Ep 196 – Trauma-Informed Care—Interview with Pamela Fitch: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

Two hands reaching out for each other.

A client stiffens up when the therapist touches her upper leg, but doesn’t know why. The therapist responds with compassion and sensitivity, and creates some amazing possibilities.

In this very special episode Ruth sits down with Pamela Fitch, author of Talking Body, Listening Hands, an expert in the role of massage therapy for people with histories of touch-related trauma, to unpack why this situation worked out well, and what kinds of skills we need to provide the best care for our clients. And it concludes with a special bonus: Pam’s own IHACW story.


Pocket Pathology: abmp.com/abmp-pocket-pathology-app

Resources for Pam Fitch:


Talking Body Listening Hands - 2nd Ed. available here:
Algonquin College Press
Hard copies and e-texts

MT Canada 6 part Webinar Series: More Than Our Hands

Massage Therapy for Clients with a History of Trauma: 6 part webinar series
Massage Therapy Association of Manitoba

Author Images: 
Ruth Werner, author of A Massage Therapist's Guide to Pathology.
Ruth Werner's logo, blue R and W interlinked.
Author Bio: 

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP's partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner’s books are available at www.booksofdiscovery.com. And more information about her is available at www.ruthwerner.com


This podcast sponsored by:

About Anatomy Trains:  

Anatomy Trains is a global leader in online anatomy education and also provides in-classroom certification programs for structural integration in the US, Canada, Australia, Europe, Japan, and China, as well as fresh-tissue cadaver dissection labs and weekend courses. The work of Anatomy Trains originated with founder Tom Myers, who mapped the human body into 13 myofascial meridians in his original book, currently in its fourth edition and translated into 12 languages. The principles of Anatomy Trains are used by osteopaths, physical therapists, bodyworkers, massage therapists, personal trainers, yoga, Pilates, Gyrotonics, and other body-minded manual therapists and movement professionals. Anatomy Trains inspires these practitioners to work with holistic anatomy in treating system-wide patterns to provide improved client outcomes in terms of structure and function.  

Website: anatomytrains.com  

Email: info@anatomytrains.com   

Facebook: facebook.com/AnatomyTrains  

Instagram: instagram.com/anatomytrainsofficial  

YouTube: www.youtube.com/channel/UC2g6TOEFrX4b-CigknssKHA  

Full Transcript: 


0:00:01.2 Ruth Werner: Hey, "I Have a Client Who... " listeners. Did you know I have a growing library of NCB-approved, one-hour, online, self-paced continuing education courses that you can do anytime, anywhere? Well, now you know. Current classes include What's Next? COVID-19 Updates for Massage Therapists and A Massage Therapist's Introduction to Pharmacology Part One and brand new, A Massage Therapist's Introduction to Pharmacology Part Two. Classes are $20 each, and they confer one hour of continuing education credit. Wanna know more? Visit my website at ruthwerner.com and check it out. Be sure to sign up for my mailing list so you'll never miss a new class.


0:00:47.2 Speaker 2: Anatomy Trains is thrilled to announce our first ever women's health symposium. This live online event takes place February 26 and 27 2022, AWST. That's Australian Western Standard Time. Register by January 21st to receive a significant early bird discount and over $400 worth of bonuses. We have invited a powerful lineup of all female authors, physicians, therapists, and clinicians to share their passion and life's work. Visit anatomytrains.com for details.


0:01:35.7 RW: Hi, and welcome to "I Have a Client Who... " Pathology Conversations with Ruth Werner. The podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology and I have spent decades studying, writing about, and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice. And sometimes, as we have all learned, that is harder than it looks. For today's episode, I have a special experience of sharing this with my good friend, Pam Fitch. Pam, would you like to introduce yourself and tell us... Just maybe give us a couple of your titles. [chuckle]

0:02:37.0 Pam: Well, massage therapist for many, many years, more than 30, and educator, writer. I do some peer supervision, some consulting.

0:02:49.0 RW: Well, and Pam's book that I have been using lately for my work is called Talking Body, Listening Hands: A Guide to Professionalism, Communication and the Therapeutic Relationship, and I will have links to Pam and all of her work and classes in our show notes today. So Pam is gonna help me take apart this week's "I Have a Client Who... " story, which comes from a wonderful massage therapist. And I'm not gonna give any revealing information this time, not even about where this therapist is located. But here's the story.

0:03:21.7 RW: I have a client who was a mental health provider who came in for her first session. She wanted a full body Swedish massage, and everything was going well until it was time for me to touch her legs and I noticed that when I touched anything from her foot up to her knee, she was great, but when I moved to her inner thigh, her whole leg just stiffened and came right up off the table. And I said to her, "I notice that when I touch you on the inner side of your thigh, your whole body just says, 'Oh, no, get away from me!' So I just wanna check in. Is there an injury? Is there any pain here?" And the client said, "Nope, there's no pain, there's no... I don't know what's going on. I don't have... " Whatever. The therapist and the client decided together that they would re-drape her leg, so that the drape came almost down to her knee, instead of being tucked up high. And then they were able to finish the session and things seemed to go pretty well.

0:04:20.4 RW: Later the next day, this client posted a review of the therapist on Yelp and said, "Oh, my gosh. You have to go see this therapist. She's trauma-informed, she's body positive, she's just great." And that client became a regular client for a prolonged time. And the therapist who had no formal training or even familiarity with the concept of trauma-informed care, was really confused, and finally realized that that must go back to what she experienced with the client's leg. And there's another piece to this. There's two more pieces to this story. One is, after the session was over, the client revealed to the therapist that she had been raped and had thought that she really had been finished with all of her processing and all of the dealing with this trauma that she had to do, and clearly, being touched on the inner part of her thigh showed her that there was more going on.

0:05:25.3 RW: And it also... Another part of this is that the therapist who was conducting the session, while she had no formal training in trauma-informed care, was herself a survivor of many years of domestic violence and had done some training to work with domestic violence survivors and had decided that was hitting too close to home, and she really wasn't ready for that yet. But my sense, Pam, is that that history and background gave her a Spidey-sense, a sort of extra sensitivity to what was happening for this client. But I thought since you are a go-to expert on the therapeutic relationship and clients who have complicated histories with touch, that I would love for you to talk about what you respond to in that story.

0:06:13.2 Pam: What a great story. This is just an amazing example of the intuitive nature of massage therapy, and we have built into our therapeutic DNA, if you will, the concept of consent, and that when we try to touch people in ways that they don't wanna be touched, it feels wrong. Absolutely gut perspective is, "Oh, I can't go there." So if a client is reacting in such a way that their whole body stiffens, there's a story there that I don't know about and in this case, you're describing the client not knowing anything about that story. She may have known her personal experience with the sexual assault, but she didn't know... She didn't connect it to her leg, upper leg, so this is an example of how our body keeps score. Dr. Bessel van der Kolk, who's an expert in trauma, wrote a wonderful book called The Body Keep Score, and he describes how our experiences of trauma become encoded in our bodies, and if we keep revisiting the trauma, we create these pathways, neural pathways that reinforce the trauma.

0:07:39.3 Pam: By not insisting on touching the upper leg, this therapist did exactly the right thing according to the science and according to the trauma literature, because the client wasn't comfortable receiving a touch and the therapist just simply said, "Let's re-drape and let's do the work where you can stay present." And that fundamentally, for me, is one of the best ways to do trauma-informed care, people need to be massaged. We have a need for touch as human beings we're wired for pleasure, we're wired for touch, but if touch doesn't feel right, then massage therapy may be premature. So it's really, really essential that we go slowly, and we only touch the parts of the client's body where they can accept comfortably what we're doing, and what that does is reinforce the positive, it doesn't reinforce the negative, the traumatic signal, I guess that's what's coming up for me.

0:08:42.7 RW: Well, and clearly this therapist through her sensitivity and her great ability to communicate clearly what she's observing created a sense of safety for this client, that that person was able to come back multiple times and be really happy with the care she was receiving.

0:09:02.4 Pam: Yeah. But I also find it interesting that the therapist had not heard the word, trauma-informed care, many of us have heard it many times in the last couple of years, because as you were saying earlier, it is a little bit of a buzzword, certainly in the therapeutic community. But really, when you unpack those three words, everything that we do should be accomplished with informed consent, where we're explaining what we're doing, how we're gonna do it, what part of the body is gonna be touched. And we give people the opportunity to say no. Okay, so that informed consent approach is fundamentally parallel to trauma-informed care. That's it, right?

0:09:45.3 RW: And it's something we do with everybody, or at least...

0:09:48.1 Pam: We should do.

0:09:49.1 RW: We should be doing with every body.

0:09:51.7 Pam: Yes, it's like a fundamental. It's not the only aspect of trauma-informed care, but it is probably the how-to, the go-to, you never touch anything that people aren't prepared to where they prepared to receive touch. The other piece of trauma-informed care that I think is really important is the first two words, hyphenated, trauma-informed, and that means that we have a responsibility to inform ourselves about the impact of trauma on our clients, on our human body, generationally, societally, we have a responsibility if we're gonna touch people and touch is our modality, we have a responsibility to actually inform ourselves what the impacts are of touch, not just the positive that make us feel good, but also what is the capacity of our touch to harm people? And we really need to be supportive and clear about that part.

0:10:55.0 RW: Yeah, I agree. It would be hard for me to agree with you anymore than I do, so...


0:11:02.8 RW: Well, I wanna thank you so much for being with me, Pam, and to help unpack this a little bit, it's a huge topic, but I just... Hearing stories like this make me really proud to be in this profession because I think as therapists, it's such a beautiful job.

0:11:18.3 Pam: Yeah. Without even realizing it, massage therapists have the capacity to do so much good work with clients, and as long as we inform ourselves about what our boundaries are, this is pretty powerful work. Thanks.

0:11:33.0 RW: Yes, it is. It is indeed. Thank you. Before we wrap up, I'd like to share a little bonus, "I Have a Client Who... " story. This comes from the early days of Pam's life as a massage therapist, her encounter with this client had a profound impact on the rest of her career.

0:11:51.0 Pam: But I had this client come in, and she was 350 pounds if she was a pound. I had a treatment room that was really too small, and I was working in a doctor's office, so I had this little tiny exam room, and the only thing I could put in there for the client to sit on was a piano stool. So this very large woman is perched on a piano stool, and she's got this deep smoker's cough voice, and she says, "Okay, look," she says, "I was... I just realized that I've been sexually abused by my father for nine years, from the time I was nine until I was older, I'm an alcoholic, I'm in recovery, plus addicted to pills and food, as you can see, I can't stand to be touched and I want a massage." Oh, my God.


0:12:49.9 Pam: That was in the realm of the holy shit moments of my practice, and that was literally... I had opened the doors three weeks before that, but honestly what was I gonna do? So my previous background was in public relations and media relations, so I'm pretty good at skating, so I said to her, "Okay," faced with a play, "How would you like us to do that?" And she says, "Well, I think I can let you touch that part of my body but nothing else." Okay, so that's what we did, the hypothenar eminence for 10 minutes. And then she said, "Okay, that's enough, I gotta have a cigarette." And she left. [laughter] And I was like, "Oh, my God."

0:13:45.6 RW: It took a lot of courage for her to show up.

0:13:49.1 Pam: No kidding, right?

0:13:50.8 RW: Yeah.

0:13:51.5 Pam: And that was evident for me from the moment she walked in that, "Wow, this woman is remarkable."

0:14:01.8 RW: On behalf of Pam and myself, and every caring massage therapist, I wanna say thank you to all of the people who are willing to take the risk of opening themselves to the possibilities of healthy touch. You are all remarkable. Hey everybody, thanks for listening to "I have a Client Who... " Pathology Conversations with Ruth Werner. Remember, you can send me your "I Have a Client Who... " stories to, ihaveaclientwho@abmp.com that's ihaveaclientwho, all one word, all lower case, @abmp.com, I can't wait to see what you send me, and I'll see you next time.


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