If your practice sits anywhere near a financial district, a private members’ club, or a five-star spa, you already know this client. They arrive late, apologising, phone in hand. They fall asleep on the table within minutes, or they never quite settle at all. Their upper trapezius feels like cable wire, their breathing lives entirely in the upper chest, and when you ask how they have been sleeping, they laugh.
High-performing clients, executives, founders, surgeons, senior lawyers, are some of the most rewarding people to treat. They are also some of the most physiologically compromised, and manual therapists are often the first health professionals to notice. This article looks at what chronic stress actually does to the tissues under your hands, how burnout presents on the table, and how to recognise the moment when the most therapeutic thing you can offer is not another session, but a well-made referral.
Stress Physiology: The Body in Permanent Overdrive
Initially stress response is healthy for the nervous system and a healthy response to demand. But returning to parasympathetic ‘rest’ after prolonged stress is problematic for the high-performer. Their HPA axis is ‘on’ for months and years, at a time when they are trying to perform at optimal levels.
Cortisol and catecholamines held high for periods of time can have several profound effects on the body that can be palpable to manual therapists. Muscles at rest can become tenser. Neck muscles such as the suboccipital, upper trapezius and levator scapulae, as well as the muscles of mastication can become tighter. ‘Apex’ breathing can become the norm loading up the scalene and sternocleidomastoid muscles and preventing the diaphragm from functioning optimally. Longstanding elevated levels of cortisol can impede the fundamental repair mechanisms that manual therapy provides. Impaired sleep and consequently reduced pain threshold or central sensitization can mean that a patient reports increased pain from pressures previously utilized months apart. Common presentations are of patients with digestive complaints, bruxism and or tension type headaches. Elevated heart rate at rest is not uncommon.
What Burnout Looks Like Under Your Hands
Burnout or emotional exhaustion is an occupational syndrome, recognized by the World Health Organization. This syndrome is comprised of three components: 1) a feeling of exhaustion; 2) a sense of detachment from work, sometimes referred to as cynicism; and 3) reduced ability to perform work tasks, often accompanied by feelings of hopelessness or inefficacy.
In trying to manage stress, a person’s nervous system can become over-activated leading to hypertonicity (stiffness) of the muscle. This means that even light contact from the therapist can be met with resistance as if the muscle is guarding itself from further injury. When treating someone with hypertonic muscles due to chronic stress, the therapist needs to recognize the person’s nervous system is in a state of permanent overdrive. The person’s stress can affect their treatment in many ways. Sessions can be cancelled and re-booked in a tighter and tighter cycle. The person who would previously happily chat with the therapist after their session about their treatment, or ask for recommendations for other treatments, now sits in silence and only answers the therapist’s questions with a single word. There are occasions when a client will unexpectedly start to cry during a treatment. The person may apologize for their behavior as if it were a professional failing. Conversely, there are some people who half-jokingly ask if they can have three sessions a week as they feel so calm on the table. This indicates that the person’s use of massage is not supporting their recovery from stress; rather it is masking their decline.
Lastly, we need to acknowledge that in some high-performers’ lives, weekly massages are the only way they get to calm down. So what I am referring to here are the treatments that support recovery from stress and its effects on the body – and not stress treatment per se.
The Limits of the Table
On the positive hand, there are many benefits to the client of having a body that functions as it should when under stress. The physical effects of increased sympathetic activity can be reversed, i.e. client’s can sleep again and be free from pain caused by overuse of muscles and connective tissue. However, as previously stated, manual therapy can only treat the after effects of stress, it cannot treat the causes of stress. Therefore, it is outside of the scope of manual therapy to treat cases of clinical anxiety and or depression and cases of dependence on alcohol or other substances as a means to try and switch off from the stress of their daily lives.
There are some very serious issues that are outside of the scope of manual therapy to treat. Issues of chronic stress can manifest into serious issues such as: clinical anxiety and depression; alcohol dependence; dependence on sleep medications; and dependence on stimulating medications such as amphetamines and cocaine. We as therapists must recognize the signs and symptoms of these serious health issues and refer our clients to the proper healthcare professionals when necessary. As massage therapists we may see some of the following signs and symptoms in our clients that would be outside of the scope of manual therapy: clients having a smell of alcohol on their breath at 12 o’clock in the day; clients saying they need something to go to sleep; clients saying they need something to wake up; dramatic weight loss or weight gain; clients with a tremor; clients with an increase in irritability that is out of character; and clients saying they don’t want to carry on anymore. Again as therapists our role is not to diagnose; our role is to care for our clients and to know when to refer them on to other healthcare professionals.
Making the Referral Well
High-performing clients rarely respond to being told they look burnt out; many hear it as an accusation of weakness. What works better is reflecting what you objectively find: that their tissue is not recovering between sessions, that their nervous system is staying in overdrive, and that this pattern usually needs more support than bodywork alone can provide.
It also helps to know referral options that match the client’s world. Executives and public figures often refuse conventional treatment settings out of privacy concerns, or because they cannot step away from their responsibilities into a group programme. Specialised residential providers exist for exactly this population. THE BALANCE Rehab Clinic, for example, treats one client at a time in private residences, combining medical and psychiatric care with the mind-body therapies our clients already trust, including massage, breathwork, and movement. Knowing that discreet, individualised options exist makes the referral conversation far easier to open, because you are offering a door the client can actually imagine walking through.
The Takeaway
Manual therapists occupy a rare position in a high-performer’s life: we see them regularly, we touch the physiological record of their stress, and they trust us. That position carries a quiet responsibility. Keep treating the tissue, keep offering that hour of genuine down-regulation, and keep sharpening your palpation of what chronic stress feels like. But when the pattern under your hands stops improving and starts deepening, be willing to say so. Sometimes the most skilled thing a therapist can do is recognise the moment their table has done all it can, and help the client find the level of care they actually need.
