our clients, and their ability to make progress toward their goals. Can we commit to doing this? Can we build out our skills to do it with purpose and intention? I believe we can.

This column would not have been possible without the generous time and input of TIC experts, including these wonderful people. Parts of my conversations with them can be found in the video that accompanies this article.

• Pam Fitch, MAdEd, RMT, author of Talking Body, Listening Hands: A Guide to Professionalism, Communication, and the Therapeutic Relationship

• Susan Rhema, PhD, LCSW, professor at Kent School of Social Work and Family Science, University of Louisville, Tip It Forward Senior Advisor and Lead Trainer

• Kammaleathahh Livingstone, LMT, founder and director of Tip It Forward (tipitforward.org), a nonprofit organization that delivers trauma-informed whole health-care services through mobile wellness clinics to underserved, under-resourced individuals

• Sahara Pirie, LMT, parent educator with special emphasis on how life experiences, especially trauma, are held in the body, and how that influences our lives and behavior

For More Education on TIC for Massage Therapists

• Pam Fitch offers several seminars and webinars on massage therapy for clients who have a history of trauma. Find more information at pamelafitch-rmt.com/seminars.html.

• Kammaleathahh Livingstone and Susan Rhema offer “An Introduction to Trauma-Informed Care” through Healwell.org. Learn more at healwell.org/courses.

• Center for Mindful Body Awareness: The center’s mission is to increase access to mindful body awareness strategies for self-care, emotion regulation, and resilience—important skills for the health of individuals, families, and society. Find more information, visit cmbaware.org/training-programs.

Resources

A Treatment Improvement Protocol: Trauma-Informed Care in Behavioral Health Sciences. 2014. https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4816.pdf.

Bruce, Marta M. et al. “Trauma Providers’ Knowledge, Views, and Practice of Trauma-Informed Care.” Journal of Trauma Nursing 25, no. 2 (Mar/Apr 2018): 131–38. https://doi.org/10.1097/JTN.0000000000000356.

Dawson, S. et al. “Trauma-Informed Approaches to Primary and Community Mental Health Care: Protocol for a Mixed-Methods Systematic Review.” BMJ Open 11, no. 2 (2021): e042112. https://doi.org/10.1136/bmjopen-2020-042112.

Felitti, V. J. et al. “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study.” American Journal of Preventive Medicine 14, no. 4 (1998): 245–58. https://doi.org/10.1016/S0749-3797(98)00017-8.

Fitch, Pamela. Talking Body, Listening Hands: A Guide to Professionalism, Communication, and the Therapeutic Relationship. Pearson, 2015.

Grossman, S. et al. “Trauma-Informed Care: Recognizing and Resisting Re-Traumatization in Health Care.” Trauma Surgery & Acute Care Open 6, no. 1 (2021): e000815. https://doi.org/10.1136/tsaco-2021-000815.

Gundacker, C. et al. “A Scoping Review of Trauma-Informed Curricula for Primary Care Providers.” Family Medicine 53, no. 10 (2021): 843–56. https://doi.org/10.22454/FamMed.2021.500263.

Levy, R. “Beyond the Buzzwords: What Does Trauma-Informed Care Truly Mean?” Mad in America. May 20, 2020. www.madinamerica.com/2020/05/beyond-buzzwords-trauma-informed-care.

McFarlane, A. C. “The Long-Term Costs of Traumatic Stress: Intertwined Physical and Psychological Consequences.” World Psychiatry 9, no. 1 (2010): 3–10.

Ravi, A. and V. Little. “Providing Trauma-Informed Care.” American Family Physician 95, no. 10 (2017): 655–57.

Rosenow, M. and N. Munk. “Massage for Combat Injuries in Veteran with Undisclosed PTSD: A Retrospective Case Report.” International Journal of Therapeutic Massage & Bodywork 14, no. 1 (2021): 4–11.

National Institute for the Clinical Application of Behavioral Medicine. n.d. “The Neurobiology of Trauma.” Accessed May 2022. www.nicabm.com/program/a3-brain-trauma-fb.

Van der Kolk, B. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Penguin Publishing Group, 2018.

Trauma-Informed Care Implementation Resource Center. n.d. “What is Trauma-Informed Care?” Accessed May 2022. www.traumainformedcare.chcs.org/what-is-trauma-informed-care.

Notes

1. Substance Abuse and Mental Health Services Administration, A Treatment Improvement Protocol: Trauma-Informed Care in Behavioral Health Services (2014): https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4816.pdf.

2. Bessel van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (New York: Penguin Publishing Group, 2018).

3. A Treatment Improvement Protocol: Trauma-Informed Care in Behavioral Health Services.

4. Anita Ravi and Virna Little, “Providing Trauma-Informed Care,” American Family Physician 95, no. 10 (2017): 655–57.

5. Marta M. Bruce et al., “Trauma Providers’ Knowledge, Views, and Practice of Trauma-Informed Care,” Journal of Trauma Nursing 25, no. 2 (Mar/Apr 2018): 131–38, https://doi.org/10.1097/JTN.0000000000000356.

6. Bessel van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma.