Psychological Factors

in the Therapeutic Relationship

By Anne Williams
[Classroom to Client]

A large body of psychology research suggests that the relationship between the therapist and the client is the single most important predictor of therapeutic outcome—even more important than the types of techniques used in the session.1 One group of researchers refers to the therapeutic relationship as an alliance, defining it as “the observable ability of the therapist and client to work together in a realistic, collaborative relationship based on mutual respect, liking, trust, and commitment to the work of the treatment.”2
In the massage profession, the therapeutic relationship is defined as a professional partnership between a massage therapist and a client in which safe, structured touch is used to help the client achieve reasonable and clearly defined treatment goals. The work is client-centered, which means it is always provided to benefit the client, with the client’s needs at the forefront.

The Power Differential
In massage, a power differential is the authority a massage therapist is granted by a client, based on the client’s perception of the massage therapist as a knowledgeable and skilled health-care provider. During a massage session, clients share details of their personal health history and are situated at a level below the therapist, in a vulnerable reclining position, while unclothed under a drape. The therapist by virtue of knowledge and skill in the area of massage is granted control of the situation, and so has a power advantage over the client.
Ethical massage therapists remain aware of the power differential and seek to minimize it as much as possible to ensure the emotional, mental, and physical safety of clients. When the power differential is minimized, clients are better able to:
• Take an active role in the decision-making process to determine reasonable treatment goals.
• Alert a therapist to an uncomfortable technique or otherwise voice their concerns.
• Give honest feedback on the quality of strokes or the effectiveness of sessions.
• Maintain their boundaries, personal power, and responsibility for health.
• Actively practice self-care activities and other types of therapy to augment the results achieved from massage sessions.
You can actively minimize the power differential by listening carefully to clients and responding compassionately to their needs, while representing the benefits of massage and your personal skill level realistically. You can give clients choices about the types of techniques that might be used in the session or about which body areas will receive the most attention during the massage. If you remain attentive, you will notice when a client tenses because of discomfort and urge the client to speak up if a technique causes pain. Finally, you can encourage clients to seek out other therapists who might help them meet treatment goals and discuss self-care options that speed or enhance treatment outcomes.
If you or the client maximize the power differential, it is likely to be unhealthy for both of you. Clients who turn over all of their healing power also tend to place unreasonable amounts of responsibility for their well-being on your shoulders. Over time, they may express resentment or bitterness at their lack of progress and blame you for poor treatment. Clients without power are less able to question your decisions or voice concerns about the quality of sessions. They are less able to protect themselves in the event that you act unethically during the session. In all cases, whether the client actively gives all of the power to the therapist or not, the therapist is always responsible for what happens in a session and must constantly strive to understand and minimize the power differential.

Transference is a normal subconscious psychological phenomenon that occurs when there is a power differential. Clients may try to establish the therapist in a place of importance in their personal life. Instead of viewing the therapist as a professional who is utilized for massage, the client seeks approval, special consideration, and support from the therapist on multiple levels. The degree to which this occurs can vary greatly depending on the state of mind, level of self-awareness, and autonomy of the client. Some clients exhibit little or no tendency toward transference, while other cases are extreme. Often, the degree to which the client is experiencing pain or coping with physical, mental, or emotional trauma can be a factor. Behaviors that signal transference include:
• Asking the therapist questions about the therapist’s personal life.
• Disclosing very personal information in early sessions.
• Regularly bringing the therapist gifts or leaving excessively large tips.
• Giving the therapist too much credit for personal progress and overly praising the therapist.
• Inviting the therapist out to social engagements, asking for friendship, or seeking sexual involvement.
• Asking to set up sessions when the therapist is not on the clinic schedule, or asking for a special schedule.
• Having difficulty leaving at the end of the session and demonstrating behavior that prolongs parting, such as asking for more treatment, asking questions about the session, or starting a personal conversation.
• Seeking the therapist’s support in emotional and personal issues and asking for the therapist’s approval and reassurance on matters not related to massage.
In some situations, the client may experience feelings of anger, disappointment, rejection, and shame when the therapist resists allowing the therapeutic relationship to be personalized. Setting good boundaries and paying attention to the way in which the therapeutic relationship is established are probably the best ways to decrease situations of transference.

Psychological Defenses
Psychological defense mechanisms are mental processes that enable the mind to deal with conflicts it can’t resolve. Everyone learns some type of psychological defense from normal experiences of life. Psychological defense mechanisms are often supported by physical tension patterns that help suppress disturbing emotions, desires, ideas, and memories.
In some cases, defense mechanisms are necessary for survival, or allow a person to adapt and function in the world after an extreme trauma. Often they create imbalances that prevent people from dealing with conflicts so they might be understood and resolved. A few primary defense mechanisms are described here in terms of the psychological dynamics that might impact the massages you give.

Suppression is the conscious pushing down of anxiety-producing desires, feelings, ideas, memories, or urges. The item that causes anxiety is recognized on a conscious level but then actively avoided, ignored, or squashed. For example, a client reared by parents who discouraged the display of emotion might feel sadness during a particular massage technique, but view the display of emotion as unacceptable and embarrassing. The client can recognize the feeling but tenses his muscles and actively dismisses the feeling to avoid expressing the sadness through tears or sobbing.

Denial is the outright refusal to acknowledge something that has occurred or is occurring. Suppression might be used to support denial. Denial protects the mind from anxiety-producing conflicts it can’t cope with. For example, alcoholics often deny they have a problem with alcohol and insist the situation is under control.
In massage sessions, clients may express denial in many subtle ways. They might deny that a technique is painful, even though the therapist can see them tense muscles and grimace. They might insist that everything is fine, even when the therapist can see that they are struggling to maintain emotional composure. They might reject the idea that their job is causing or contributing to their repetitive stress injury. It is important that you maintain the therapeutic relationship and provide a safe environment for the client without directly challenging him. Focus on areas of tension and keep in mind that the physical softening the client experiences is likely to facilitate a psychological softening, and that, over time, the client may be able to accept or allow more awareness.

Projection is the unconscious transfer of impulses, feelings, or thoughts to someone else. Projection allows a person to disown or place outside of himself what he cannot accept about himself, whether positive or negative. For example, a woman who is unaware of her own negative attitude believes that the people she works with are negative. In massage sessions, clients project their unrealistic expectations (e.g., massage will change everything about my life), fears (e.g., this will just be one more therapy that doesn’t work), unwanted weaknesses (e.g., I don’t want to cry), and abandoned strengths (e.g., I can’t heal) onto the treatment or onto the massage therapist. The massage therapist may also be projecting onto the client. This is normal but may have negative effects on the session if the therapist is unaware of it and feeds the client’s projections.
One way to minimize projection is to center the sessions in reality. Ask the client questions like “What are the results you expect from the next six sessions?” “Was last week’s session what you expected?” “How was last week’s session different from what you expected?” You can also be attentive to the verbal and nonverbal signals you send clients during a session. A comment like “Well, here we go again working on this knot in your neck” might send the client the message you have grown tired of the work and are unhappy with progress. Instead, you want to send the message that you accept the client’s progress and are willing to spend as long as necessary for the condition to resolve.
People also project their moment-by-moment needs and feelings and thus decrease their level of self-awareness about their own bodies. One of the positive things that can come from regular massage is greater attention to how the body feels. When you are attentive to projection and can reflect a projection back to clients, you help them recognize their feelings and needs as welcome and acceptable. For example, clients might project their own foot pain onto you and say, “Standing on your feet all day must make your feet really tired.” You reflect the possible projection by saying, “Are your feet really tired today? Do you want me to spend extra time working on your feet during the session?”

The term deflection refers to ignoring or turning away from stimuli that trigger emotions in order to prevent recognition or full awareness of the material associated with the emotion. For example, clients might talk continually during a massage session to avoid paying too much attention to their feelings brought about by massage. The client may unconsciously distract you away from a body area that is emotionally charged by complaining of pain or tension in another area. If an emotionally charged area is massaged, the client might try to focus on other body areas and report the sensations felt in that area to you (e.g., “When you massage my feet, I feel a buzzing in my hands”). It is useful to gently ground the client in an awareness of the area where massage is occurring. You might say something as simple as, “The buzzing in your hands is interesting, but while I massage your feet, see if you can focus your awareness in this area and use your breath to release tension here.”

The term resistance was originally used by Sigmund Freud to refer to the blocking of memories from consciousness by patients, thereby slowing the therapeutic process. In massage, it more directly relates to the client’s feeling that change, even change perceived as desirable, is threatening, resulting in an unconscious opposition to the therapeutic process. For example, Sue has been working with you to reduce tension in her shoulders and jaw. As the tension softens with progressive sessions, Sue has started to remember incidents from her childhood when she felt overwhelmed and controlled by her mother. With each session, Sue’s overall discomfort and anxiety are increased, and now she has fears of what might surface next. While Sue verbally affirms that she is committed to weekly massage sessions, she misses one appointment, is late for the second, cancels a third, and fails to use the warm packs on her shoulder for self-care as she agreed. You may not even be aware that Sue is starting to recall repressed memories, and may think she is just irresponsible.
Resistance might also surface as recurring tension. You might work with a client to free tension in a particular area, only to find the tension is back or even increased at the next session. The client may be unconsciously reinforcing the tension pattern as a way to keep repressed items from surfacing.
Dealing with resistance is challenging. You must be careful not to step outside your scope of practice by confronting the client. Often, acknowledging and honoring the resistance can be helpful, and you can affirm for clients that, “Tension often has a positive purpose in helping people cope with stress and anxiety. Your body may not yet be ready to release this tension. We will just keep working with this tension until your body is ready to let it go.”

Armoring is the use of physical tension to support psychological defenses such as suppression and denial. Wilhelm Reich, considered by many to be the founder of psychotherapeutic body therapies, introduced the idea of armoring in his classic text Character Analysis published in 1933.3 Reich believed that in an effort to protect ourselves from physical and emotional stress, we disconnect from tender, vulnerable feelings. He called this phenomenon “body armoring,” and defined it as the body tightening muscle groups in an effort to control or minimize feelings, thereby creating physical, emotional, and mental tension patterns.
People learn how to express emotion properly for the society in which they live. For example, in our society, males are not supposed to express emotions like sorrow by crying, but are allowed to show a certain amount of anger. Sorrow and crying by females, on the other hand, is generally accepted while anger is frowned upon.
The suppression of emotion shows up in physical tension because muscular contractions can be used to block the display of emotion or suppress emotion so that it can be ignored.4 People can develop patterns of muscular tension in relationship to repeated emotional triggers.5 Tension in the chest and arm muscles is likely to remain as a chronic and unconscious expression of the repressed emotions for years or even for life.6 Massage reduces the muscular tension used to suppress emotion and so can lead to emotional release.

The Therapist’s Role During Massage
An increased comprehension of client defenses can help you better understand the dynamics at play in a massage session. The most important thing you can do for clients is provide a safe and nonjudgmental environment and encourage clients to develop their awareness of body sensations and be open to what they feel. If clients share with you that they are experiencing the surfacing of repressed items, if an emotional release occurs during a session, or if they express the desire to explore surfacing feelings, memories, and thoughts, refer the client to a mental health-care professional who has the training necessary for processing the client’s experience appropriately.

1. Susan C. Whiston and Thomas L. Sexton, “An Overview of Psychotherapy Outcome Research: Implications for Practice,” Professional Psychology: Research and Practice 24, no. 1 (February 1993): 43–51; William West, “Clients’ Experience of Bodywork Psychotherapy,” Counselling Psychology Quarterly 7, no. 3 (1994): 287–303.
2.    Steven A. Forman and Charles R. Marmar, “Therapist Actions that Address Initially Poor Therapeutic Alliances in Psychotherapy,” American Journal of Psychiatry 142, no. 8 (August, 1985): 922–6.
3.    Wilhelm Reich, Character Analysis, 3rd ed. (New York: Farrar, Straus and Giroux, 1980).
4.    L. A. Gottschalk, H. M. Serota, and L. B. Shapiro, “Psychologic Conflict and Neuromuscular Tension: I. Preliminary Report on a Method, as Applied to Rheumatoid Arthritis,” Psychosomatic Medicine 12, no. 5 (1950): 315–19.
5.    Wilhelm Reich, Character Analysis, 3rd ed.
6.    D. A. Weinberger, “The Construct Validity of the Repressive Coping Style,” in Repression and Dissociation,  ed. Jerome L. Singer (Chicago: University of Chicago Press, 1990).

Anne Williams is the director of education for Associated Bodywork & Massage Professionals and author of Massage Mastery: from Student to Professional (Lippincott Williams & Wilkins, 2012), from which this article was adapted, and Spa Bodywork: A Guide for Massage Therapists (Lippincott Williams & Wilkins, 2006). She can be reached at