How Can Massage Help With Mental Health?
“Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all
of which have the potential to turn a life around.” - Leo F. Buscaglia
So I’m going to let you all in on a little insider secret that not many of my fellow massage practitioners are hip to…it’s that the science of manual therapy is still quite under-baked and filled with holes. That is to say, in comparison to other medical professions, the evidence supporting the effectiveness of manual therapy is quite sparse. This isn’t just cutting in the direction of massage therapy either, it’s chiropractic, osteopathy, and even huge chunks of the gold standard - physical therapy. This isn’t to say that millions of people across the world and throughout all of history haven’t found benefit through these practices, it’s just that we don’t really understand the mechanisms behind them or if they’re replicable across all individuals. It turns out, the body is very complicated, and even more-so, pain is VERY VERY complicated. While the prevailing consensus of the body is that it’s similar to a car in that a part can break down and then be replaced or fixed - it’s actually a lot more complex than that. The pain system in the body, instead of relying on levers and pulleys and gears, is more like a neurobiological soup of immune system functions, endocrine pathways, psychic forces (as in pertaining to psyche, not like…magical powers), and yes the maintenance of our physical tissue. The more we learn about this central part of our human experience, the less we can actually replicate a reliable fix that will carry over to each person universally.
With all of that said, throughout the years of research invested into manual therapy, there actually has been one clear and definitive benefit of receiving clinical touch….you ready for it? Well, it’s the name of this blog post so I hope so. It’s been shown to be a tremendously beneficial treatment for mental health problems - whether it be depression, anxiety, insomnia, loneliness, or a whole host of other issues. Study after study into the effects of massage in particular have yielded some very promising results for folks who are struggling with chronic stress and the other manifestations of mental illness. This isn’t a small thing since poor mental health has been a widespread epidemic of the 21st century, I mean…can you blame us? It’s also possible that our mental health is a contributing factor to our experiences of pain, as many of the variables that make us feel mentally unwell are also breeding the conditions for our aches and tensions. So I want to take a moment to share with you some of the studies that have detailed this research and to answer the question: can massage be a support for us when we’re navigating a mental health episode?
The Studies on Massage for Depression and Anxiety
So the state of the scientific literature on massage therapy isn’t something that I want to hammer home too much but it is the beginning place of our story. As of the early 90’s, there was a growing interest in the hows of massage but the scientific community didn’t have a lot of resources at their disposal to properly research the mechanisms. That all changed in 1992 with the founding of the Touch Research Institute (TRI) which was created by Tiffany Field and her colleagues. Over the course of the next six years, the TRI examined the effects of massage on a huge number of different pathologies ranging from infant growth and development, spinal cord injury, PTSD, multiple sclerosis, autism, depression, and various forms of cancer (plus many more). Out of the entire list of research focuses, the two most compelling cases were that of depression and anxiety.
Quantitative research reviews went on to show that a series of massage therapy treatments consistently produced sizable reductions in depression among adult recipients “similar in magnitude to those of psychotherapy”. (Source 1) This conclusion was drawn from a meta-analysis of 37 different studies. On the other side of the world a couple of years later, a second team of researchers reached the same conclusion via their own independent meta-analysis of 17 different studies containing 786 people. (Source 2). This second analysis was interesting because they chose studies that focused solely on recipients who were only receiving massage without any alternative treatments. There are still many questions surrounding these findings such as what the ideal protocol would look like to maximize effectiveness, the severity of the depression being reported, and other lifestyle factors. Still, this is an impressive body of independent studies being represented and it’s rare for physical therapy modalities to have this much data to support a claim. So as they say, if there’s smoke, there’s probably fire.
As for the exploration of massage and anxiety, the first meta-analysis from the TRI suggests that just a single session of massage could significantly reduce the immediate effects of anxiety, which is referred to as state anxiety. This is the acute emotional experiences of apprehension, tension, and worry that we generally refer to when we say that we’re feeling anxious. Even more promising than that, it was shown that multiple sessions of massage therapy performed over the period of days or weeks significantly reduced the test subjects tendency over time to fall into anxious states. In the research this is known as trait anxiety. If I can speak anecdotally (which you can’t stop me), I’ve recognized this in some of my long term clients - one of which first came to see me to help curb their panic attacks. It’s been years since they last reported feeling that level of anxiety and we’ve since moved onto other issues and general maintenance.
This reduction in depression and anxiety is a big deal not only for its own sake but also because it could serve as an explanation as to how massage helps people who are in pain. The suggestion of the researchers is that the pain alleviation could be a secondary order effect of the primary effect of treating stress, anxiety, and depression. Since pain is a multifactorial experience with many smaller parts coming together to create something that feels big, the effect of targeting our stress could be the softening of the glue that allows our painful experience to come apart.
Now as any good science will naturally do, this body of research raises a lot of questions. Namely…how? Well we still don’t definitively know but here are some of the top contending theories that are interesting to mull over.
The Potential Mechanisms
So I’m going to present the top proposals for how massage is suggested to help with mental health. I’ll be sharing both the relevant studies as well as some of my own thoughts and feelings on the subject. I think it’s important to tap into where the broader scientific community is standing. At the same time, I also feel that my personal viewpoints gathered over the course of my career not only as a bodyworker but also a meditation instructor have some valuable insight for the discussion. Nothing I share in this section is intended to replace the counsel of a licensed mental health professional so if you’re currently struggling with a mental health event, please start there. Once you have an established relationship with someone who’s more directly trained in helping you with your particular issues, then I would recommend seeing if massage could work as a complementary therapy. Now that that’s out of the way, let’s get started.
1. The Therapeutic Alliance
One of the main parallels between massage therapy and regular psychotherapy is that both modalities hinge on the client-therapist relationship. Both situations are predicated on a private interpersonal contact between a therapist and a client generally for 50-60 minutes on a routine basis. This relationship is unlike other dynamics that the client may have in that it’s solely focused on their well-being. It’s a structured environment with clear boundaries and a forward momentum that seeks to alleviate the symptoms that are arising in the client. Over time the relationship tends to deepen as a mutual understanding begins to emerge. This deepening involves greater degrees of trust and familiarity which are crucial for the healing of many psychological and physical pathologies.
On one hand, the therapeutic relationship provides a space for connection to occur, which can sometimes be disrupted when someone is experiencing severe depression. The tendency to isolate can become incredibly strong as somebody struggles with their mental health. Stable routine meetings with clear expectations can create a rhythm in the client’s nervous system that can help serve as a resource for them as they navigate their psychological stressors. It’s like having a buoy out in open waters, it gives someone a sense of reference as they explore greater depths within themselves. The more nodes in someone’s support system, the greater chance they’ll be able to make their way back to shore.
Another element of the therapeutic alliance that can be tremendously healing is the emphasis that’s placed on permission and consent. The hallmark of a good massage therapist (from my point of view) is that they’re not merely mashing muscle tissue to fix some physical ailment, but rather that they’re in dialogue with the nervous system, which requires a constant granting of permission to allow change. The best therapists I’ve worked with have alleviated a lot of my tension not through brute force but by providing an inquisitive, attentive, and curious touch. Therapists need to understand that the nervous system is what fundamentally allows change and that it’s not up to some exotic technique. When there is some acknowledgement of that, tremendous results follow. This process, if done right, is a sequence of questions, patience, and deep listening to what’s being presented by the client’s nervous system. This creates an experience where the client’s body feels seen, which can be profound for those who feel isolated.
2. Primate Social Grooming and Feel Good Hormones
We are social creatures by nature and have evolved over millions of years to be in close contact with our peer groups. As infants we are solely reliant on our parents to take care of us and whether or not they are sufficiently present creates cascading changes throughout the rest of our lives. One of the primary ways in which our young developing brains know whether we’re being cared for is by touch. It’s shown that premature babies who receive consistent touch actually develop and grow much better than their counterparts who are isolated (Source 3). Not only does it help them grow, but it also strengthens their immunological function, improves their sleep quality, and enhances their emotional communication abilities. Naturally, these foundational neurological networks within us are primary to our feelings of safety, containment, and confidence in the world. As we grow older, these systems don’t just go away, they evolve and take on the subjective dimensions that our culture places on them. In our culture in particular, we’re rather touch-averse. We’ve developed a lot of social ritual and context around the exchange of touch and many of us are sorely touch deprived. This has a whole cascade of negative effects on our system and can greatly contribute to feelings of loneliness, loss of community, loss of meaning, and a disconnect from our bodily ground.
Massage therapy is a great safe way to reestablish contact with our human animal bodies and our need for touch. So often in our culture we delegate touch to a limited number of forms, whether it be in a greeting as with a handshake or the touch we use in courtship. While those are certainly valid uses of touch as a communication tool, there’s also another form of communication that we can use touch for: therapy. Therapeutic touch is a specific kind of touch that seeks to provide a sense of safety or reassurance not just in the mind, but in the body itself. A trained and sensitive manual therapist is beyond anything else, communicating a quality of safety that invites an activated nervous system to relax. In terms of psychological care, this bodily relaxation changes the environment the troubling thought patterns are emerging from. This can create a bottom-up relaxation that may not have been available to a client.
On top of the embodied safety and meeting the base level needs of human contact, touch also changes us physiologically. There’s a flood of important hormones that get released when we’re touched by another person. (Source 4) One of the primary ones is oxytocin, which is a neuropeptide that has been shown to inhibit the release of cortisol (stress hormone) in the body. The caveat here is that the release of oxytocin is highly contextual, it’s generally more potent the more familiar someone is with the one doing the touching. (Source 5) The same touch in different contexts can produce vastly different results. This is another reason why having a touch based therapist can be tremendously helpful, there’s clear expectations and boundaries which ensure the treatment remains effective.
Some of the other hormones released by the body when being touched include endorphins which serve as a natural painkiller and mood booster. While there are a lot of different kinds of endorphins, we can think about the sensation of a runners high as a good comparison. This might be why so many people rely on jogging as a part of their mental wellness regimen. Another set of hormones that are released when we’re touched include dopamine and serotonin which are chemicals that activate our brain’s reward center and stabilize our moods. Having a safe and reliable way to access the body’s natural pharmacopeia can help us change the chemical substrate that could be contributing to our sense of depression or anxiety.
3. Coregulation and Somatic Empathy
This really is an offshoot of the therapeutic alliance but I feel like it’s a big enough topic to warrant its own mention. As discussed above, we as humans are very social creatures and we evolved to live in close knit communities. As a result of this, we are much more sensitive to each other than we like to give credit for. So much so that our physiological processes are in a constant state of mirroring those who we are interacting with. There’s a seminal book that details this process called ‘Another Self’ by Cindy Engel which I found to be tremendously influential in my massage career. In it, she explains the concept of somatic empathy. This is a process carried out by the body to mirror those that it comes into contact with. It does this through physiological means, emotional means, and psychological ones as well.
The reason for this is that if the body can predict what another is feeling through experience, it can better understand others which aids in making connections or determining if someone poses a threat. What was once an idea reserved for people who are in consistent contact has ballooned to also include people that we pass throughout our day to day activities. This could include the barista at our favorite café or even someone we’re sitting next to on the bus.
(Source 6 for Link to ‘Another Self’)
The book is chock-full with tons of great research to back up its premise. Its essential point is that our view of ourselves at any given moment is inextricably linked to those that we’re interacting with. We borrow not only ideas and ways of speaking from each, but also subtle physiological states that work underneath our conscious attention. When we’re depressed or anxious, we often have a tendency to pull away from those that care about us or put excessive strain on those relationships. The advantage of a therapeutic relationship is an unconditional positive regard that our therapist holds for us (ideally). Uniquely for touch based therapies, that unconditional positive regard is matched with intentional and calming touch. If the therapist is grounded in their role, they should be holding a space of presence which can be deeply nourishing for the client. This presence is then transmitted through touch and can help bring clients’ nervous systems back down from their states of hyper-arousal and into the calming field that the therapist is holding.
Another unique element of working with a therapist of any kind, manual or psychological, is that you have a good amount of time to spend with them. When we have a weekly or biweekly 60-90 minute session with another person who is holding this space for us, it can prove to be a regulating facet of our lives that can introduce this calm in a regimented manner. This punctuation in our stream of mental illness can become an island in an ocean of confusion or suffering that provides the client a space to rest. During that rest, there very well could be some form of regulation that can take root. Again, this all depends on the qualities of the therapist, the nature of the relationship, and the outlined expectations. Below is an interview I had with the author of ‘Another Self’, Cindy Engel.
4. Shifting the Autonomic Nervous System
One of the frequently mentioned topics in this blog is the power of massage to help us switch into what’s known as our parasympathetic nervous system. This is a facet of our Autonomic Nervous System (ANS) which is the aspect of our nervous system which mediates organ and muscle function. I have an entire article on this subject which goes into much greater detail than I’ll go here. (Source 7) What I will say for the sake of this post is that the ANS is what primes our body for responding to potential threats or helps us enter into a state of rest. It’s divided into three branches, two of which are important for our discussion here: the Sympathetic Nervous System and the Parasympathetic Nervous System. The third, Enteric System is interesting but not totally relevant for this exploration.
The former, sympathetic system, is generally referred to as our ‘flight or fight’ response while the latter, parasympathetic system, is the ‘Rest or Digest’ response. When we’re feeling stressed or handling a lot of responsibility, we’re operating out of the sympathetic nervous system. It’s geared toward action, movement, building and releasing energy through the muscles. It’s a great thing and it’s helped our monkey ancestors hunt and run away from tigers. When we’re in the parasympathetic response, all of the body’s energy is dedicated to processing nutrients in the digestive system and repairing broken down cells.
In our fast paced society, there’s often a lot asked of us. It could be taking care of our family, handling the responsibilities of our job, or even just driving down the expressway. We’re in a constant state of go go go, and as a result we tend to get kind of stuck in the sympathetic response. Anxiety disorders are at an all time high (Source 11) and people are struggling to remember how to actually relax. If you pair this with a constant drip feed of terrible news stories, high intensity action movies, loud short-form content, we’re a society that doesn’t place much value on slowing down. Doing this over the course of weeks or months or years as many of us do taxes the nervous system and makes us prone to all sorts of different ailments: high blood pressure, anxiety, insomnia, irritability, poor relationships, etc. Massage has been shown time and time again to help us shift back into the parasympathetic response. (Source 8) While the effects of this are temporary, it can provide an immediate stop gap for severe states of anxiety. From this brief space of ease, we can think more clearly and maybe create some new patterns to help us manage our trait anxiety over time. At the same time, the more we introduce this relaxation to our nervous system, the better we can be at identifying when we’re in or out of it. This way we can have a greater degree of awareness of the stimuli that are stressing us out and maybe discover some new solutions for how to mitigate their effect on us.
Fundamentally, relaxation is the antidote to anxiety. What they don’t tell you is that relaxation is a learned skill. It’s not something that comes intuitively to us in this culture, we need to work at it. This work takes place over many dimensions but sometimes it’s great to have something with a low skill barrier to help us get started. Massage is as low barrier of an entry as we could ask for and makes for a wonderful first step in reclaiming our inherent ease.
5. Insights from Deep Relaxation
One of the unique aspects of massage therapy that I don’t often see discussed is the subjective states of deep relaxation that it puts you in. Many of my clients report entering into a half-asleep, half-awake state that is referred to as a hypnogogic state. This occurs when the brain enters into the theta brainwave rhythm. (Source 10) This level of brain activity is often associated with intuition, creativity, and the subconscious. When we’re in this half-asleep/half-wakeful state, it’s not uncommon to have mini dreams, insights, and other meaning-rich impressions bubble up from our subconscious. These could relate directly to the things that ail us or they could be indicators of other phenomena that we haven’t directly acknowledged having interacted with. In either situation, they provide fresh data points for the mind to chew on, contemplate, and draw conclusions from. The effect of this will vary from person to person depending on their experience with contemplative practice or their overall relationship to awareness.
This is obviously going to be the softest of the explanations as it gets into some more metaphysical dimensions but I can attest to the power of subconscious forces in our interpretation of life experiences. Anecdotally speaking, I’ve had many clients report vivid recollections of past dreams that brought fresh understanding to what was previously seen as chaotic and confusing. Another client reported having their visual field flooded with a lavender purple color that helped them integrate the grief from a recent loss. I can’t bring in any specific study to back these claims but after witnessing events such as these a handful of times, I think there’s something worth contemplating.
So those are some of the supposed mechanisms of how massage can help us navigate the complexities of mental health. There are a few other topics that I think are important to explore to round this conversation out. Namely, one of the big buzz words in the 2020’s…trauma.
Massage and Trauma
I’m not sure if I’ve ever shared this on this blog but one of the biggest inspirations for me to start massage therapy was Bessel Van Der Kolk’s ‘The Body Keeps the Score’. It’s one of the breakthrough books on the nature of trauma being something that is stored in the body rather than existing solely in the mind. (Source 9) If this is a new topic to you then I’ll give you a very brief primer as it’s a huge subject. Namely, modern research has come to suggest that traumatic experiences get logged in the body and are lived anew every time the proper triggers present themselves. It’s not that the sufferer of trauma is simply remembering a past event but rather their whole system is recreating the conditions as if it were happening again. This includes physiologically as well. It does this as a protective mechanism to help prime the person to take the same actions that they took in the past to survive the troubling incident. This could be fighting, fleeing, or more commonly freezing. The reason that this happens is because oftentimes when something seriously bad happens to us and our protective response doesn’t prevent the incident from occurring, the process gets stuck in our nervous system, unable to resolve. This creates a sort of looping that brings about all of the troubling energies that were present in that defining moment. You can think of the classic case of the war veteran becoming erratic and unreachable during a fireworks display. In this scenario, there were enough stimuli present to convince the nervous system that they were back in the war and at that point, the survival mechanisms take over and create unpredictable and sometimes dangerous behavior.
Now that’s just one example, and it’s an extreme one at that. There are a wide spectrum of trauma responses that can manifest in a person, and there’s also a wide variety of stimuli that can create them. Even something as innocuous as a neutral smell that was present during the time of the original incident. Needless to say, this is a very complex and nuanced phenomenon that’s going to vary drastically from case to case. With that, massage can certainly be a great modality to explore in one’s journey of recalibrating their nervous system. That’s not to say that all massage is created equal and not every therapist is going to be sufficiently equipped to navigate someone’s traumatic history. There are specific trainings and modalities that one can take to better prepare themselves to work with this part of the population but I will say - if it’s a training that takes less than multiple YEARS, I would personally avoid it. If someone doesn’t have the proper training to meet the needs of a traumatized nervous system, the risk of retraumatization is possible. This occurs when somebody’s trauma response gets activated and is not met skillfully, ultimately reestablishing the disrupted pattern and cementing it more in the nervous system.
Some of the ways that massage can help in the right context is to model what safe touch looks like. This is especially useful for folks who have undergone sexual abuse. Oftentimes in these cases, boundaries have been crossed and consent had not been given which can create a whole litany of issues. Trauma informed touch can serve as an opportunity to empower the client’s ability to direct the course of the treatment. If things get uncomfortable, they have the ability to say no and then reaffirm that their ‘no’ is respected and has weight. If something feels good then they can say ‘yes’ and actually invite more of that touch. This ability to say yes or no to experience and have it respected helps bolster confidence in one’s self and a stronger sense of containment and safety. It’s hard to do this kind of work without the assistance of another person since the original infraction was relational in nature, so it often needs to be healed relationally. In opening up to another person in this way, it could help the client reintegrate touch as a safe and enjoyable experience which opens up all of the benefits that were mentioned above.
One of the key themes in trauma informed work is that of titration. This is essentially a process of rocking back and forth between states of activation and ease. This was discovered by the esteemed Dr. Peter Levine and is exemplified by his Somatic Experiencing modality. The goal here is to access the body’s activated state which has within it a tremendous amount of stored energy that left unprocessed will manifest as anxiety and panic. In accessing it, we’re moving very slowly to not overwhelm the system but to build a quality of resiliency that allows us to free up that energy and reintegrate it into our wider being. Over time of working this way, it clears the stored charge and allows our system to unfold more naturally and without constriction. There is a touch based way of doing this work but it needs to be done with a trained specialist. Being trauma informed and a trauma therapist are two different things entirely. The former is simply trained to minimize potential activation and navigate the experiences where it becomes overwhelming for the client - the latter is trained to help the client integrate and heal. Understanding this difference helps us have proper expectations for what a practitioner can provide for us.
In Conclusion
In my many years of studying the science behind manual therapy, I am kind of shocked at the state of the current research. I’m somewhat of a heretic among my fellow massage therapists but at the same time, I think that it’s important we take full inventory of where we’re at. There aren’t many conclusions to be drawn yet in favor or against any specific treatment but one thing is pretty clear: massage is a great and safe treatment for depression and anxiety. It may not be for everyone but it was for enough people to repeatedly draw excitement from the many researchers who have studied it. It is important to keep in mind, massage - and really any other form of manual therapy is an ALTERNATIVE medicine. This is by no means a finished story and until it is, I strongly recommend working with a trained clinical mental health professional first and foremost. There are quite a few great options here in Grand Rapids, Michigan (where I’m writing this article from) but I would love to take a chance to plug a group of incredibly talented colleagues of mine who I would trust above all else. They’re the folks over at Beyond The Couch.
I’m pretty well-versed to all things relating to the mind, perception, emotions, pain, and trauma, and I can attest that these folks are the real deal. If you’re feeling up for the journey that it will require you to take, I’d recommend starting there and then seeing if massage could serve as an adjunct therapy. Their website is down below. Beyond that, I of course have to also shine a spotlight on my fellow collective members over at the GR Therapy Collective. I’ve had the great fortune of working side by side with the many wonderful therapists there over the past year and would wholeheartedly encourage anyone to check them out as well!
While there’s still tons of research to be done on the connection between massage and mental health, I hope that the explorations listed here have been insightful and inspirational. The best part about this is that the barrier for entry is incredibly low for engaging with massage therapy. Unless you have an exceptionally poor massage therapist, chances are you won’t get hurt so there’s no harm in giving it a try. I’d encourage you to be open and honest about what’s bringing you to the session so that your therapist can meet you where you’re at. If after a couple of sessions you’re not noticing any considerable shift then you can always hang it up for later. I would recommend committing to at least 3-5 sessions as the the benefits of the therapeutic relationship are strengthened by actually developing a relationship with your therapist.
Our unique pathways toward wholeness are going to be deeply personal and vary depending on who we are. At the end of the day you have to trust yourself and follow your intuition on the modalities and spaces that you feel will best support you. With that, I wish you the best of luck on your journey! If you wish to book a session to see if this could be a part of your wellness regimen, head to the top of the page and book now!
Source 1: https://psycnet.apa.org/record/2003-11000-001
Source 2: https://www.psychiatrist.com/jcp/treatment-effects-massage-therapy-depressed-meta-analysis/
Source 3: https://pmc.ncbi.nlm.nih.gov/articles/PMC11568710/
Source 4: https://pmc.ncbi.nlm.nih.gov/articles/PMC10229112/
Source 5: https://pmc.ncbi.nlm.nih.gov/articles/PMC10181820/
Source 6: https://www.amazon.com/dp/1800492804?lv=shuf&channelId=500&plpRedirect=mhFallback
Source 7: https://www.bkbodyworks.net/blog-1/why-safety-is-important-for-your-nervous-system-and-how-massage-can-help
Source 8: https://pubmed.ncbi.nlm.nih.gov/19283590/
Source 9: https://www.amazon.com/dp/0143127748?lv=shuf&channelId=500&plpRedirect=mhFallback
Source 10: https://nhahealth.com/brainwaves-the-language/
Source 11: https://www.psychiatry.org/news-room/news-releases/annual-poll-adults-express-increasing-anxiousness
Beyond the Couch: https://beyondthecouchcounseling.com/