George was candid about his weight and concerned that I was up to the task. “I should let you know,” George said when he called to set his first appointment, “I’m a big guy.” “Oh, that’s not a problem,” I said. “I’ve worked with plenty of big people.” It’s true. I had a weekly client who was under 5 feet tall and weighed more than 300 pounds. In massage school, I practiced on a friend who was also around 300 pounds. But when George walked into my office, I was surprised to find a man who was 6’4” and well over 400 pounds.
This is a good time to mention my own height and weight—5’4”, 140 pounds. This means that even with my table at its lowest setting, George’s body was so high that I still had to reach up to massage him. Not only that, but he specifically wanted deep massage, so good body mechanics were out the window—and so was everything I thought I knew about giving massage to an obese person.
A Matter of Semantics
The word obese is a medical term that expressly applies to a person whose body mass index (BMI) is over 30. BMI equals a person’s weight, in kilograms, divided by height, in meters squared (fairly inconvenient for those of us using the American measurement system). Fortunately, there are many Internet sites with BMI charts; all you have to do is plug in your height in inches and weight in pounds (www.cdc.gov/nccdphp/dnpa/bmi).
By now, we’ve all heard about the rising obesity rates in America. We’re a fat nation getting fatter. According to the Center for Disease Control, since the mid-70s the percentage of obese adults has more than doubled from 15 percent to 32.9 percent (based on surveys conducted 1976–1980 and 2003–2004). In 2006, only four states had a prevalence of obesity less than 20 percent.
The stress of carrying several extra hundred pounds puts enormous pressure on a person’s body. Knees, hips, neck, low back, feet—you name it—are prone to pain. If a person is sedentary, circulation may be compromised, sometimes resulting in edema, and range of motion may be decreased. Obese people are also more likely to suffer from high blood pressure.
Fortunately, these conditions can be helped by massage. And yet, the massage community is often hesitant to directly address the issue of treating the obese population.
Massage school schedules are chock full of classes on working with the elderly, pregnant women, infants, people with HIV, and cancer patients. But try finding a class on working with the obese. Considering that one-third of the population is obese, that’s one-third of the population that most massage therapists are ill-prepared to help.
Mara Nesbitt-Aldrich, a retired massage therapist in Portland, Oregon, who weighs nearly 450 pounds, has received many massages where therapists only concentrate on the middle third of her body—including her peer students in massage school. “It’s like they couldn’t believe there was any part of me that extended out here,” she says, gently grasping her girth. “And they refused to deal with folds of skin, to touch them, or get under them.”
Lisa Barck Garofalo, the curriculum coordinator and massage fundamentals instructor at the Oregon School of Massage (OSM), is honest when asked why education designed to address the challenges of giving massage to the obese is so limited. “It’s probably because there’s some sort of stigma with naming folks obese,” she says. “I’m most comfortable using the word deep, because you can be deep for lots of reasons and there’s no real judgment associated with it.”
And yet the word obese is simply a medical classification and would seem perfectly appropriate in a clinical setting. Confounding matters is that many obese people, especially those involved in the fat acceptance movement (National Association to Advance Fat Acceptance; www.naafa.org), prefer to be called fat. For most average-weight people—and especially those practicing compassion—it would never occur to them to refer to anyone as fat. But, as Nesbitt-Aldrich explains, assuming the word fat is offensive means you have judgment tied up in it. For fat people, it’s just an accurate statement of their size—not their self-worth, personality, or anything else. “Many people are offended by the word fat, because they haven’t really doubted the stinging power of it,” she says.
Listen for clues in the language your clients use. This will give you a pretty good idea about where they are in their own size acceptance. More often than not, it still seems safer to revert to the clinical term obese, since we are healthcare professionals.
It May Seem Obvious, But …
The majority of obese people know they’re fat. By the time a person is 100, 200, or even 300 pounds overweight, their weight has affected many aspects of their lives. They have a hard time sitting comfortably in chairs, the seatbelts in their cars aren’t long enough, finding clothes that fit is difficult, and they might be forced to pay for two seats on an airplane. If all that isn’t enough, everyone from healthcare professionals to well-meaning (and not-so-well-meaning) relatives remind them of their size all the time. Unsolicited diet and exercise advice lurks around every corner. It is unlikely that acknowledging a client’s size in a nonjudgmental manner will come out of left field.
But why acknowledge it at all? An obese person is just as deserving of massage as an average weight person. They are a soul within a body deserving loving respect. But there are physiological differences that will cause challenges to the massage therapist who isn’t prepared. Things don’t always go smoothly and you’ll sometimes need to improvise. If you’re uncomfortable acknowledging a person’s size, it will make these glitches all the more awkward. “Someone who weighs 500 pounds knows she’s posing challenges for you,” says Theresa Brennan, a Seattle therapist who specializes in bodywork for obese clients. “She will appreciate the fact that you’re trying your best.”
Why It’s Called Bodywork
Because of their girth, obese clients’ bodies rise higher off the table. In order to maintain the body mechanics that allow you to apply pressure from the weight of your whole body, instead of just your arms and hands, you must be a certain height above a client. When working with obese clients, that means lowering your table to give you the height advantage. But what if lowered all the way, and it’s still not low enough? Brennan suggests eliminating the table entirely and working with clients on a mat on the floor (first make sure both the therapist and client are physically able to get on and off the floor). Or you might want to position your client in a side-lying position and work seated. Not only will this help with your body mechanics, but it might be a more comfortable position for your client, as many obese people are uncomfortable and experience breathing problems in the prone and supine positions.
Joy Terkelsen, a Denver massage therapist and certified ergonomics specialist, emphasizes how important it is for therapists to be aware of their own body mechanics. “Try to keep your body in the most neutral position possible,” she advises. This means keeping your wrists straight, not twisting or bending your back, and bending from the knees when lifting or moving a body part (especially important to keep in mind when doing range of motion on, say, a 100-pound leg). “Keep your body in line with your client’s body,” Terkelsen says, “and this will minimize injury to yourself.”
A common misconception about working with obese people is that deep pressure must be applied in order to get through the adipose tissue to the muscle. But just because you can’t feel the muscle or bony landmarks doesn’t mean they’re not being affected. Brennan also advises that fat tissue is avascular. “This means the tissue needs to be warmed up very well.” And the best way to warm up tissue is with light, Swedish massage strokes.
Additionally, many obese clients experience constant low-grade pain. “Most don’t even realize it because the pain is so constant,” Brennan says. So, work gently. Even if clients request deep-tissue massage, check in with your own body to make sure you can handle it. If not, it’s OK to apply a lighter stroke or do something more energy oriented. “It might not be what they thought they were going to get,” Nesbitt-Aldrich says, “but you’ll know you’re doing the very best you can.”
Make Your Space Friendly
In a massage session with overweight clients, challenges will exist not just for you, but for them as well. They’re used to going through the world faced with physical challenges, so do everything you can to minimize them in your healing environment. Provide large enough chairs (preferably without arms) for obese clients to sit in. Make sure your table is wide enough and sturdy enough to accommodate their body size, and provide bolsters to help make them more comfortable. Make sure sheets are ample enough to cover large clients’ bodies.
Many obese clients have a hard time climbing on or off the table, so it’s good to have a step stool handy. These clients also might have a hard time turning over, and it will be easier if they get completely off the table, and then get back on in the opposite position (just make sure you hold the sheet up for a privacy drape, or leave the room while they reposition themselves). “If you’re comfortable and matter-of-fact about these issues,” Brennan says, “your clients will be, too.”
Beyond the Body
For many obese people, there are emotional and psychological ramifications to their weight. In everything from work environments to medical settings, obese people are sometimes presumed to be stupid, unsuccessful, weak-willed, unpleasant, and lazy. According to the North American Association for the Study of Obesity, this weight stigma results in higher rates of depression, anxiety, social isolation, vulnerability, and low self-esteem. Of course, this doesn’t mean all large people are depressed and self-doubting. Plenty have been able to eschew the negative messages aimed at them and go through life feeling happy, confident, and sexy. However, receiving massage puts even the most healthy, well-adjusted person in a state of vulnerability; for clients who are repeatedly exposed to stigma about their bodies, it can feel downright dangerous. It’s essential that massage therapists maintain a safe atmosphere that encourages their obese clients to feel welcome and not judged.
Making your office fat friendly, as discussed, is one of the most practical ways to create a safe space for clients. But what you say—and don’t say—is equally important. One of the crucial steps you can practice is to refrain from diet and exercise advice. Not only is weight-loss advice outside the scope of your practice, but it can reinforce the idea that your clients aren’t OK just as they are. “Everyone from their mother to their doctor to plenty of strangers on the street have done that all their lives,” Brennan says. Furthermore, studies have shown that many obese people delay or cease going to the doctor because they don’t want to be lectured every time anything’s wrong with them. You certainly don’t want your clients to stop coming to you for this reason, and you might very well be one of their main outlets for wellness care.
Large clients may even start talking negatively about their body. Through your compassionate touch and safe space, you have the opportunity to counteract that self-hatred. Whenever Nesbitt-Aldrich’s clients start talking negatively about their bodies, she says, “While you’re here, in this time and in this space, you are beautiful and you are perfect.”
Self-Care
Let’s revisit George, the 400-plus pound client who wanted deep massage. George was coming in for 90-minute massages weekly—which had great financial benefits—but I was never able to work on him in a way that didn’t cause me varying levels of pain. My skills also felt compromised, and I never felt like I was giving him my best work.
Additionally, George had a range of complicated psychological issues he’d been working through. Like many obese people, George had been abused as a child. He felt that putting on weight was a way of protecting, or armoring, himself. Although he had done a great deal of work around these issues, he still struggled with boundaries. This meant my boundaries were challenged, and trying to be on guard all the time was exhausting. Sometimes my boundaries became fuzzy, too. I also found myself absorbing much of his emotional pain—which no doubt exacerbated my own physical fatigue and pain. I didn’t know what to do.
Terkelsen suggests the importance of self-care when working with these kinds of physical and emotional challenges. After the massage, practice counteractive measures—like stretching your body the opposite of how you worked with it—in order to unwind back to a neutral position. Don’t schedule a client right after any challenging massage; give yourself at least a few hours to rest and revive yourself, or make that client your last of the day.
As for the emotional challenges, Terkelsen suggests setting an intention for your space that provides safety for both you and your client. Conversely, after a session, clear the space of stuck or negative energy. If this isn’t your style, then do something physical to clear your head, like taking a walk.
If you practice all these measures and still find yourself compromised, then you might have to consider letting the client go. Barck Garofalo says that in OSM’s communication and ethics class, they role play a scenario where an overweight client comes in. They ask students to consider what they will do. “Are you going to turn them away, and what words would you use?” Barck Garofalo asks. “Will you suck it up, or will you find a level in yourself you didn’t know was there?”
When asked if it’s ever OK to let a client go because of the weight issue, Brennan makes the distinction that if it’s about your own unresolved prejudices, you need to “get over yourself.” Be honest with yourself about what’s really bothering you about the situation and whether you’ve done everything you can to best serve the client and your own well-being. We live in a society where the fat stigma is widely practiced and accepted, and it would be amazing if none of us absorbed any of those negative messages. As you discover your own prejudices, practice the same nonjudgment on yourself that you would with others. As Buddhist nun and author Pema Chödrön suggests in Start Where You Are: A Guide to Compassionate Living (Shambhala, 2004), simply acknowledge the thoughts, then send them on their way. Working with an obese client gives you an opportunity to challenge common assumptions. You will undoubtedly find that obese people are smart, ambitious, and beautiful—just like everyone else.
You also have the right to, first and foremost, take care of your own body. If you simply have not found a way to adapt to the physical challenges, let your client know how valuable he or she is to you, but because of your own body size, strength, etc., you are unable to offer them the relief they need. Tell them you’d like to refer them to a massage therapist who can better meet their needs. This may feel awkward—I could never empower myself enough to do it with George—but the reality is, you’re setting a good example of how to care for yourself—physically and emotionally. This is the best gift you can give any client.
Liz Prato has been a massage therapist in Portland, Oregon, for more than a decade. Her writing has appeared in numerous publications, including LivPdx, Iron Horse Literary Review, Subtropics, Northwest Women’s Journal, Berkeley Fiction Review, and ZYZZYVA. Contact her at lizprato@comcast.net.