Grant J. Rich, PhD, LMT, BCTMB1*
1Richard W. Riley College of Education and Human Sciences, Walden University, Juneau, AK, USA
This article focuses on the use of massage therapy for mental health in refugees, immigrants, and asylum seekers. First, the article reviews data and definitions concerning this population in the United States. Next, the article reviews data and evidence concerning the mental health challenges experienced by this population. Finally, the article summarizes data and evidence on the effects of massage therapy for mental health issues. Particular attention is devoted to clinical considerations that are unique or special regarding massage therapy for this population, including cultural concerns and trauma-informed care. Suggestions for future research are noted.
KEYWORDS: Massage therapy; refugees; immigrants; asylum seekers; trauma; depression; anxiety; culture; international; psychology
In their recent research, Ferguson and Birman note that “The United States of America is a dynamic multicultural nation built to a large extent by immigrants” (p. 396).(1) This is a valid observation, though it is essential to recognize that Indigenous peoples were the first to arrive—over 10,000 years ago—and to live in what is now the United States.(2,3) Today, according to the Pew Research Center, 20% of the world’s international migrants live in the United States, and as of 2023, the US foreign-born population totaled 47.8 million, with immigrants representing 14.3% of the US population.(4) Today’s immigrants to the United States come from almost every nation on earth, with 28% from Asia, 23% from Mexico, 27% from Latin America and the Caribbean (excluding Mexico), 12% from Europe and Canada, 5% from sub-Saharan Africa, 4% from the Middle East and North Africa, and the rest elsewhere.(4)
Technically, immigrants, refugees, asylum seekers, and migrants are related but distinct terms. According to the International Rescue Committee (https://www.rescue.org/),(5) an immigrant consciously decides to leave their home nation and move to a foreign country, such as the United States, and many eventually become lawful permanent residents and citizens. In contrast to immigrants, a refugee is someone who fled their country due to safety issues, human rights abuses, and persecution.(6) An important distinction between a refugee and an asylum seeker is that while refugees are afforded the right to international protection, an asylum seeker also faces human rights abuses in their home nation but has not yet been granted status as a refugee. As Amnesty International(6) notes, it is a human right to seek asylum, and thus persons should be permitted to enter another nation to seek asylum. Finally, there is the term migrant, which is defined in various ways; for example, an island-born Puerto Rican who migrates to the mainland United States or a person who resides outside their home nation who is not a refugee or an asylum seeker but instead seeks work, educational opportunities, or family reunification.(6)
Thus, the population of immigrants, refugees, asylum seekers, and migrants in the United States is exceptionally diverse. There are racial differences, of course, such as White immigrants or Black or Asian/ Pacific Islander immigrants, but also immigrants who were Indigenous within their nation of origin. There are also tremendous differences in type and level of education between and within immigrant groups; some immigrant groups may tend to have higher than the average education in the United States, such as advanced degrees, whereas immigrants from other groups may tend to arrive without much formal education at all.(2,7) Likewise, some immigrants may arrive with great wealth reserves and large bank accounts, whereas others may scarcely have a dollar in their back pocket. The language barrier is often, but not always, an issue, as some immigrants may have learned English as their first language or have learned to speak well prior to arriving in the United States. It is important to not make assumptions about the person’s language ability, as the linguistic experiences among immigrants reflect great diversity. According to Moslimani and Passel,(4) immigrants from “Canada (97%), Oceania (82%), sub-Saharan Africa (76%), Europe (75%), and South Asia (73%) have the highest rates of English proficiency” (p. 1).(4) They also note that “Spanish is the most commonly spoken language among US immigrants.” About four-in-ten immigrants (41%) speak Spanish at home. Besides Spanish, the top languages immigrants speak at home are English only (17%), Chinese (6%), Filipino/ Tagalog (4%), French or Haitian Creole (3%), and Vietnamese (2%)” (p. 1).(4)
There is great variation in religion and spirituality as well, with representation from various Christian faith traditions, as well as Judaism, Islam, Buddhism, Hinduism, Sikhism, Indigenous spiritual practices, and many more. All this diversity also includes variation in learned practices and shared norms for the immigrant group regarding preferences for various cuisines, clothing styles, art and music types, and especially important for massage therapy, beliefs about health including views of traditional healing modalities versus Western-style allopathic medicine. It is worth noting that different cultural groups may have strong beliefs about age, gender, and social class, which is a consideration for clients seeking massage therapy that is culturally appropriate and comfortable for them and their community. There are a number of useful books and websites available that offer capsule culturagrams and cultural orientation that are especially helpful for health-care providers, such as massage therapists. For instance, Rich, Kuriansky, Gielen, and Kaplin(2) offer a collection of scholarly articles by psychologists on migrants, refugees, and asylees in the United States, with chapters that focus on individual cultural groups, including chapters focused on Mexican, Central American, South Asian, Caribbean, European, African, East Asian, Middle Eastern, and Afghan cultures, among others. Beyond books by psychologists, helpful resources are often also produced by scholars and practitioners from the disciplines of medical anthropology or transcultural nursing; see, for instance, Caring for Patients From Different Cultures: Case Studies From American Hospitals by the anthropologist Galanti(8) or the resource-rich website EthnoMed,(9) which has health-related assessments and materials in many common and less common languages (https://ethnomed.org/#). Coupled with cultural immersion, smart use of cultural community guides, and sensitive communication with clients and community members, the quality of care can often be improved significantly.
Given the range of countries and situations from which immigrants, refugees, and asylum seekers come to the United States, and given the range of individuals arriving in terms of life experience, personality, genetics, age, and so on, it is not surprising that there is great diversity in types of mental health challenges experienced by such groups and individuals.(10) That said, there are several more common conditions and themes that evidence suggests are often prevalent in such communities.(2) López(11) discusses common psychological issues associated with the migrant experience, highlighting the stressors in individual and family adjustment. She highlights several bona fide mental illnesses (i.e., diagnosable clinical psychological disorders), while also addressing the dynamics of how financial and legal challenges, as well as contending with policy bureaucracy, can add stress. In fact, acculturation and acculturative stress are among the most common stressors experienced by migrants.(2) Acculturation may be defined as a “dynamic and multidimensional process of cultural adjustment occurring on individual and groups levels when distinct cultures come into sustained contact” (p. 236)(12); acculturation stress can be defined as “the host of difficulties that arrivals may face upon relocation” (p. 43)(11) and can occur when the “challenges and demands associated with cultural learning and maintenance in particular exceed one’s coping skills and resources” (p. 236).(12) Vasquez(13) details a model of phases and stages in migration stress that she terms Migration Struggles. Her model acknowledges the impact of reasons for the move, the particular difficulties encountered during the transition and journey, and the specific stressors in the adjustment process in the host nation. These phases too can be further impacted if the migrant brings other stressors to their experience, such as intergenerational trauma or a personal trauma history. Other scholars have noted elevated risks experienced by immigrants and refugees, such as increased odds of being victims of hate crimes and targeting an individual or group based on their membership or perceived membership as an immigrant or refugee.(14) Often, an individual migrant’s gender (such as being a woman or nonbinary) or age (such as being a child, youth, or older person) intersects with their identity as a migrant to add additional complex stressors and dynamics that can impact mental health and well-being.(15,16) In sum, among the most common conditions in migrant populations are those related to anxiety, depression, and posttraumatic stress.(2)
Given that the prevalence of depression, anxiety, and posttraumatic stress is elevated in immigrant, refugee, and asylum-seeking migrant populations, it is critical that massage therapists consider whether massage therapy can reduce the negative impacts of emotional states. There are a number of research studies supporting the effectiveness of massage therapy for these conditions.(17–24) The following subsections examine research on massage therapy for depression, anxiety, and posttraumatic stress in general populations.
Massage therapy’s effects on alleviating depression are well documented. In a classic meta-analysis, Moyer, Rounds, and Hannum(25) examined 37 studies. Analyzing results from 10 randomized controlled trials on massage therapy, the authors found that after treatment, depression was lower in the massage therapy group compared to 73% of those in the control group. Tiffany Field’s research often examines the effect of massage therapy on depression, utilizing tools like the Beck Depression Inventory assessment. Her studies show massage therapy can help alleviate depressed mood.(18,26) More recent studies confirm this general finding; for instance, Erol, Ertunc, and Ozturk(27) found that hand massage reduced depressed mood in a sample of older adults. In a recent small pilot study of five persons with diagnosed major depressive disorder, Okamoto et al.(28) found that aromatherapy massage was a useful supplemental therapy for depression.
Massage therapy’s effects on reducing anxiety also are well documented. Psychologists typically distinguish between what is termed “state anxiety” and what is termed “trait anxiety,” where state anxiety is a temporary emotion/feeling at the moment, and trait anxiety is a more enduring, long-standing, and chronic condition, more akin to a personality trait than a momentary emotional reaction.(29) The 1991 president of the American Psychological Association, Charles Spielberger, developed the now widely used quantitative assessment measure, the State-Trait Anxiety Inventory (STAI), to assess both types of anxiety.(29)
In the meta-analysis of 37 studies referenced earlier, Moyer, Rounds, and Hannum’s research(25) also concluded that single applications of massage therapy reduced state anxiety (as well as heart rate and blood pressure) and, after multiple treatments, trait anxiety. After reviewing 25 studies of massage therapy, Moraska and colleagues(30) concluded that single applications of massage therapy reduced salivary cortisol and heart rate. Many studies conducted by Tiffany Field also investigate the effects of massage therapy on anxiety, often utilizing the Spielberger STAI to assess outcomes and find positive effects on alleviating anxiety.(18,26)
Related to anxiety is posttraumatic stress disorder (PTSD), a condition that involves intense feelings, anxiety, and distress triggered by traumatic events. PTSD may be defined as a negative reaction, which is a “severe, often chronic, and disabling disorder. PTSD develops in some people following their exposure to a traumatic event involving an actual or threatened injury to themselves or others. A person with PTSD may have intrusive thoughts, nightmares, and flashbacks of traumatic events” and may become hypervigilant and/or easily angered (p. 5).(31) Though some studies of massage therapy for PTSD exist, and preliminary results are encouraging, there remains a paucity of research on the topic,(32) despite some small quantitative studies.(26) For instance, Van der Kolk(33) documented a 2002 survey of 225 people who escaped the World Trade Center on September 11, 2001, and the survivors noted that massage therapy was the second most helpful healing modality for them. Anecdotal reports by massage therapists working with traumatized populations in post-2010 Haiti earthquake(34,35) and with refugees in Jordan in the Middle East also reported that careful use of massage therapy benefited clients who had been traumatized.(36) As an additional example, Price and colleagues(37) found body-oriented therapy utilized as an adjunct to medication for opioid use disorder improved PTSD symptoms. Another study by Price(38) found body-oriented therapy reduced PTSD symptoms in a sample of females in psychotherapy for child sexual abuse. Price(38) defines body-oriented therapy as involving “the combination of bodywork - an umbrella term for touch therapy modalities (e.g., massage, polarity, acupressure) and the emotional process of psychotherapy” (p. 47). It is important to note that while massage therapy may sometimes be the only available therapy for PTSD or indeed the most appropriate one, there are also other alternative therapies for PTSD that are effective for many persons.(39,40) Additionally, modern therapies such as professional psychotherapy and prescription medicines have proven effective for many individuals.(41–43) More recently, virtual reality therapies have emerged as a high-tech approach to treat trauma.(44,45)
It is worth noting that a number of scholarly publications have documented the effectiveness of massage therapy specifically for use with refugee and immigrant populations. Given the diversity of such populations, ideally one seeks research support for each population, a challenge given the arguably almost limitless number of cultures around the globe. Given the diversity of cultures, it is critical not to stereotype cultural groups or individual culture members, though there may be general issues that are often faced by migrants in general, and thus some principles and research may be helpful in working with more than one group. Nevertheless, it is important to proceed with caution and to recognize the diversity within and between each group and each individual; for information on general principles, theories, and research on psychological health with migrant groups, there are several available resources, such as The Cambridge Handbook of Acculturation Psychology,(46) the Handbook of Refugee Experience,(47) and Psychosocial Experiences and Adjustment of Migrants: Coming to the USA.(48)
Among existing studies of massage therapy with immigrants, refugees, and asylum seekers, one may categorize the research into several general categories: studies examining reductions in pain, studies examining reductions in trauma and torture symptoms, and research examining reasons for use and utilization rates of massage therapy. The following subsections describe existing research in each category.
Among extant studies, several focus on Somali populations to alleviate pain and stress(48) and improve mental health and reduce pain.(49) Additionally, there is a study of simple acupressure to improve mood, sleep, and pain in a Rohingya refugee camp,(50) as well as studies with Southeast Asian refugees (i.e., Cambodian and Lao)(51) which show the benefits of massage therapy for such ailments as body aches and headaches; notably in many Southeast Asian cultures, mental health concerns may manifest in physical ways, such as the body and headaches.(52)
Additional research examines the effectiveness of bodywork for traumatized Arabic-speaking refugees (from Iraq, Saudi Arabia, and Lebanon) in Scandinavian countries; these refugees have experienced torture, and over half suffer from PTSD.(53) A review study of the literature on complementary and alternative medicine (CAM) for treating refugee survivors of torture provides preliminary support for certain CAM modalities including massage therapy, but notes further research is needed, such as appropriate uses and populations, as some traumatized survivors may be uncomfortable or anxious with physical touch. However, others may find that appropriately administered massage therapy helps reduce anxiety.(54) Similarly, a caveat is to be prepared that psychological dissociation from the body is a common occurrence among those who have been tortured or traumatized; yet if used appropriately, massage therapy can sometimes be used to reduce such body dissociation.(54) Scholars continue to call for the adoption of trauma-informed care in complementary and integrative health services.(55) Studies also show the use of massage therapy in refugee populations such as Muslim Bosnians to alleviate PTSD and for depression and anxiety in a female population from El Salvador.(56) Further research found manual therapy could be utilized to manage PTSD and associated pain and sleep disturbance in refugees, though it cautions that practitioners must take into account cultural variation in how various ethnic groups express somatic distress.(57)
Massage therapy may often be especially favored by older refugees as the practice may be familiar from their homelands, as found in a study of older Southeast Asian refugees.(58) An additional factor in help-seeking behavior in refugees and immigrants may be trust and a lack of trust or familiarity with Western medicine and doctors may also be a driving force leading some refugees to seek out more familiar CAM practices such as massage therapy.(58) Finally, of course, an added issue is often the language barrier; if a Western MD does not provide a clear explanation in the refugee’s language, this is one other reason the refugee may seek out traditional practices such as massage therapy with traditional practitioners from their own culture who speak their language.(34–36)
Massage therapy has been utilized widely across cultures and across time, for centuries, even millennia, as, for instance, it is depicted in 15,000-year-old cave paintings in the Pyrenees in Europe,(59,60) utilized in ancient Greece and Rome,(61) and seen on the ancient reliefs at Cambodia’s Angkor Wat.(61,62) Its use in modernity, in the 21st century, remains widespread in the Americas, but also in far-ranging world regions such as Southeast Asia, including Cambodia,(63) and in Oceania and the Caribbean, including Haiti.(64)
Immigrants, refugees, and asylum seekers to the United States may be at elevated risk for a range of mental health conditions, often related to stressors and traumas, some experienced in their home nation and some experienced in their host nation, such as acculturation stress and stress resulting from hate crimes. Massage therapy has the potential to be a healing modality that can be effective as part of interventions to support such populations, in that it is often an already familiar treatment and may be more accessible than some conventional allopathic therapies. Some examples of cultures that value and are familiar with massage therapy or hands-on bodywork are many Caribbean cultures such as in Haiti(32,34) and Southeast Asian cultures such as in Cambodia.(24,52) In addition, sometimes conventional talk therapies may be less effective for migrant populations for several reasons, including the language barrier, stigma in some cultures for speaking with psychotherapists, and high costs of some treatments such as psychotropic medications.(2,52,63) Furthermore, for some clinical conditions and for some clients (such as children or elderly or those deeply traumatized), a healing journey may begin through touch, rather than the unfamiliar situation of talking to a strange foreigner about one’s deepest, most private emotional pains. Thus, some scholars have argued in favor of integrated care for the traumatized, a whole-person approach that may supplement conventional talk psychotherapy and medication. Such complementary therapies can include expressive arts, animal-assisted therapies, dance therapy, and massage therapy.(65,66)
That said, as with all applications of massage therapy, special care must be taken to ensure that massage therapy is the appropriate modality for the right client, performed by the right massage therapist, in the right situation. Additionally, there are caveats, cautions, and considerations when working with migrant populations. As noted earlier, for instance, a therapist should exercise sound judgment when considering whether a particular case and client are within their scope of practice and should take care to ensure that common cultural differences in language, age, status, gender, and trauma and migration-related stressors are taken into account. When in doubt, the massage therapist should seek supervision or consultation with other health-care professionals, as well as sound cultural guidance, and refer out if appropriate.(24,32,62)
As noted near the start of this article, about 20% of all the world’s migrants live in the United States, with immigrants representing nearly 15% of the population of the United States.(4) While the experiences of refugees, immigrants, and asylum seekers may differ by reason for migration and particular geographic regions and cultures, many migrants experience elevated rates of stress, such as acculturation and assimilation stress, and trauma-related mental health conditions, including depression, anxiety, and PTSD. Massage therapy has been demonstrated to show some effectiveness in improving these psychological conditions. Working with diverse migrant populations requires special and careful attention to cultural considerations to ensure culturally appropriate care and optimal results. Furthermore, working with diverse migrant populations may also necessitate careful care coordination with an interprofessional team, such as physicians, legal professionals, psychologists and social workers, case managers, interpreters, and other professionals as the situation may require.(67)
A critical concept to remember is cultural humility. “Cultural humility involves a lifelong process of self-reflection about how one comes to know and an openness to learn. Self-reflexivity, humility and an acknowledgment that we don’t know it all, an appreciation of other people and communities’ knowledge, flexible thinking, a desire to learn and to address power imbalance and privilege are considered important attributes of cultural humility, as is being respectful of other cultures” (p. 28).(68) Authentic cultural humility represents truly a lifetime commitment to evaluation, critique, and reflection of oneself. The concept is essential for researchers, teachers, students, and practitioners to know and to work toward implementing.
To conclude, presently, some research supports the use of massage therapy for a range of mental health conditions in addition to conventional care, such as professional psychotherapy and/or prescription psychopharmaceuticals. Future research must examine best practices for massage therapy with migrant populations in a more nuanced manner, including research with particular cultural populations, and research examining the impact of massage therapy type, qualities of optimal massage therapists, and how best to integrate massage therapy interventions and massage therapists with other mental health treatments and with other mental health providers.
The author declares there are no conflicts of interest.
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Corresponding author: Grant J. Rich, PhD, LMT, BCTMB, Richard W. Riley College of Education and Human Sciences, Walden University, PO Box 21551, Juneau, AK 99802, USA, E-mail: optimalex@aol.com
COPYRIGHT
Published under the CreativeCommons Attribution-NonCommercial-NoDerivs 3.0 License.
International Journal of Therapeutic Massage and Bodywork, Volume 18, Number 3, September 2025