A Plea for Responsible Practice
Subtle Ways to Increase Your Profitability

By Sue Radosti, LMT
Certified Trauma Touch Therapist

A tornado rips through a Midwestern city, leveling block after block of homes and businesses. Emergency services personnel rush to the site - police officers, firefighters, paramedics, nurses, doctors - working together to locate and care for survivors. The Red Cross converts a church hall into a relief shelter. Massage therapists set up tables to ease stress and muscle strain for those who bear the physical brunt of rescue and clean-up efforts.

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As massage therapy gains credibility in mainstream America, professional bodyworkers are found with increasing frequency at such sites of natural and man-made disasters. They are generally applauded by their colleagues and professional journals for their compassion and generosity. But could there be something wrong with this picture? In contrast to highly-trained and often-drilled emergency responders, do massage therapists really have adequate training and protocols for offering treatment in a setting of profound emotional and physical distress?

In order to assess the role of massage therapy at the scene of a disaster, it is first necessary to understand some of the other factors involved in that context; namely, the unique nature of critical incident stress, the stress-coping tactics of emergency responders, and the goals of other professionals (primarily mental health counselors) who address on-site stress management. Every rescue worker brings a blend of these factors to the massage table, with as many (if not more) ramifications than any other pre-existing conditions of health or lifestyle.

The emergency response professions involve constant exposure to dangerous and frightening situations. Because most emergency responders thrive on the role of rescuer, they often achieve heroic levels of professional excellence despite routine, on-the-job stressors most people would find intolerable. Large-scale disasters, however, go so far beyond the realm of "normal" experience for an emergency responder that they are classified as critical incidents. As the label implies, critical incidents are characterized by extreme stressors, such as the death or severe maiming of responders themselves or the people they serve. Such events have even more impact if the victims are children or people with whom the rescuers are acquainted.

The 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City is an extreme example of a critical incident. Karen Sitterle, who coordinated the mental health activities at the death notification center after the bombing, summed up the major stressors: "What we know about the long-term effect of a disaster is based on certain factors. Was the event sudden? Senseless? Of human design? Violent? Was there loss of life - particularly children's lives? We had all of that in Oklahoma City."l In addition, rescue workers' own lives were at serious risk because of the unstable building and the threat of additional bombs. Beyond the initial hours of actual rescues, there were also few rewards for those who searched for survivors. Most of their efforts involved retrieving the dead, most of whom were maimed. Due to the clustering of such extreme stress, Oklahoma City emergency responders were encouraged to work only in two-hour shifts.

Responding to Disaster
Studies of human response to disaster are very clear: No one can experience a disastrous event, even as a witness, without being affected. Reactions such as emotional numbness, feelings of helplessness and grief, nausea, headaches, sensory distortions and cognitive confusion are so nearly universal that they are considered normal responses to the abnormal stress of disaster. Such reactions may be experienced immediately or may surface as a delayed response in the disaster's aftermath.

Fortunately, most emergency responders are very skilled at creating functional patterns which enable them to do their jobs without becoming overwhelmed by their own stress reactions. They focus intensely on their technical procedures, striving for a level of automatic efficiency and precision. They may avoid making eye contact or looking at the face of the people they are assisting. They draw on a deep sense of professionalism, duty and loyalty to their vocations and to their co-workers. And (as any observant bodyworker may notice) they often maintain body postures which resemble a military "attention" stance - an upright, top-heavy, armored-bearing stance that creates inner and outer impressions of strength and competence. The most important functional skill emergency responders employ is a state of emotional containment. Containment is not an absence of emotion; it is a conscious choice to temporarily isolate certain emotions from the interactions and decision-making processes at hand. Containment enables emergency responders to function adequately even when they are feeling fear or horror.

Obviously, containment is essential in the midst of a critical incident. Lives depend on the rescue worker's ability to think clearly and act decisively. If he "loses it" on the job, he also faces the double whammy of perceived personal and professional inadequacy just when he feels the most pressure to perform his job admirably. Both his career and his mental health may depend on his competence under severe duress.

Dealing with the Aftermath
As our culture has allowed men a broader range of emotional experience - beginning with the acknowledgment of post-combat stress reactions in Vietnam veterans - the emotional stress of rescue work has also been recognized. A new specialty in "disaster mental health" has emerged within the psychotherapy field, addressing an implicit tension between healthy tactics for stress recovery and the skills which enable emergency responders to perform their jobs competently.

Recovery from critical incident stress requires a delicate transition from a state of functional containment to a fuller experience of emotion and self-expression. When that transition does not occur, or when it occurs too abruptly, in an inappropriate context, or with inadequate personal support, stress may actually be increased rather than alleviated. In some cases, the individual's mental health may be seriously compromised.

Most community disaster plans now include provisions for on-site stress management and ongoing stress education services for emergency responders. Regional Critical Incident Stress Management (CISM) teams, comprised of mental health professionals and specially-trained emergency services personnel, are often the providers of such services.

Under the guidance of CISM teams, the management of critical incident stress is a careful process which first strengthens a rescue worker's capacity for containment at the disaster site, and later facilitates the transition from containment to recovery. The primary goals are to prevent the development of serious stress disorders and to prevent an accumulation of effects from one critical incident to the next. Cumulative stress, even from a series of not-quite-critical incidents, can create the same response patterns as a single exposure to a large-scale disaster. The stages of stress management offered for emergency responders are "de-fusing" and "de-briefing."

De-fusing and De-briefing
According to trauma expert Judith Lewis Herman, M.D., "The capacity to preserve social connection and active coping strategies, even in the face of extremity, seems to protect people to some degree against the later development of post-traumatic syndromes."2 De-fusing introduces that protection at the site of the critical incident while rescue efforts are underway. At this stage of treatment, counselors interact with emergency personnel on a cerebral level. They ask factual questions about the worker's role in the event: "What time did you get here?" "What did you do first?" "When will you go back to work?" "What will you do next?" De-fusing thus focuses on the most stable and pro-active factors in a chaotic situation: professional protocols, technical skills, the regularity of time, ongoing job duties, etc. It provides emergency personnel the opportunity to relax into a matter-of-fact social interaction, while still preserving the containment of volatile emotion. Emotional issues are addressed only if the worker volunteers them; and even then, counselors do not invite emotional release, but assist the worker to establish the most
manageable level of emotion.

De-briefing is the stage of stress management which occurs when the critical incident is over. Only then are emergency responders encouraged to tap into the emotions they experienced during their work. This, too, is done in a context of social connection, usually in a group of co-workers. Sessions begin with an emphasis on thought processes and gradually shift toward an invitation for emotional responses: "What was the worst part of the incident for you?"

Counselors witness and accept the participants' feelings during de-briefing, offering reassurance that strong emotion - rage, horror, terror, despair, sadness - are normal reactions to an abnormal event. They work to eventually bring the responders' stories back to the level of thought processes, where logic can be integrated with the newly-released emotions. Finally, they explain the symptoms of potential stress disorders (such as Post-Traumatic Stress Disorder) and help identify personal sources of support for ongoing management of residual stress.

What Role Massage?
When massage therapy is randomly introduced into the scene of a critical incident, it carries the potential to either disrupt or harmonize with the other stress management tactics employed there. Massage therapists enter this precarious environment without any relevant research, specific contraindications, assessment guidelines, or proven treatments for critical incident stress. Every choice depends solely on the individual therapist's personal judgement and self-education about critical incident stress. For the sake of professional integrity and client safety, it seems imperative that "disaster massage therapy" be acknowledged within the profession as an experimental therapy that demands more research, information and training opportunities before it can be encouraged and promoted.

Meanwhile, what can massage therapists do when the opportunity arises to serve the needs of emergency response personnel? How can they pioneer this new therapy without subjecting clients to unreasonable risk? The first step is the very goal of this article: Discussing the possible ramifications of bodywork procedures and techniques in the overall context of critical incident stress. Such discussion raises many possible hypotheses, such as those that follow, which may help define a conservative, preliminary framework for further exploration and research.

* Massage therapists should educate themselves about the psychological, practical and ethical issues of disaster relief before attempting to participate in an incident. At the scene of a disaster, extraneous personnel and services can pose a serious threat to the competent execution of frontline rescue and stabilization efforts. Massage therapists who wish to volunteer their skills should be very careful to do so without interfering with the activities, protocols or goals of emergency operations. They should seek professional assessments of the situation (rather than mere media reports) before determining whether their skills would contribute worthwhile benefits. Above all, they should learn all they can about disaster psychology in advance of such incidents.

* Disaster massage therapy should be coordinated with other stress management tactics. Massage, by its very nature, tends to invite responses which are more appropriate to the de-briefing stage of stress management than to the de-fusing process. Such responses, elicited prematurely at the time of a critical incident, could be devastating to the mental health of an emergency responder. If on-site disaster massage therapy is to be offered, every effort must be made to support de-fusing's immediate goal of maintaining and strengthening the capacity for emotional containment. This is a verydifferent approach than most massage therapists are accustomed to. Many bodywork methods facilitate the release of emotion. Even Swedish massage, by inducing deep relaxation, may encourage more emotional presence than an emergency responder can safely tolerate in the midst of a disaster. Massage techniques which may contribute to the de-fusing process would include those that energize, support mental alertness and address very specific muscle fatigue without inducing general relaxation. Upright treatment postures (as on an on-site chair) may be less emotionally charged than horizontal positioning; similar emotional connotations may restrict types of strokes and body areas. All methods must be applied with respect for the client's personal defenses against overwhelming stress. Stubborn holding patterns may be serving a vital purpose.

* Thorough screening must precede every massage session at the site of a critical incident. Few massage therapists would accept a seriously injured client without a release from his doctor. In disaster massage therapy, similar precautions are necessary with respect to the mental health of emergency responders. Whenever a disaster qualifies as a critical incident (involving death or severe maiming), it is probably unwise for rescue workers to receive massage prior to a de-fusing session with a counselor. If counselors are not present at the site, massage therapists must consider whether they are qualified or willing to be responsible for the fragile emotional state of their clients (see box, page 43.)

* Massage therapists should contain their feelings of strong compassion and empathy when working at the scene of disaster. In times of personal crisis, people often tell friends, "Don't touch me - I'll start crying." Compassionate touch is a powerful accessor of emotion, and for that very reason, care must be taken to maintain a firm, matter-of-fact quality of contact when a massage therapist touches an emergency responder, striving to physically ground the client, rather than to comfort him. Just as counselors engage emergency responders only on a cerebral level during de-fusing, massage therapists can provide a safely limited interaction by focusing strictly on the physical facts of a client's stress. This, too, is an unfamiliar approach for most bodyworkers who may resist the idea of offering a "cold," business-like touch. But effective de-fusing requires a therapist to mirror his client's emotional restraint, especially in his touch.

* Massage therapists should recognize their own stress reactions to the disaster and seek appropriate assistance with stress management. Emergency responders and disaster mental health professionals have learned from experience that it is not wise to work alone in a context of trauma, nor to process their experience of disaster stress in isolation. Massage therapists must also be aware of their need for social connection during and after participation in disaster relief. Physical and emotional stress reactions contained during the incident need to be accepted later within an environment of support and safety, whether with colleagues, other disaster relief workers, a counselor or loved ones.

* Bodyworkers who desire to facilitate somatic de-briefing for disaster relief workers need specific training in relevant therapies. Guiding a client through the management of critical incident stress requires more than a high comfort level with emotional release. Release of traumatic memories and emotions must occur within safe parameters if the client is to successfully integrate his experience. Massage therapists who do post-disaster sessions with rescue workers (or victims) need a thorough understanding of trauma integration techniques, as well as a clear sense of their own scope of practice. The body plays a valid role in de-briefing processes, but psychological de-briefing should be facilitated only by those with specific training in mental health therapies. Ideally, clients will have access to both types of therapy with practitioners who value each other's roles and contributions to the healing process.

As massage therapists extend the range of applications for their craft, the possible benefits of disaster massage therapy deserve serious and careful exploration. While other established forms of critical incident stress management provide a potential frame of reference for developing complementary treatment guidelines, further research is the key to legitimizing this massage therapy service.

Notes
1 "Effects of Oklahoma City Bombing Persist," Behavioral Health Treatment,
Nov. 1997, p. 2.

2 Herman, Judith Lewis. Trauma and Recovery, Basic Books (New York), 1992,
p. 156.

Resources
Allen, R., ed., "Handbook of Post-Disaster Interventions," (special issue) Journal of Social Behavior and Personality, Vol. 8, No. 5, 1993.

Campolo, Lois. Coordinator of Counseling Services, Briar Cliff College, Sioux City, IA. Personal interview, May 1998.

"Effects of Oklahoma City Bombing Persist," Behavioral Health Treatment, November 1997, pp. 1-2.

Hartsough, D.M. and D.G. Myers. Disasterwork and Mental Health: Prevention and Control of Stress Among Workers. National Institute of Mental Health (Rockville, MD), 1985.

Herman, Judith Lewis. Trauma and Recovery, Basic Books (New York), 1992. Marmar, Charles R., Daniel S. Weiss, Thomas J. Metzler and Kevin Delucchi. "Characteristics of Emergency Services Personnel Related to Peritraumatic Dissociation During Critical Incident Exposure," American Journal of Psychiatry, July 1996 (s), pp. 94-102.

Mitchell, J. and G. Bray. Emergency Services Stress, Prentice-Hall (Englewood, NJ), 1990.

Myers, D. Disaster Response and Recovery. A Handbook for Mental Health Professionals, U.S. Government Printing Office (Washington, DC), 1994. National Institute of Mental Health, Center for Mental Health Studies of Emergencies. Role Stressors and Supports for Emergency Workers, NIMH (Rockville, MD), 1985.

Taylor, A.J.W., PhD, and A.G. Frazer, DCH, DPM. "The Stress of Post-Disaster Body Handling and Victim Identification Work," Journal of Human Stress, December 1982, pp. 4-12.

Sue Radosti, LMT, is a certified Trauma Touch Therapist and practicing massage therapist. This article, based on Radosti's final project for her Trauma Touch training, is an attempt to stimulate discussion within the profession regarding disaster massage therapy.

Reach Radosti at 4242 Gordon Drive, Suite 208, Sioux City, IA 51106; call 712/274-0357; or e-mail at
suemradosti@hotmail.com.

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