Panic in the Massage Room
By Tim Clark
It’s a horrible feeling.
Your client is on the table, you’re doing everything ‘right’ but something’s wrong. Maybe you notice their breathing is quick and shallow. Maybe they’re twitching or shivering. You ask them how they’re doing.
“I’m not sure,” they say. “I’m having trouble breathing.”
Or “Something’s not right.”
Or “I…um…I don’t…Can I…um…?”
They sit up for a moment on the table but it’s not enough. The laboured, panicky breathing continues. Maybe it gets worse. Maybe not.
Something today has led this client to respond to your massage in a way that is the exact opposite of what you both hoped for at the outset. You did your best to summon feelings of safety and soothing but an uninvited guest has arrived.
You and your client have found yourselves in the presence of panic.
My heart was smashing, everything had gone from full colour to grey and I was sweating. I thought I was having a heart attack, moments from fainting and was convinced I was about to die. I was struggling to breathe; my heart wasn’t slowing down and all I could think of was that I needed to sit down before I fell down. Probably dead.
Even before COVID-19 hit, anxiety, panic and their related disorders were growing in prevalence, and the pandemic has caused them to spike.
We can expect more and more clients to present with panic symptoms and we need to be prepared if these symptoms show up in our treatment rooms.
Panic vs. Anxiety
A note on terminology.
Although some of the symptoms overlap, ‘panic’ and ‘anxiety’ are not interchangeable terms. ‘Anxiety’ covers a broad range of experiences, including generalised anxiety, phobias, stress and panic. It’s probably easiest to think of panic as an episode of intense or acute anxiety, but whether panic attacks originate from anxiety is still unclear. It’s quite common to hear people use the term ‘anxiety attack’ to mean ‘panic attack’ but it’s not a clinical term.
Sometimes when we panic, it’s easy to see why we’ve panicked. Maybe we remember we’ve left the stove on or forgotten an appointment. We get flustered and worried. In these situations, the panic wants the best for us. All going well, we take some sort of corrective action and our relatively moderate discomfort reduces.
For some panic, though, there is no clear trigger and the symptoms are extreme. There may be sweating, shortness of breath and shaking. We might feel a pounding or racing heart, chest pain, nausea, dizziness, numbness, chills or hot flushes. We might also feel detached from ourselves, or fear that we are losing control or even dying. The attack may come on in situations that would usually put us at ease, such as a relaxation massage or even on waking up in the morning. This kind of apparently unprovoked panic attack is what I’m writing about here.
If I was to write about the causes of panic attacks, I’d have to write a whole other piece. The causes are not known and there are many possible explanations.
Someone who experiences unexpected panic attacks on more than one occasion (along with a host of other qualifiers specified in the DSM-V) may be diagnosed with panic disorder.
Before Panic Arises
While we can’t predict what might trigger panic in our clients, and their panic might not even have an identifiable trigger, there are some things we can do to make panic more manageable if it does arise.
Include panic attacks in your client history taking and talk to your client as sensitively as possible about their experience with panic attacks. How often do they experience them? When was the most recent one? What usually happens? Consider collaborating with the client on a safety plan for what you’ll do if a panic attack comes on during treatment.
Make it easy to breathe
We need to ensure that there is nothing that will make it difficult for our clients to breathe during their massage.
We need to monitor air quality and ventilation, use of aromatherapy oils and ensure that the massage table itself affords the client a clear airway regardless of their position. In prone, face holes or cradles can have a dramatic impact on the airways, depending on how well they accommodate the client’s head. In supine, a cushion under the head can help or be a hindrance. And, of course, COVID mask-wearing can make people feel like breathing is a struggle, so factor that in too.
Keep an eye on your client’s breathing patterns. If their breathing is rapid or at all laboured, is there anything you can do to help ease it? It might be a matter of reducing pressure or pace, or maybe modelling slow breathing as you work.
Stay in touch
Because each client is different and because their level of comfort can change over the course of the treatment, we need to foster open and honest communication so our clients feel they can be honest with us about any discomfort as it arises. (And remember, discomfort comes in many forms: an exceeded pain threshold, an upsetting topic of conversation, a full bladder.)
We might need to be particularly vigilant with clients who are not overly chatty in the first place. They might give us indirect clues that they’re uncomfortable, like a subtle recoil from excessive pressure or monosyllabic responses to ‘friendly’ conversation.
When Panic Arises
The Mental Health First Aid protocols for responding to panic attacks are well established and I recommend reading them in full. I’ll cover some points that are specific to our work in massage.
Make them comfortable
The client may not express any discomfort before it’s already well-developed. By the time they say anything, their system may be telling them to get off the table. They may do this quite automatically and unannounced. If they’re partially undressed, it would be useful to have a gown or robe within reach; it could be used to protect their privacy as they put it on, and then to keep them warm once seated.
They may prefer simply to sit up on the table, where draping with towels or sarongs may be easier. Be sure to ask the client about what feels best for them.
If you’ve pre-assessed and safety-planned, you’ve already got a good idea of what’s happening and what to do. If the client has no history of panic attacks, it may be very difficult in the moment to distinguish a panic attack from other kinds of attack, especially a heart or asthma attack. Get as clear a picture as possible of the client’s symptoms and, if in doubt, use physical first aid protocols.
Validate and reassure
The client may be experiencing anything from moderate distress to sheer terror, so it’s important that we don’t invalidate their experience by saying things like, “This is nothing,” or “It’s just a bit of panic”. We need to remain as calm as possible but we can still acknowledge for the client, “This is a scary experience for you”, while affirming for them that they are safe and it will pass.
Witnessing a panic attack can bring up all our problem-solving urges. It’s not easy to sit by when someone is in such distress but the best thing we can do while a client goes through this is to maintain a reassuring, hopeful presence. We may need to be the ones to hold the hope for our clients if things feel hopelessly out of control for them. Encourage them to let it run its course; fighting unwanted thoughts and feelings (e.g. “This shouldn’t be happening” or “Stop panicking!”) can actually fuel them.
Use your professional judgement about whether or not to make physical contact, always remembering that what you consider to be a reassuring hand on the back or shoulder can be interpreted in many different ways.
After the panic
Give it time
Encourage the client to breathe slowly as they recover – not too deeply, just slowly. If you can count five-in and five-out with some pauses in between, even better.
They might not feel like talking for a while; let them do what feels best for them. A bit of time to chat may help to restore good spirits and mental clarity before they get in the car to drive home.
What to charge for the session, if anything, will be a matter for the individual practitioner. If you haven’t got a policy to fall back on, consider devising one now.
Provide information and support self-help
If it was the client’s first panic attack, they may be feeling quite confused and worried about it, so refer them to their GP and offer some reliable information, such as this toolkit from Lifeline (Australia) or the many resources at the Centre for Clinical Interventions.
If they’re motivated to undertake some online education, a course like this one from This Way Up may help. They might also consider joining an anxiety or panic support group if one operates in their state (most are currently operating online).
Encourage them to make use of their support networks and talk to their loved ones about their experience if they can.
Take care of yourself
While the client’s experience in this situation is clearly more frightening and unpleasant than ours, it’s essential to acknowledge that we are impacted too and we need to take care of ourselves in the aftermath. Ask yourself if it’s a good idea to go on and treat another client soon after helping a client with panic. Exhaustion or residual stress may impact your ability to give your best. Debrief with a trusted colleague if you can and prioritise self-care.
Also remember not to take your client’s panic as a sign of professional failure. Think of the hundreds/thousands/tens of thousands (?!?!) of massages you’ve given where your client hasn’t panicked. You just happened to be there on the day of the perfect storm.
October is National Mental Health Month. Find out more about events and forums here.
About the Author
Tim Clark is a massage therapist and psychotherapist in Melbourne. Tim spends more time creating his bio than he spends on his daily exercise allowance. He’s looking forward to leading a guided meditation at the AMT 2020 Virtual Conference on 25 October.