Research: Massage for Female Veterans with PTSD

By Martha Brown Menard, May 24, 2016

The study question: Post-traumatic stress disorder (PTSD) is an anxiety disorder characterized by the intrusive re-experiencing of trauma, avoidance and emotional numbing, and hyperarousal of the sympathetic nervous system. Can massage therapy, as a component of body-oriented therapy, promote relaxation and pain relief, greater body-mind connection and an increased sense of trust?

This article presents pilot data from a 2010 study conducted in the state of Washington that assessed the feasibility and acceptability of body-oriented therapy for female veterans diagnosed with PTSD and chronic pain who were taking prescription pain medications. One in 5 female veterans who seek Veterans Affairs (VA) services screens positive for PTSD, and many have a history of sexual trauma. Statistically, female veterans with PTSD have significantly more somatic distress and medical conditions compared to female veterans without PTSD. Body therapy approaches to treating trauma focus on accessing and accepting sensory and emotional awareness in the body, an important foundation for self-awareness and self-regulation in the treatment of PTSD, which is helpful in the treatment of physical pain in individuals who have a history of trauma. The goal of the study was to gather preliminary data and clinical experience to facilitate the design and implementation of a future randomized controlled trial with a larger sample of the same population.

The study intervention consisted of “Mindful Awareness in Body-oriented Therapy” (MABT), a body-oriented therapy developed by the study author (CJP), focused on facilitating sensory and emotional awareness using a combination of hands-on and verbal therapy, with the goal of promoting mind-body awareness and integration. The MABT intervention has three stages. Stage 1 uses two sessions of massage to reduce tension and increase awareness of physical stress cues in combination with body literacy to develop a person’s ability to identify and articulate sensory experience. Stage 2 focuses on body awareness exercises to teach access to inner-body sensory/ emotional experience and self-care skills, again across two sessions. Stage 3 includes four sessions focused on mindful body awareness practice to facilitate presence and acceptance of and connection with (vs. dissociation from) inner-body experience. The intervention is responsive to the individual need for comfort and safety, and the protocol is necessarily flexible to accommodate client needs. Each session began with the participant seated and consisted of a 10-minute semi-structured intake to assess physical and emotional well-being, followed by 40 minutes focused on the primary elements of each stage of the intervention as outlined. The last 10 minutes of each session, again performed with the participant seated, included a review of the session experience and creation of a take-home body awareness exercise.

The study methods. Fourteen participants were enrolled and randomly assigned to either treatment as usual (control group) or treatment as usual plus eight weekly individual body-oriented therapy sessions (mindful awareness in body-oriented therapy group). Study inclusion criteria required participants to be female veterans receiving primary care at the women’s clinic with verified diagnoses of PTSD and chronic pain, with use of prescription analgesics not available over the counter and who agreed not to seek (non-study) massage treatment during study participation. Study exclusion criteria were a change in psychotropic medication during the past eight weeks, active dependence on alcohol or drugs, a current abusive domestic/interpersonal relationship, hospitalization for suicidality within the past three months, diagnosis of psychosis and/ or more than three months pregnant. The MABT intervention was delivered as eight one-hour sessions within a 10-week period.

Outcome measures included the Brief Symptoms Inventory, PTSD Checklist-Civilian Version (PCLC), Dissociative Experiences Scale (DES), Medical Symptoms Checklist, the Scale of Body Connection (SBC) and Body Investment Scale (BIS). Measures were administered at three time points: baseline, post-intervention or 10 weeks from baseline (for the control group), and at six-week follow-up after the post-intervention appointment. Research assistants administered the baseline questionnaire. To assure treatment fidelity, process measures assessing administration of the study protocol and homeexercise compliance were completed by the treating therapist and participants, respectively.

Both descriptive statistics and qualitative analyses were used to provide empirical and experiential perspectives on the study process. Analysis included evaluation of baseline equivalence of the study groups and descriptive statistics to examine recruitment feasibility, sample characteristics, session attendance, completion of questionnaire items at each time point, adherence to take-home practice and aspects of treatment fidelity. Content analysis was used to examine participant experience of the intervention as expressed on post-intervention questionnaires and during the post-intervention interview.

The results. During the three-month enrollment period, 31 women expressed interest in study participation, 16 met eligibility criteria and 14 were enrolled. Primary reasons for exclusion were lack of confirmed PTSD diagnosis and lack of medication use. Study completion rates were high—all participants attended seven out of eight scheduled sessions; however, therapist flexibility played a role, as participants also reported rescheduling many of the sessions.

The outcome measures performed adequately, although quantitative results were not reported, likely due to the small sample size. Qualitative comments about participants’ experiences fell into three primary categories: learning tools for pain relief/relaxation, increased body-mind connection and increased trust/ safety. Four of the seven participants indicated that the MABT intervention had positively influenced trauma recovery and their psychotherapeutic process, one participant was unsure and two responded that the intervention had not had an influence on abuse recovery or in psychotherapy. Overall, participants found the intervention to be both rewarding and at times challenging.

Limitations of study. The study sample was small, especially in terms of the number of outcome measures included, which also limits the generalizability of the findings. The investigator also served as the treating therapist. Participants in both groups attended the same group psychotherapy sessions, which may have allowed them to compare notes regarding the MABT treatment.

Implications for evidence-informed practice. Massage therapy can have positive benefits for female veterans by reducing pain and promoting greater awareness of the mind-body connection. Therapists working with female clients who are veterans should be aware that this population may have high levels of both physical and psychological distress. If clients are not already in psychotherapy, either concurrently with receiving massage or having had psychotherapy in the past, therapists should be prepared to make a referral to a psychotherapist with experience in working with trauma survivors. Establishing and maintaining a positive therapeutic relationship with good interpersonal boundaries is important for promoting the client’s sense of safety. Massage therapists should also have a peer supervision system in place.