First published in Jivaka Journal, by Jeffrey S. Thompson and Laura Hoge

“Every day we sit, stand, read, work and exercise in positions that are detrimental to our posture. Posture is an aspect of training that is often overlooked; however, improving your posture is just as important

to your regular fitness routine as proper nutrition, exercise and stress management. Improving your posture can help improve your health.”1

What is Rounded Shoulder?

Rounded Shoulder, or Protracted Shoulder Girdle, is a chronic condition which is defined as “an increase in the convex [curving or bulging outward] nature of the curve”2 of the upper back. A person suffering from this condition may take on a ‘hunched’ or anterior compressed posture, which, if left untreated will increase in severity with age. Currently, this disorder affects over two thirds of the population in the United States.3 As our increasingly sedentary society continues to ignore proper posture when behind the wheel, while watching television and/or working at a computer,4 and at the same time, continues to adopt exercise routines that over- focus pectoral muscles and neglect opposing muscle groups in the back, incidents of Rounded Shoulder will continue to increase over time.

Physiological Effects of Rounded Shoulder

The physiological effects that are often attributed to Rounded Shoulder vary in incidence and severity from person to person. Compressed nerves in the shoulder girdle are common and in some cases cause numbness, tingling or even pain which may radiate down the arm. Since the pectorals are in a continually contracted state “Rounded shoulders can restrict rib cage expansion”5 and as a result, may lead to difficult or labored breathing. Tight pectoral muscles can also pull the shoulder girdle forward, out of its anatomical plane of movement, and cause a decreased Range of Motion,6 discomfort or even pain. Continued contraction over an extended period of time will eventually lead to a shortening of the tight muscle, lengthening/weakening of the opposing muscle group in the back, and leave a person vulnerable to knots and/or permanent muscle damage.

Treating Rounded Shoulder – Western Style

The list of contributing factors for Rounded Shoulder is long. Because of this, there is no one set method of treatment, no silver bullet that will eradicate pain, pinpoint cause and erase existing muscle damage. That being said, an assessment of possible causative factors and a change in lifestyle can eliminate the suspected cause(s) of the disorder and stop its progression.

The aforementioned change in lifestyle often takes the form of a prescribed set of stretches and/or exercises that are specifically designed to elongate the pectoral muscles, release tension in the shoulder and allow the chest, shoulders and back to return to their anatomically correct position. Other exercises that are also suggested are those that strengthen the over-stretched and weakened back muscles to create a more stable operating environment for the free-floating shoulder girdle. Of course, the success of these stretches depends primarily on the determination of the client, so progress is reliant upon strict adherence to one’s prescribed stretching regimen.

How Thai Massage Can Help

When a client receives a diagnosis and calls upon a Thai Massage practitioner to help with recovery, the initial response must be to translate the patient’s needs from ‘Western’ concepts of disease into a traditional Thai approach. Since Thai massage works primarily with preserving and/or re-establishing energetic balance to the body, the most sensible place to begin treatment would be to first ascertain which of the sen line(s) (aka. energy lines, meridians, etc.) appear to be affected. Once this diagnosis is made, a course of treatment can be designed and put into practice.

According to Thai belief, Rounded Shoulder occurs as a result of energetic blockage in the Kalatharee sen:

Sen Kalathari starts at the navel, where it divides into four lines like an X that travels symmetrically on both sides of the body. The top two lines travel up to the armpits, passing above the nipples on the way. From there, they travel inside the middle of the arms to the wrists. At the wrists, Sen Kalathari splits into five branches, with each branch running to the tip of a finger. They then retrace themselves up the hands and arms, to the collarbones which they run under, up the sides of the front of the neck and face, overt the temples to the end of the eyebrows. From there, they run up over the sides of the head and then down the back sides of the neck. Just below the neck, they branch off to the armpits, where they merge with the aforementioned lines traveling inside the middle of the arms. The main trunks continue down the back to the ischial tuberosities (the bones at the bottom of the pelvis that bear the body’s weight when you are sitting down – commonly known as the “sit bones.”). From there, they go down the backs of the thighs to the backs of the knees. From the backs of the knees, they travel down the middle of the backs of the calves to the feet. At the feet, Sen Kalathari splits into five branches with each branch running to the tip of a toe. Sen Kalathari then retraces itself up the feet and then travels up the fronts of the lower legs to the knees. It goes through the knee joints and then travels up the fronts of the lower legs to the knees. It goes through the kene joints and then travels up the backs of the thighs to the ischal tuberosities. From there, it goes through the legs to the femoral pulses in the inner and upper thighs, where there is a pathway from one femoral pulse to the other, connecting the right and left lines. From the femoral pulses, Sen Kalathari returns to its starting place at the navel.7

Since Kalatharee travels through the shoulder girdle, manipulating it with acupressure, joint mobilization and yogic stretching can effectively locate the source of the blockage and encourage a more healthy flow of energy through the body. Salguero supports this theory and offers further advice in the treatment of Sen blockages in his book Encyclopedia of Thai Massage. He says that it is important to:

“Apply strong presses to the site of the blockage, and then to move along the sen away from the site, as if ‘flushing’ the blockage away” Travel all the way to the ends of the meridian or meridian segment, and finish by returning to the site. This encourages the disposal of stagnated energy, and then encourages the flow of fresh energy.” 8

In some cases, the client may be experiencing numbness, tingling and pain radiating down the arm. In such an instance, it is advisable that the practitioner begins treatment with this “flushing” at the point where the Kalatharee travels through the shoulder. This is most commonly the site of the blockage and the altered sensations in the arm are often referred pain brought on by the lack of proper energetic flow. It is also effective to apply heat, hot compresses and direct acupressure to the site of injury in order to break any energetic obstructions in the area that may be impeding proper flow of energy and, as a result, causing pain and impinging movement.

According to Thai medical theory, if the client’s shoulder girdle is anatomically misaligned, it is also believed to be a result of energetic blockage in the Kalatharee sen. Despite this similarity, the actual causes and site of the blockage are quite different. The location of the energetic blockage is often situated in the pectoral muscle itself, and as a result, the client frequently presents with difficulty breathing. When this occurs, administering pressure to the site of blockage is difficult as it is often uncomfortable for the client. Symptoms of the condition are best alleviated by treating the correlating Sumana sen which “runs from the navel to the base of the tongue.”10 This, combined with intentional acupressure and joint mobilization to the Kalatharee Sen will effectively treat Rounded Shoulder.

Specific Thai Yoga Massage Stretches for Rounded Shoulder

*Please note that the following stretches should only be performed by qualified Thai Massage Practitioners and should not be attempted otherwise. These exercises require knowledge of proper body alignment in order to reduce the risk of injury for both client and therapist.

WALKING BACK STRETCH

Have your client sit in front of you on the mat with legs straight or in a cross-legged position. Ask the client to reach both arms toward you with palms facing up and thumbs rotated towards each other. Reach forward and grab both forearms. Position your feet so that your toes are just beneath the client’s scapula. Your knees should be bent. From this position, use your body weight to pull back on the arms, rotating toward you slightly (medially). At the same time that you pull on the arms, apply a small amount of pressure with your feet while the client exhales. Hold for a breath or two before releasing. Repeat the stretch a few times, dropping your feet an inch or two with each adjustment. This stretch elongates the pectoral muscles and helps maintain and/or re-establish proper vertebral alignment. It also applies pressure to the rhomboids, which may be damaged, and/or have “knots.”

BACK STRETCH

Have your client sit cross-legged in front of you with both arms extended skyward and palms together in a prayer like fashion. From a standing position, take hold of your client’s forearms and place your knees just between his/her shoulder blades. Gently lift the client’s arms up and toward you, while at the same time, applying pressure to the upper back with your knees. This stretch will lengthen the pectoral muscles and open the chest to inspire deeper breathing and proper energetic flow along the Sumana sen.

COBRA

Have the client lie face down in a prone position. Situate yourself on top of the client with your knees just above the iliac crest. (This is important so as not to force extreme compression in the lumbar spine.) Hold the client’s forearms in the same manner as seen above in the Walking Back Stretch. Gently lean back with your body weight to lengthen the pectoral muscles and encourage the chest to open.

For clients that are suffering from more severe forms of Rounded Shoulder, Cobra pose may be difficult and/or too intense to perform. It can be supplemented by hooking your fingers under the client’s shoulders and manually drawing the scapulae together by leaning your body weight back. This will open up the chest and inspire proper energetic flow on both Sumana and Kalatharee sen.

SHOULDER MOBILIZATION

From a side-lying position, have your client bring the back of his/her hand to the sacrum, creating a 90 degree angle at the elbow. Using thumb presses, finger presses, and/or a bladed hand, apply gentle pressure just below the scapula. At the same time, use the other hand to pull the front of the shoulder, just lateral to the deltoid, toward you in a rotational motion. Repeat on the other side to lengthen the pectoral muscles. From this position, you can also address knots and/or energetic stagnation in the rhomboids with finger presses and/or thumb presses.

MODIFIED FISH POSE

Fish Pose may be too intense for clients with Rounded Shoulder, so this modification is more appropriate. Have your client sit with his/her legs extended forward. Place a bolster or firm folded blanket behind his/her hips. Support the head and thoracic spine as the client leans all the way back to lie flat. Sit behind the client’s head and from this position, gently hook your fingers underneath the skull at the occipital ridge. Lightly pull to lengthen and align the cervical vertebrae. You can also encourage further chest expansion by pulling the armpits open and out.

Endnote

While it is always important to address specific issues that a client brings to the mat, it is equally important to practice mindfulness for the well being of your client, to trust in the knowledge of the Father Doctor and to respect the lineage from which this energetic healing has been passed down through generations. “The true practice of the art of healing – be it nuad boran (Traditional Thai Massage) or any other type of medicine – is in the compassionate intent of the healer.”11

1 Vlach, Stephanie

2 McPeck, Christopher

3 Christman, John Ph.D (right rounded 73%, left rounded 66%)

4 International Chiropracters Association

5 Vlach, Stephanie

6 Vlach, Stephanie 7Apfelbaum, Ananda, pg 45

8 Salguero, C. Pierce

9 Salguero, C. Pierce

11Salguero, C. Pierce

Works Cited

Apfelbaum, Ananda. Thai Massage: Sacred Bodywork. New York: Penguin Group, Inc, 2004, pgs. 39-45.

Christman, John Ph.D. “The Prevention of Posture Related Problems in Orthodontists, Their Staff, and Their Patients.” Presentation at III Barcelona Orthodontic Meeting 13- 15 March 2003.

Gray, Henry F.R.S.. Gray’s Anatomy. New York: Barnes & Noble Books, 1995, pp. 222 – 226, 356 – 360.

International Chiropracters Association. “Perfect Posture Guide.” [online] Available http;//www.chiropractic.org/chiroinfo/posture.htm

Salguero, Pierce. Encyclopedia of Thai Massage. Scotland: Findhorn Press, 2004, pp.177 – 189

Vlach, Stephanie M.S.. “Stand up for Health.” [online] Available http://www.honoluluclub.com/pulse.php?ID=26

McPeck, Christopher. “The Cause of Internet and TV Addiction.” [online] Available http://www.causeof.org/posture.htm

Note: The information presented in this article is in no way intended to be used as a tool for diagnosis and or treatment. It is meant only to compare Eastern and Western approaches to a specific physical condition.

First published in Jivaka Journal, by Ann Airey

Neurologically involved clients (and their families) have been through an incredible trial physically, emotionally, mentally, and spiritually. Thai Yoga Therapy can be a medium for teaching clients to feel pleasure in their body again, and to show clients that they can still move their body in meaningful ways. When clients are taken passively through the stretches, they are able to relax and let go of the frustration caused by their body no longer moving like it used to. The gentle, rhythmic motions reduce tone and muscle tension, allowing clients to enjoy the therapeutic movement provided by this form of massage. Most clients find the sessions to be an oasis of calm in their tumultuous lives. Thai Yoga Therapy is often referred to as a “meditation of compassion,”1 and when done in the spirit of metta it is a beautiful dance between giver and receiver.

Case Study

In order to best illustrate the use of Thai Yoga Therapy as an adjunct treatment for neurological clients a case study is presented.

Patient History

The patient is a 72-year-old male with a history of cervical spinal stenosis (narrowing of the spinal canal causing compression on the spinal cord and spinal nerves). The patient underwent a cervical fusion in January 2003 with good initial results. After discharge from the hospital, however, the patient lost consciousness while getting up one night and fell to the floor. As a result of the fall the bony fusion became unstable. Additionally, the patient tore his left rotator cuff muscles (which had been surgically repaired two times previously), and he sustained a mild head injury.

Once medically stable the patient underwent a second surgery to have metal rods implanted along his vertebrae to stabilize the joints. After the second surgery the patient underwent intensive inpatient and outpatient rehabilitation to regain ROM, strength, balance, and functional mobility.

His recovery was complicated by many medical issues, including respiratory difficulties requiring supplemental oxygen, difficulty with bladder control requiring a catheter and eventually surgery, feeding problems that necessitated placement of an N-G Tube, increased tone and spasticity that impeded functional mobility, stiffness of the left shoulder due to the injury to the rotator cuff, loss of fine motor control in both hands, digestive difficulties, and loss of appetite. Additionally, the client experienced nearly constant pain, which prevented him from sleeping.

When I met the patient, he required assistance to stand up from a wheelchair, and he walked with a rolling walker. He required assistance to roll from one side to the other and to move side to side in bed. When seated, he could not reach outside his base of support without losing his balance, and he had fallen to the floor several times at home. The combination of tone, weakness, and joint stiffness caused him to walk with a rigid, shuffling gait. Because of pain in the left shoulder, stiffness in his joints, and muscle weakness, the patient had great difficulty transitioning from standing to tall kneeling or quadruped position. These factors initially made it difficult for the patient to get to the floor mat for sessions.

Treatment Modifications

I initially treated the patient in an outpatient rehabilitation setting in the hospital, where we were able to use a raised mat table to avoid the floor transfer. The client simply walked to the mat using his walker, sat down, and then came to supine. This technique is helpful for most neurological clients who have loss of balance and decreased functional mobility. It is also useful in working with clients with spinal cord injuries who may be unable to transfer to the floor—they can transfer directly from their wheelchair to the mat table. This is the safest and most comfortable way to adapt the Thai Yoga Therapy session for those clients who have difficulty getting to the floor.

In settings where a mat table is not available the therapist must adapt the floor transfer. Once this patient was discharged from therapy at the hospital I worked with him in his home. We were able to adapt the process of getting to the floor by having the patient first come from standing to tall kneel in front of a coffee table. Once he was steady in tall kneel I was able to help him transition to his elbows and knees; from there I assisted the patient into prone position, and then slowly to supine.

In my opinion, a bed is soft and yielding, so it is not an ideal surface for energy line work. It is, however, a safe option for those clients who are unable to get down on the floor safely. One session, after this patient underwent surgery, I treated him bedside with a modified session to decrease pain and to work specific acupressure points and energy lines for the bladder, kidneys, and prostate. The patient experienced almost immediate reduction of pain and anxiety from this session.

When working on the floor we made adaptations to accommodate the stiffness of the patient’s joints. The patient’s neck ROM was limited because of the cervical fusion. For comfort we used a pillow under his head to keep the spine in alignment. Once the patient was comfortable he was able to relax, and we started each session with gentle rocking motions of the trunk and extremities to reduce tone. This was followed by working the foot sen and marma points and kneading the feet with oil. Over the course of treatment the muscles in the patient’s feet relaxed, allowing the toes to extend and the arches to spread; as a result, the patient’s standing balance improved once more of the foot was in contact with the ground.

Once the feet were relaxed the inner and outer leg lines were worked to stimulate the balanced flow of energy to the spine and organs. The compression from palming along the lines also kneaded the tight muscles. Stretching postures for the lower extremities, hips, and low back were performed gently and slowly. Over time, the patient gained range of motion in the legs and spine, which increased functional mobility and decreased his back pain.

In Thai Yoga Therapy, the back of the body is worked with the client prone. Since the patient was unable to remain prone for any length of time because of the cervical spine fusion and pain/stiffness in the left shoulder, I worked the back sen and back muscles with the client in side- lying position with a pillow supporting his head. I also stretched the chest muscles and mobilized the scapula with the patient in side-lying position. Another alternative for clients with limited neck ROM is to use a “prone pillow,” which is a firm, spongy pillow with a cutout for the face, similar to a face rest on a massage table.

After the work done in prone (side-lying in this case) the middle arm line was worked with the client supine, followed by hand massage and wrist/finger stretches. Since this patient had a history of pneumonia and emphysema we worked on diaphragmatic breathing and abdominal massage in supine to free up the diaphragm. Abdominal reflex points for the organs were also worked during this section of the massage to stimulate digestion and peristalsis.

The sessions were concluded with massage to the upper back and neck muscles in supine position, followed by facial massage with essential oils. The client was visibly more relaxed, and his breathing was deeper and easier by the end of each session.

Results

This patient has attended a total of 13 sessions since November 2003. His overall level of health, vitality, and functional mobility has improved tremendously. The patient now transitions from standing to supine on the floor with only standby assistance. He turns from side to side and scoots up and down independently. He has regained a significant amount of active movement in his lower extremities and has regained some degree of fine motor control in both hands. He can balance in tall kneel and quadruped positions, withstanding minimal challenges to balance, and can reach six inches outside his base of support in sitting. He walks independently with a quad cane (four-pronged cane) and is able to get into and out of a car with standby guarding for safety. He can rise to standing position from a low surface independently and his posture is more upright. He can stand independently without his cane, maintaining his balance against minimal challenges (light nudges/pushes). He has regained some of the weight he lost over the course of events, and his skin tone and skin quality have improved. He enjoys the increased independence and mobility he has gained, which allow him to attend family events and resume a modified work schedule.

Conclusion

Thai Yoga Therapy is a powerful healing art suitable for the treatment of clients of all ages and ability levels. The skilled therapist, working with the client’s physician, can adapt sessions to meet each client’s needs. The results stated in this case study illustrate the complimentary effects of Eastern and Western healing. I encourage Western-trained physicians and therapists to go beyond treating the physical body to treat the patient as a whole. The most wonderful aspect of Thai Yoga Therapy is that it is healing for body, mind, and spirit for both the practitioner and the client, providing a space for healing in the midst of our chaotic lives.

References

1 Raye, op cit.

Resources

O’ Sullivan, S., and T. Schmitz. Physical Rehabilitation: Assessment and Treatment. 3d ed. Philadelphia: F. A. Davis Company, 1994, pp. 491-508.

Umphred, D. Neurological Rehabilitation. 3d ed. Baltimore: Mosby-Year Book, 1995, pp. 375- 420.

Adams, R., and M. Victor. Principles of Neurology. 5th ed. New York: McGraw-Hill, 1993, pp. 749-775.

Taber’s Cyclopedic Medical Dictionary. 17th ed. Philadelphia: F. A. Davis Company, 1993.

From Jivaka Journal, 2006, by Laura Hoge

When a person loses a loved one, s/he embodies a host of physical, emotional, spiritual and psychological symptoms of distress. Often times, the weight of the loss is compounded by months of anticipatory caretaking, an exhausting process that can deplete a person’s energy to the point of illness. Some emotional symptoms of this depletion may include, but are not limited to, restlessness, emotional numbness, nightmares, cognitive impairment and lack of motivation. Physical symptoms may also impede function. Some of these include, but are not limited to, suppressed immunity, weight loss, muscular tightness, joint pain, digestive distress and/or an exacerbation of preexisting physical conditions.

Using traditional Thai massage to treat grief related energy depletion, practitioners can effectively help their clients to release emotions and alleviate physical symptoms. This is accomplished through a combination of knowledgeable soft tissue manipulation and compassionate intention. In the following case study, a client’s overall grieving process was addressed.

Case Study

In order to illustrate the effectiveness of addressing the energetic imbalance caused by grief with Thai Massage, the following case study is presented.

Patient History

The client is a 42-year-old female with a history of stress induced gastrointestinal disorders and sciatica. Her husband had recently died of an inoperable Glioblastoma (brain tumor). The length of his illness was more or less four months from time of diagnosis to time of death. The deceased underwent an ineffective protocol of both radiation and chemotherapy and was unconscious for the last week of life.

Shortly following funeral arrangements, the client became increasingly irritable, had isolated herself to the point of depression and was undergoing cognitive therapy and meditation instruction by a Zen influenced psychologist. She had begun a course of anti- depressant therapy (Prozac and Klonopin as needed) approximately one week prior to receiving Traditional Thai Massage Therapy.

For two months following funeral services, the client felt increasingly fatigued and cut back on the amount of exercise she was doing. She would have liked to have decreased the dosage of her medication, but found it effective in relieving symptoms of anxiety. She was plagued by the mental picture of her sick husband and was often irritated by the fact that she “couldn’t remember him when he was well.” She was also upset that her friends could not understand what she was going through and “never said the right thing to make her feel better.” When they tried to reach out and socialize, she became unavailable, emotional and exhausted. This upset her very much.

When I met the client, she presented as being very nervous and in digestive distress. She complained of lack of sleep and asked if it would be okay if she got up from the mat every so often to use the restroom. She complained of hip/low back and radiating sciatic pain and appeared weepy. The client was also having trouble staying asleep at night and found herself sluggish and cognitively “foggy” during the day as a result.

Treatment Modifications

I initially treated the client on the floor of her living room, though I would have preferred a smaller space to create a more nurturing environment. The living room was adjacent to a restroom though, which was necessary, as she often had to run to relieve herself. Chronic diarrhea was a problem for her, so I propped her torso up and increased the angle at the hips, which seemed to relieve her abdominal discomfort.

The prone position was not an option because of her gastrointestinal issues, so instead I used pillows to prop her on her side while manipulating the energy lines of the back.

Treatment Notes

Once the client was comfortable, I began the first few treatments with some light foot manipulation and joint mobilization at the ankle. The client was hypersensitive to pressure initially so most of the points on the foot were done lightly with a steady focus on metta. When it came to joint mobilization, (i.e. rotating and stretching the ankle joint) she found it difficult to release the full weight of her leg. This was eventually achieved with light shaking and prompted inhalations and exhalations of breath. I ended up spending over fifteen minutes on the feet at the start of the first few sessions because it gave her room to transition into the massage without me being physically invasive. It also enabled her body to become accustomed to the feel of manual support. At the start of our sessions, she would occasionally experience cramping in the internal arch of her foot. This stopped after the third or fourth treatment.

During treatment, I manipulated all 10 major meridians of the body and then concentrated specifically on Kalatharee and Sahatsarangsi-Tawaree Sen to address the emotional aspects of her grief as well as the physical manifestations of it in the form of gastrointestinal problems and sciatica. Eventually, light abdominal manipulation was incorporated to inspire proper digestion. Though I did incorporate some of the yoga stretches into the massage (i.e. lateral hip stretches, abduction and adduction of the hip joint, quadriceps and iliopsoas stretches), my main focus was in helping the client to release energetic blockages by means of acupressure (jap sen) along the aforementioned meridians. I also addressed digestive distress with hot herbal compresses on the abdomen and treated her sciatic pain with jap sen along the sacroiliac joint and outer thigh.

Sessions were concluded with a 20-minute head and neck massage with a primary focus on jap sen to the third eye point with the hope that it would relieve some of her problems staying asleep. I also used many of the points associated with Itha Pingala Sen and incorporated gentle neck mobilization into the massage to open up Kalatharee just above the axilla. The client often said that she felt her hands “tingling” while I mobilized her neck. Since Kalatharee runs down the arms and out each fingertip and thumb, this led me to believe that it had a positive effect on that specific energy line.

During sessions where her trapezius muscles were noticeably tense, I placed herbal compresses in that area while I focused on other parts of the body. This loosened the muscles and helped me to deliver deeper acupressure to the region toward the end of treatment.

Results

The patient received a total of 12 massages and during that time there was a noticeable improvement in her ability to sleep through the night without interruption. Though her digestion is still affected greatly by her mood, it has definitely improved to a point where it no longer interrupts the massage sessions. In the past month, she has begun to make appointments to see friends and socialize. She says that her sciatica only bothers her when she is in the car for a length of time and no longer keeps her up at night. She rarely experiences neck pain and attributes this to the constant use of herbal compresses and application of heat. I have recently segued this client out of weekly massages and into a steady yoga and meditation practice. This is complimented with consistent visits to her psychologist and she is attending a bereavement support group.

Conclusion

Though this particular client received Thai Massage in conjunction with western pharmacological and psychological therapies, she believed that her weekly massage sessions were effective in addressing both the physical and emotional complications of her grief. I would not recommend the use of Traditional Thai Massage as a sole treatment for those who have just lost a loved one, but I do believe that with a compassionate and trusting relationship between client and practitioner, a client can more effectively navigate the storm of emotions and physical symptoms that normally occur during this time. I encourage family members, psychologists, psychopharmacologists, etc. to incorporate this or a similar type of energy work into the protocol for addressing grief and grief related complications. I believe that it helps to expedite the processing of overwhelming feelings as well as encourages re-identifying one’s self in what can be a shocking and changed world for the client.