Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.

While the changes accompanying aging can be unsettling and frightening to the elderly, it's comforting to know that something as simple as frequent touch can stimulate maturing minds and bodies, ensuring that the concomitant traumas of our later years are minimized. As a bodyworker, bringing touch to this facility-bound population can bring both heartache and joy, but the value of your work cannot be denied.

As most people age, they begin to notice a gradual slowing down of their physical and mental capabilities. Joints become worn, making them susceptible to crippling and painful conditions such as arthritis, bursitis and tendinitis. The skin loses some of its elasticity and moisture, as well as changes in pigmentation. Lung capacity decreases as does blood flow to the brain. Decreased mobility contributes to poor circulation and constipation, as well as a gradual loss of muscular strength and tone. And changes in physical and mental acuity, including hearing deficiencies and visual impairments, often lead to decreases in functional abilities.

Growing older also means facing a number of irreversible and potentially stress-producing life changes like retirement, relocation and widowhood. The losses associated with aging often are permanent (as opposed to losses in earlier stages of life from which we more readily recover) and occur closer together with less time to adjust between events. Chronic illness and functional limitations can increase anxiety about the future and create greater dependency on others.

As life spans increase, the number of people requiring long-term health care is also increasing. It is estimated that in the coming year, almost 9 million older Americans will need extended health care services. Some of these men and women transfer to nursing homes for rehabilitation after an accident or injury, or to convalesce after a serious illness. Others will live out their lives confined to care facilities. Those people may be too frail to take care of themselves and live safely, or they may suffer from a chronic illness and need medical attention. Family care may not be an option because there is no family member available, or because family members are unable to provide the care that is needed.


A Loss of Independence
The move into a health care facility signals a significant loss of independence and constitutes a major lifestyle change for both the person involved and their family. Relocation may create additional losses, including forfeiture of one's home, familiar surroundings and privacy. Treasured possessions may need to be sold, put in storage or given away. Also, those living their lives in care facilities usually have less contact with the outside world and fewer social relationships than those who live independently or with family.

When a person becomes a resident of a care facility, he or she is suddenly relegated to rules. Meals, rest periods and activities are scheduled for efficiency in management and convenience of caregivers rather than according to individual preferences, lifestyle choices or personal habits and rhythms.


Depression and Stress
Multiple losses combined with decreased mobility and functional impairments frequently lead to depression. According to a recent article by Paula Dranov entitled "Depression and the Elderly," the suicide rate among people over 65 is higher than any other age group.

Combined with health conditions requiring medical attention, a gradual decline in functioning and increased dependency on others can make these losses extremely stress-producing. While a certain amount of stress can be positive, we all know too much or prolonged stress can be unpleasant and unhealthy. Stress lowers resistance to viruses and can lead to more acute, chronic or even life-threatening health problems.

Massage therapists know stress affects the physical body by causing muscular tightness, tension, stiffness and restricted energy flow. Continued stress can lead to muscle spasms, as well as bodily contraction, restricted movement and rigidity. Other signs of stress may include headaches, backache, fatigue, insomnia, stiff neck, cold hands and/or feet, perspiration, shortness of breath, constipation, etc. Physical stress tends to produce more emotional stress, thus setting up a cycle of disease, discomfort and anxiety which can generate feelings of confusion, frustration, isolation and vulnerability for the elderly. Such feelings eventually lead to inertia, despondency, withdrawal and a "failure to thrive" syndrome.


Reaching Through Isolation
In his classic book, Touching: The Human Significance of the Skin, Ashley Montague says it is the "emotional involvement of touch that can reach through isolation."1 Touch can communicate love, affection and warmth which can help alleviate feelings of loneliness and separation. Touch becomes especially important for those confined to health care institutions who may receive few visitors from the outside world. Though basic needs are met, these individuals often remain starved for the nourishment that comes through caring, attentive touch and skin-to-skin human contact.

Massage and touch therapy are, in fact, ancient healing modalities which somehow became lost in the maze of modern medical technology, pills and paperwork. Back rubs were once routinely and effectively administered by nurses as a non-invasive therapeutic tool to promote rest and relaxation. Fortunately, massage is being rediscovered as a complementary and alternative therapy in caregiving. Age-appropriate, gentle massage and attentive touch techniques are particularly effective in providing comfort care and in enhancing quality of life for those who reside in a nursing home or extended care facility environments.

Massage therapy is well-known for its ability to reduce muscular tension, relieve minor aches and pains, increase circulation and induce a relaxation response in the body. Tiffany Field, through her research at the Touch Institute in Miami, has gained worldwide attention in discovering that therapeutic massage seems to stimulate the release of endorphins - the body's natural painkillers - into the brain and nervous system, boost the immune system and promote faster healing after injury, trauma or surgery.2 While little hard research is, at present, being conducted on the benefits of massage for nursing home residents, anecdotal reports from those working in this field have been extremely positive.

In 1996, a six-month pilot program on the use of massage therapy as an intervention for problem behaviors in nursing home residents with dementia, conducted at the Methodist Home in Chicago, found correlations between certain types of massage - and where it was applied on the body - and managing specific behaviors. For example:
- Back rubs worked wonders for those confined to wheelchairs, for people in chronic pain and for residents exhibiting irritability or even anger.
- Foot massage proved calming for those exhibiting hyperactive behavior or restlessness and "wandering" behavior.
- Hand massage or face stroking seemed to help those exhibiting anxiety, worry, sadness and fearfulness.
- Massaging the temples, scalp and forehead helped reduce headaches and tension, and shoulder and neck massage seemed useful for those exhibiting tiredness, irritability or mild upset.3

An unpublished report from a case study conducted by Christine Gruschke, nurse consultant for Beverly Health and Rehabilitation Services, Inc. (1997), showed a tremendous improvement in mood and anxiety levels in residents receiving geriatric massage therapy in a Florida nursing home once a week for an average of three months. Perhaps most noteworthy was the documented reduction in medications (representing a significant financial savings) taken for pain management for many of the 21 residents in this particular study.

Nursing manuals have long prescribed massage to help in the prevention of skin ulcers (pressure sores), a chronic problem for the frail elders who spend most of their time in a bed or wheelchair. Even very gentle massage can help improve circulation.

The focused attention afforded in massage and touch therapy sessions to residents of health care facilities also has significant psychosocial benefits, including:
- one-on-one attention
- skin-to-skin contact
- tactile and sensory stimulation
- an opportunity for social interaction
- nurturing
- comfort
- reassurance
- pleasure

Touch is a universal language. Gentle massage is a way of communicating with those who are non-verbal or unable to express themselves well orally. The practitioner who is able to keep her attention on the individual who inhabits the body and who is alert to the subtle nuances and changes in the physical being, breathing patterns and so on, will have little trouble understanding what the person needs.

Massage therapist Jeannie Battagin tells a beautiful story about sitting next to a lady in an intermediate care facility who was seldom able to speak in intelligible language but would babble for long periods of time as though she was trying to communicate.

"As she continued to 'talk,' I put my hand on hers. I began to slowly stroke down her arm from the shoulder, very gently. She seemed to relax into this, so after a little while I did the same thing with her other arm, stopping to spend extra time massaging her hands. For some reason, I felt drawn to put one of my hands on her cheek. She closed her eyes at this point, as if she was savoring the touch there. So I put my other hand on her other cheek and just stayed there cradling her face in my hands. A minute or so went by and I realized by the weight of her head and by her breathing that she had let go enough to fall asleep."4


Combating Dementia
At least half the population in most skilled nursing facilities suffer from some form of dementia. Massage offers therapeutic support for such people by increasing body awareness and helping to ground those who are confused and disoriented, bringing them back into present time and physical reality.

The use of conscious and compassionate touch helps address quality-of-life issues common among residents of long-term care facilities:
- touch deprivation
- low self-esteem
- anxiety
- boredom
- depression
- lethargy

In addition, skilled touch is a great aid in managing challenging behaviors sometimes characteristic of those living with dementia-related conditions, like Alzheimer's disease, restlessness, wandering, agitation, fearfulness and withdrawal. Utilizing skilled touch can help in such situations by focusing and engaging attention, redirecting energy, promoting interaction and calming.

A back rub or lotion massage to hands or feet might also be used as a distraction, if necessary, to help in accomplishing the tasks of daily care. Years ago, nurses were taught how to give back massages, instead of pills, to help lull their patients into restful sleep at bedtime. Unfortunately, most nurses these days are kept so busy dispensing pain-reducing and sleep-inducing medications they have no time to give their patients one-on-one attention or to touch them in a conscious, caring way.

Much has been made of the fact that human contact in the form of touch is crucial during the early stages of life. Research has proven that institutionalized infants deprived of caring touch soon stop eating and fail to thrive. Similarly, my observation and experience in working with the elderly has shown that those who are deprived of nurturing physical contact experience a diminishing quality of life, a lessening of their desire to relate to others and a weakening of what may already be a fragile relationship with physical reality.

As a therapeutic modality, age-appropriate massage is a cost-effective, non-pharmacological resource for reducing stress, managing challenging behaviors and enhancing quality of life for the elderly and ill, particularly those who are confined to care facilities. Montague writes, "The use of touch and physical closeness may be the most important way to communicate to ill and aged persons that they are still important as human beings."5

Unconditional, caring touch is a powerful acknowledgment to the individual that, regardless of the condition of the physical body, he or she is still a part of the human race, and still has value as a whole human being. This is healing in its true and deepest sense.

Dawn Nelson, CMT, founder and director of Compassionate Touch for those in later life stages, is an internationally recognized speaker, author and educator, and a pioneer in the effort to include massage in care plans for those in Alzheimer's facilities, nursing homes and hospice programs. Her first book, Compassionate Touch: Hands-On Caregiving for the Elderly, the Ill and the Dying has been recommended by one Kaiser Permanente medical director as "essential reading for all caregivers." For a list of training workshops and resource materials offered through Compassionate Touch, call 925/935-3906 or e-mail cttrain@jps.net.

References
1. Montague, Ashley. Touching: The Human Significance of the Skin, 3rd ed. (Harper and Row: New York, 1986).
2. Field, Tiffany. Keynote to AMTA National Convention, Nov. 7, 1997, Salt Lake City, Utah.
3. Belle, Cynthia. 4th National Alzheimer's Disease Education Conf. presentation, Chicago, Ill, July, 1995.
4. Battagin, Jeannie, CMT. Personal Communication, 1997.
5. Montague.

Originally published in Body Sense magazine, August/Winter 2005. Copyright 2005. Associated Bodywork and Massage Professionals. All rights reserved.

It started as a typical visit. Jennifer was seeking help for chronic low back and hip pain and over the course of several bodywork sessions, we worked to clear areas of tightness throughout her legs, hips, and lower back. But on this day, as I gently freed the side of her hip, her facial expression changed from one of pleasure to one of puzzlement.

"That's interesting," she said. "I just remembered when all this started."

I listened as she recalled the accident that began a pain cycle she had endured for years.

"I fell from the top of a human pyramid at a summer cheerleading camp in high school. What's odd is that the memories are flooding into my brain -- things I had forgotten long ago. I remember the day, the weather, the smell of bacon when I woke up, what I had for breakfast. It's all so vivid." As tears welled she described the fall, how she felt helpless and embarrassed when she couldn't get up. How she had to quit the camp and leave the squad her senior year.

I waited, watched, and listened, giving my full presence and support as she relived the event. From that session forward, Jennifer got better. Physically, her hip and low back pain began to resolve, and she felt she had gotten in touch with an important event in her life.

"I had no idea that fall had been so devastating," she said. "It was a key point in my life when many things changed."

What was happening in this pivotal session? Jennifer experienced an emotional release as a result of the bodywork. Because she felt safe and supported, she was able to work through some of the feelings that came up which helped her understand the origin of the chronic pain.

We've heard much about the connection between the body and mind, but what's really happening when you suddenly feel a strong emotion or retrieve a memory while getting a massage? It helps to first understand how the mind-body connection works.


The Body-Mind Connection
From an early age, we learn habits about how -- or how not to -- show our emotions. Some emotions such as anger, rage, or even frustration are discouraged. Suppressing emotions may be the difference between being accepted by our parents, friends, and teachers or being punished, criticized, or shamed.

But what happens to suppressed emotions? Where do they go when we're not allowed by parents or even ourselves to show them?

Our conscious mind has many functions. It directs voluntary movement in our bodies. It determines how we feel about our environment, and it makes choices about most aspects of our lives. Because the conscious mind gets information from our senses and directs our muscles to move, it is fully linked to our nervous system. Our nervous system controls our bodies. Further, our unconscious mind -- those things that we think but aren't aware of -- is also part of our nervous system.

When we learn not to show our feelings, they usually go into our bodies. We tense the muscles in our neck instead of frowning, we hold our breath instead of crying, or we clench our jaw instead of yelling. When these patterns are repeated, emotional suppression becomes a habit, the unconscious mind takes over, and the body becomes a storehouse for unexpressed, unconscious feelings.

At some point in almost all our lives, we've experienced a clear example of the mind-body connection. Recall a time when you had to give a speech or played your first music recital. Were your palms sweating, did you feel dizzy, was your heart pounding? In a stage fright situation, you were probably perfectly safe, no one from the audience was going to jump out and grab you, but your own feelings about the situation caused your body to react in a way that was completely out of your control. Were you able to stop the sweating in your palms? Probably not. Your mind took control and expressed your fears in a purely physical way.

Body language is another example of the mind-body connection. Someone who is feeling uncomfortable in a situation may sit with arms folded and legs crossed. They may show little feeling on their face, but their body tells something about what's going on in their mind. Many persistent pain patterns are associated with postural habits that have an emotional component. Think about how you sit or stand when you're feeling depressed or anxious. Postural holding can be entirely unconscious and may become fixed over time.

Finally, breathing patterns often reveal unconscious mind-body connections. Stress, chronic fear, or anxiety will show up as shallow and/or rapid breathing as the body stays in a chronic state of fight or flight.


Bodywork and Emotional Release
With an understanding of how emotions are stored in the physical body, we can understand why bodywork helps release them.

Muscle tension is one of the most frequent ways we hold emotion. Many people seek massage to help relieve tension from chronic stress. By relaxing muscles and reducing tension, massage frees the pattern where the unconscious feeling is being held. Once the tension is gone, the unconscious mind loses its grasp and an emotion may emerge.

People who hold excessive tension often have hypersensitive nervous systems. Supportive touch offered by a trained massage therapist can calm the nervous system, which changes the mind-body pattern. This calming effect creates freedom for feelings to come forth and be released in a safe, supportive, nonjudgemental environment.

Some bodywork systems such as Rolfing and Hellerwork actually help to change body posture. These whole body approaches can even help change a general emotional pattern by reorganizing the structural pattern that developed as a result of the initial depression or anxiety.


What is an Emotional Release Like?
Emotional releases can take many forms. As a client, you may feel sadness, grief, anger, fear. Positive feelings may come up in releases, but this is rare since our culture is more supportive of expressing positive feelings in the moment rather than suppressing them. You may have memories of a particular event, but you may not be able to associate your feelings with anything from your past. You may feel like crying or your feeling may simply come with a desire to take a deep breath.

Some emotional releases are associated with specific traumatic events while others reveal more chronic thought patterns. You may get in touch with old unconscious beliefs or attitudes that no longer serve you, or you may be surprised to learn something about your relationship with your body. What's important to know is that your body is offering you an opportunity to grow and change beyond habitual patterns. If you're getting a feeling that seems to be out of context with the circumstances of the massage, it may be an emotional release surfacing. Pay attention to your feelings and tell your therapist what's happening.

Many bodyworkers are experienced in working with emotional releases. While they're not trained as psychotherapists, they can be there to support you through the release process. By simply maintaining a grounding touch and listening, they are there to support you as you release a feeling that no longer serves you. If you feel supported and safe, you're able to let go of the emotion -- most importantly, don't push it back down in your old way of suppressing. When the emotion surfaces, your body is telling you it's time to let it go.

Most releases surface and resolve quickly. However, if you have frequent strong emotional releases in your massages or if you're feeling more anxious or fearful as a result of the bodywork, it's important to seek the help of a professional counselor.


Counseling and Bodywork
Professional counselors are trained to work with clients in the psychological realm. They know how to treat mental health conditions and are able to create a safe environment in which to explore psychological material. Counselors offer solutions to emotional issues and can give advice related to personal concerns.

While many people seek the help of a counselor to work on deep psychological wounds, counseling is also a great avenue for personal growth. By working on old thought patterns and belief systems, clients can discover new ways of making choices and new ways of being.

Because bodywork can reveal unconscious thought patterns, many counselors work closely with massage therapists and bodyworkers as a way of enhancing this personal growth.

I collaborate with several psychotherapists who refer their clients for bodywork to help them access unconscious patterns that can then be explored in their psychotherapy sessions. The combination is a powerful personal growth tool. The body and mind can finally be connected in a healthy way, and the client learns new ways of expressing feelings.

Bodywork helps the client become aware of how and where she stores emotions. Not everyone experiences emotional releases in bodywork sessions, and I've never seen anyone have an emotional release in every session.

Many times the release takes both therapist and client by surprise, but if we're prepared for the possibility, it can be a freeing, learning experience. The body becomes the teacher for the mind and if we stay open, we gain the power to make new choices, learn new patterns, and create a healthier, more conscious, life.

Cathy Ulrich is a freelance writer, artist, physical therapist, and Certified Advanced Rolfer. She maintains a private bodywork practice in Colorado and teaches workshops on intuition and personal energy management. She can be contacted at cathy@circleofbeing.com.