For me the experience underlined the importance of establishing and working within a frame that the client can recognise and feel safe within. Initially, the lightest touch direct on the main tension was intolerable because there was no experiential frame that the client felt she could control. This reminded me of how unhelpful it is for someone to tell you that you are suffering while you are not ready to open to it. Later, after the cooperative work on her neck had established a frame for her, we could work successfully into the tension, starting in surrounding proximal areas and working distally. I was struck by how much better things worked once she was actively guiding the process herself rather than being processed by me. It seems to me that as massage therapists, we do not heal clients as much as help the clients heal themselves. Its not something done to the client, but something done by and with the client. It also gave me a sense that my ideas on psychosomatic tension were quite reasonable.

Early researchers in the field of psychotherapy recognised the essential unity of the mind and body. However, the most influential of them, Sigmund Freud, excluded the body from a meaningful position in his theory, propagating the mind/body split that Descartes had instigated many centuries before. Consequently, for most of the 20th century, psychology and medicine have largely ignored psychosomatic connections, even to such an extent that the very term itself came to be used as a label for “phoney” symptoms. More recently, the New Age movement has drawn from Eastern tradition to generate an upsurge of interest in the mind/body connection, encouraging well-being activities such as meditation and yoga. Western medicine is beginning to adapt to the evidence of the efficacy of these practices, and the mind/body connection is being returned to centre stage in the understanding of illness. Due to the dual nature of the condition, treatments for psychosomatic tension can work with both the mind and the body. Massage therapy is a powerful body-based treatment modality that can greatly benefit clients suffering with chronic psychosomatic tension.

Stress and the HPA axis

One mind/body process that plays a pivotal role in generating chronic tension patterns is the HPA axis. The hypothalamic-pituitary-adrenal axis controls the reaction to stress, regulating many body processes, including digestion, the immune system, mood and emotions, sexuality, and energy storage and expenditure. The HPA axis generates the primal fight or flight response to stress, secreting adrenal that brings the mind/body to a state of hyper-arousal. This is an adaptive response to an acute environmental stressor since it primes the mind/body to react quickly to a potentially dangerous situation. However, in the presence of a long-term stressor (either real or perceived) the HPA axis can “jam” itself into a constant state of hyper-arousal. Unable to switch off and recover, this state of constant anxiety causes a slow erosion of the body’s immune system, and chronic muscular guarding, particularly in the shoulders, neck and stomach. Chronic muscular guarding is a bracing response to pain or the threat of injury. It destabilises normal patterns of muscular tone, causing hypertonia and knots in the tensed muscles, and hypotonia and flabbiness in nearby protected regions. This is one way that chronic psychosomatic tensions come to manifest in the body. It is a potentially life-threatening condition that left untreated can lead to a total mind/body burnout, plunging the client into a state of total exhaustion lasting for months or years. More serious still, chronic psychosomatic tension has also been implicated in the onset of many auto-immune diseases. In a chronic state of hyper-arousal, the immune system becomes hyper-vigilant and in the absence of any real immune challenge misguidedly attacks a part of the client’s own body.

Negative Emotions and Psychic and Somatic Defense mechanisms

When we open ourselves to experience emotions such as grief, fear, anger, and joy, they are felt through our bodies. Extreme or chronic negative experiences cause psychological dissociation from our emotional responses. Such psychic dissociation is manifested in the body. One of the primary roles of muscular guarding is to restrict movement near the site of an injury in order to immobilise the area and protect it from further harm. Since emotions are also felt through our bodies, muscular guarding is the physical corollary of psychic dissociation. The body braces itself against the experience of negative emotion, physically locking the unwanted sensations out of our awareness. This compensatory process of physical and mental denial can generate chronic adaption in our character and body posture. Maintaining these defensive responses requires energy, and causes us to become rigid. In the same way as armour protects us against the outside world but limits our freedom of movement, chronic psychosomatic tension protects us against our own feelings. As with a heavy suit of armour, this protection requires energy to maintain, and also limits the range of our physical and psychological xpression as we become unconsciously preoccupied with defence.

Physical Signs and Symptoms

Chronic psychosomatic tension manifests in the body as changes in muscle tone (hypertonia and hypotonia) referred to as muscular guarding . Hypertonic muscle is stiff and tight under palpation, and can become knotted, particularly if the underlying injury has a long history. Hypotonic muscle feels flabby and soft, even spongy in extreme cases. Unlike guarding due to purely physical injuries, psychosomatic tension manifests in coordinated patterns that can physically restrain the client’s whole range of movement. Recent stressors often generate tension directly in the shoulders, neck, and stomach creating a hunched up posture, with rigid holding patterns across the upper arms and shoulders. Tension due to defensive dissociations can manifest in complex networks across the entire body that cause postural changes, either holding the client’s energy back, or up, or stifling their energy down inside their bodies.

It is important to note that chronic muscular guarding may reflect an entirely physical rather than psychosomatic process, the therapist must consider a full range of explanations. Long periods of typing can cause tension in the shoulders and neck, waitressing can cause tension in lumbar regions and hips, and sports can create specific muscular tensions.

Behavioural Signs and Symptoms

The best signs that a particular pattern of muscular tension may reflect a psychosomatic process come from the client’s behavioural responses. Careful massage work on or near psychosomatic tension often brings the client into contact with dissociated psychic content, thoughts and feelings that can elicit strong emotional responses. Resistance, defensive mechanisms, acting out, and emotional release are behavioural response patterns that can be activated by massage therapy work on chronic psychosomatic tension, and it is important for the therapist to be trained to recognise and understand these behaviours, and respond appropriately.

Treatment Strategy

Treatment strategies for chronic psychosomatic tension have all the normal elements of any massage program aimed at relaxation. Rather than bringing new skills to the table, what is required of the successful massage therapist is a change of emphasis, a shift in the focus of attention. What matters is the client’s subjective experience of being accompanied by the therapist during the journey of their massage. A good dancer must learn the steps of the dance until they become totally familiar, and listen carefully to the story of the music, before being able to articulate it and communicate gracefully. In the same way, the therapist’s must master a broad range of movements, and study the nature of the relationships between mind, emotion, and body in practice, before being able to successfully guide and support the awareness of the client.

Mind/Body Support

There is an undeniable intuitive aspect to successful massage work with chronic psychosomatic tension. There is a close relationship between chronic psychosomatic tension and trapped negative emotion and psychic pain. Dissociated feelings are locked away for the very reason that the client subconsciously believes that they are not safe to be experienced. Bringing awareness to these feelings is a deeply threatening process for the client. It should always be the client’s choice to proceed at their own pace. Failure to listen to and respect the client’s comfort levels will reduce the efficacy of treatment and in the extreme could lead to the danger of retraumatisation. A useful analogy is that of the massage session as a trip through the mind/body mansion of the client’s being, with the therapist as guide. The client’s past dissociated experiential states can be conceptualised as certain rooms inside the mansion that have be closed off and are no longer visited because they are considered too unpleasant and dangerous. Extending the analogy, chronic psychosomatic tensions can be imagined as the physical bars in the client’s body that prevent the client from entering these forbidden rooms. Working on or close to such tension patterns, we bring the client’s awareness to the threshold of these forbidden states. It must remain the client’s choice to relax the tension patterns and enter these stifled spaces, the therapist can only guide the client’s awareness, and provide support and reassurance through their presence. If the therapist blindly forces into the tensed muscles, the client will experience the work as invasive, and simply move their attention away, running elsewhere in the mansion, and thereby increasing their dissociation. If the client’s unconscious mind feels safe, and supported, and is ready to reintegrate the spaces, the tension patterns may relax, causing a flood of feeling as the client’s awareness slides into the reopened space. Intense emotions such as fear, sadness, and anger may be re-encountered at this point, and it’s essential that the therapist continues to accompany the client, providing non-judgemental (and preferably non-verbal) support during the release. Tension patterns have a tendency to reoccur, but with continuous treatment over time the client may reintegrate the dissociated states, often through a process of mourning, allowing them to change and become recontextualised. This permanently reduces their tension, freeing the client’s energy and mental and physical range of expression.

Therapeutic Frame

Put simply, the therapeutic frame is the set of agreed policies and environment that contain the therapeutic process. It covers such elements as payment, scheduling of appointments, cancellation policy, and relationship boundaries. While therapeutic frame is an important part of any massage therapy practice, it becomes particularly relevant in working with chronic psychosomatic tension. This type of therapy tends to be longer in duration and more profound than single-shot encounters, and this can deepen client/therapist attachment. The therapeutic frame provides explicit agreements that delimit the therapeutic process, allowing the client to understand clearly what they can reasonably expect and what lies outside the scope of therapy. With clear boundaries,clients can ask for things to which they are entitled, and understand why certain requests fall outside the frame, lending an important sense of security and stability to the process. By explicitly delineating the therapeutic frame, boundary transgressions can be more easily identified, allowing appropriate and timely reframing. Active management of the therapeutic frame is an important responsibility of the massage therapist engaging with this type of work.

Scope of Practice

Working with chronic psychosomatic tension, the massage therapist encounters the entire being of the client. As the therapist massages the client, accompanying and supporting them on journeys through their mind/body, it is not unusual for more explicitly psychic material to be encountered. As the client returns through their bodies to old dissociated experiences, memories and emotions often resurface. Re-experiencing and working through these memories and emotions can cause the client mental discomfort and potentially require psychotherapeutic support. In the same way that a massage therapist is a professional body guide whose tools are manual, so a psychotherapist is a professional mind guide whose tools are verbal. There is a danger of crossing the border between massage and psycho-therapy, bringing the therapist out of their scope of competence and into dangerous ground for both client and therapist, with many potential negative consequences. While the therapist must have some limited verbal communication with the client, during the session it should be kept to a minimum. It is the massage therapist’s hands that guide the client on their journeys. It is absolutely essential for the massage therapist to recognise and respect the limit of their professional competency and be able to refer clients in need of psychotherapeutic support to relevant resources.