Client-centered care

Many of us who attended junior high or high school in the United States had to read and analyze "The Road Not Taken", a poem published in 1916 by Robert Frost.

It reads:

1. The Road Not Taken

TWO roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;         5

Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same,         10

And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.         15

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.         20

--Robert Frost, "The Road Not Taken", http://www.bartleby.com/119/1.html accessed 6 April 2013

Source: Vincent van Gogh, "Waldweg (Path in the woods)", Paris, 1887 http://upload.wikimedia.org/wikipedia/commons/3/36/Van_Gogh_-_Waldweg.jpeg accessed 6 April 2013

What emotions do you hear in the narrator's voice about having to choose between the two paths?

...sorry I could not travel both
And be one traveler...

Among other possible interpretations, one thing that come through is the narrator's regret at having to choose only one path, rather than being able to take both.

He does hold out the hope of coming back someday and taking the other one as well, yet he is realistic that it is unlikely that he will ever be able to do so:

...Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back...         15

To be able to embrace all ideas and opinions equally is a lovely idea in theory--but, throughout millennia of human history, including the ancient Indians and Persians as well as the classical Greek philosophers, no one has yet figured out a universally-accessible way to resolve the contradictions the attempt to do so creates in practice.

The principle of non-contradiction, on the other hand, seems to have withstood centuries' worth of challenges, at least well enough to serve as a general rule for evaluating whether claims have the potential to be the basis of sound clinical reasoning.

The principle of non-contradiction states that a claim cannot be true and false at the same time.

So an idea can be true, but if that is so, then its exact contradiction in every way cannot simultaneously be true as well.

Smiliarly, if the exact contradiction of the idea is true, then the idea itself must be false at that time.

Like the narrator in Frost's poem, we have to choose to take one or another, but we cannot take both at once.

Choosing whether we make our commitment to "This claim is true" or "This claim is false" often takes us in a direction opposite from the other choice.

Many MTs are among the nicest people that I've ever had the honor of knowing.

Lots of us don't like correcting or disagreeing with other people's ideas--we'd prefer for everyone to always be right, and to feel good about it.

Unfortunately, the natural universe doesn't work that way. The principle of non-contradiction, reinforced over centuries, means that the contradiction of a true idea must be false.

So, sometimes, we are going to have to practice skillful discernment, to distinguish among ideas that are right and those that are wrong.

Sometimes, because of episodes of oppression in history, we especially want to be sensitive cross-culturally and we don't want to echo that oppression by evaluating as right or wrong the ideas of someone else from another culture. Especially in light of the toll that colonial history and slavery took in Africa, those of us who are white Americans might be extremely hesitant to contradict beliefs that some Africans hold.

Yet, sometimes, as the healthcare professionals we aspire to become, sometimes we have to do so, for the sake of others' health and well-being.

The following case report illustrates such an idea that we have to stand up against, because it is unequivocably wrong:

Meel BL. 1. The myth of child rape as a cure for HIV/AIDS in Transkei: a case report. Med Sci Law. 2003 Jan;43(1):85-8. PMID: 12627683. The entire free fulltext PDF is available here, although you should consider whether you want to read about real-life sexual violence toward children before you click the link.

Source: Department of Forensic Medicine, Faculty of Health Sciences, University of Transkei P/bag X1 Unitra, Umtata 5100, South Africa.

Abstract: South Africa has one of the highest cases of HIV/AIDS infection in Africa, and Transkei, a former black homeland, now a part of the Eastern Cape Province, is one locality with a large number of HIV/AIDS sufferers. The unemployment level is very high and crime, including child rape, is very common. This report presents the case of a victim of rape, a nine-year old female child who was brought to the Umtata General Hospital, a victim of the mistaken belief that sex with a virgin will cure an HIV-infected person or AIDS sufferer of his illness. The alleged rapist was an HIV-positive uncle of the child. The myth of the 'HIV/AIDS virgin cure' is prevalent in the community. The history, physical examination and laboratory investigations of this case are given. A conclusion is drawn and preventive methods are suggested.

Of course, African countries are not the only place the virgin cleansing myth is found; I've encountered it in my massage work among Southeast Asian refugees as well. And here in America, where I am writing this, we certainly have our share of ridiculous, counterfactual, and damaging health beliefs, as well.

I chose this example, not to imply in any way that this is a uniquely African problem, because it's not--if anything, it's a uniquely human problem that we all share. We all risk falling into this trap ourselves, which is why we try our best to remain viglant against doing so.

I chose the African example for this reason: The history of the treatment of African people by American and European national powers has been uniquely and shamefully brutal on a sustained basis. One part of that horrific treatment was dismissing the subjugated people's empirical knowledge and other beliefs as "primitive", "wrong", and "pagan", among other epithets.

In light of that awful history, vowing to never again commit that particular brutality is certainly the right thing to do. We agree on that much.

What can be difficult is understanding exactly how to keep that vow.

It might seem at first that the way we do it is to keep silent as someone else expresses their ideas, no matter how different they may be to our own. After all, we agree that being tolerant is a desirable ethical behavior.

The problem with that approach is this: If we keep silent in order to be tolerant of African (and other places') belief in the virgin cleansing myth, then we stand silent as African (and Cambodian, and other) children are harmed by child rape in the material physical natural world.

If we keep silent in order to be tolerant of Burmese refugees' beliefs that malaria is caused by swimming, then we stand silent as Burmese people are harmed by failure to seek effective malaria prevention and treatment in the material physical natural world.

If we keep silent in order to be tolerant of the ultra-Orthodox Jewish tradition of "metzitzah b'peh, during which the mohel, or person performing the procedure, orally sucks the blood from the infant's newly circumcised penis", then we stand silent as two Orthodox Jewish boy babies in New York City die, and potentially thousands more contract or are exposed to herpesvirus infections in the material physical natural world.

If we keep silent in order to be tolerant of climate skepticism's disbelief in the science pointing to the ecological effects of global climate disruption, then we stand silent as the food supply, habitat, and lives of people and animals are put at risk with no contingency plan or mitigation in the material physical natural world.

If we keep silent in order to be tolerant of vaccine skepticism's belief in ill effects of vaccinations and the resulting drop in immunization rates, then we stand silent as babies, young children, healthy vibrant young adults, the elderly, and the immunocompromised are killed and left injured by preventable diseases in the material physical natural world.

If we keep silent in order to be tolerant of other massage practioners' claims (no matter how well-meaningly they were taught) that contradict biology, chemistry, and physics, then we stand silent as our clients--at some of the most distressed and vulnerable times in their lives--are confronted with the added cognitive burden of sorting out contradictory healthcare information in the material physical natural world.

If we truly want to evolve into the healthcare professionals that we often say we want to become, then--when the paths of traditional (or non-traditional, for that matter) practice or ideas necessarily lead to avoidable material physical harm to other people and animals--then we have to choose to commit to the path of practicing tolerance and beneficence by actively speaking up in the interests of people and animals against that harm, even at the expense of those ideas or practices.

If that goal is what we really want for our profession, then we have to choose the road less-traveled.

Why you may want to know this

While the statistics on domestic violence vary widely, we know at the very least that it is a large and underreported worldwide problem. It doesn't respect class, income, religion, or any other number of demographic factors; it cuts across all of them and is represented in every population group. While women are most often the victims of male abusers, it is also true that there are female abusers as well as male victims. The gay and lesbian community is also not immune from the problem, so probably one of the most important things we can do is not to bring assumptions into the therapeutic encounter that create the impression that we cannot be confided in if our client needs to reach out for help.

Depending on the licensing jurisdiction (state, province, other region) you live in, as an MT, you may or may not be considered a healthcare provider, and you may or may not be a mandated reporter, which means you have to report cases of abuse, or your suspicions that abuse may be taking place. Patient confidentiality and privacy is always important, and even required, but there are times when for the safety of yourself or another, patient confidentiality may have to be broken in order to fulfill the mandated reporter requirement. I really can't give you a one-size-fits-all answer here, except to say that you should be aware of the laws that apply to you, and what your responsibilities for protecting your clients under those laws are.

Not everyone encounters domestic violence, but many of us will have a client, a friend, or a relative who faces it. Some of us may experience it ourselves. We may never need this information, but if we ever do need it, it is better to have it in advance, rather than try in the middle of an emergency to find it from scratch.

In general, massage schools don't prepare us for what to do if, in the clinic, a client tells us they are being abused, or if we suspect that a client is being abused.

This general information from GroupHealth (such as definitions, the description of the battering cycle, the effects on children, and making a safety plan) is relevant for anyone, while the specific information (such as telephone numbers) is relevant for people, primarily GroupHealth Cooperative members, in the Seattle area.

What you may want to do with this information:

• Find out what your legal responsibilities are where you live and where you have your license. Specifically, find out whether you are considered a healthcare provider, and whether you are considered a mandated reporter. If so, for what populations are you a mandated reporter? Everyone, children, elderly clients?
• Take the following information provided, and replace the phone numbers and websites with information that is relevant and helpful where you live--local resources, for example.
• Visualize scenarios with clients where you may need to provide information about where to turn for help, as rehearsal in case this situation ever occurs in real life. You may wish to adapt this information for a brochure that you keep in your office, and can give to clients who need it. You can find brochures online, or you can adapt the following information.
• Be clear on our limits and scope of practice--we are not psychotherapists, and we do not counsel. But we can have general educational material, such as is contained in this brochure, available for distribution, and we can refer out when we are confronted with a situation that is outside our scope of practice. And counseling domestic violence victims is definitely outside our scope of practice.
• Reach out for help, preferably before you need it--cultivating a network of therapists and counselors to whom you can refer clients, if you ever need to, is always a useful step. And you may find you want to check in with a counselor or mentor as well, if a particularly harrowing story from a client has a strong bad effect on you (secondary trauma) as well.
• Be prepared. If someone else in your life, other than a client, ever confides in you that they are in a domestic violence situation, you can be a supportive friend to them as well, and urge them to get professional help. And if you ever find yourself in a domestic violence situation, please don't hesitate to reach out. There are caring people out there who want to help. No one ever deserves to be abused. You deserve to be safe.

All of this information is copyright 2009 GroupHealth Cooperative. I thank them for distributing it, and I appreciate their willingness to assemble and provide the information.

When I picked up the flyer at their medical center, I inquired about disseminating the information, and was told that they care more about getting the information out to people who need it than strictly about the copyright, so it would be ok to reproduce it here.

I have, however, enclosed it in block quotation to make it clear that I am not representing them as my words, but simply quoting the information they provide. GroupHealth gets the full credit for authoring this information.

Domestic violence

• The battering cycle
• How children are affected by domestic violence
• Develop a safety plan

 

© 2009 GroupHealth

What is domestic violence?

Domestic violence is violence or the threat of violence in an intimate relationship. This is often referred to as intimate partner violence or IPV An intimate relationship includes couples who are married, living together, or dating.

Domestic violence is sometimes called "battering" or "wife beating": it's always abusive. An abuser is a person who uses or threatens the use of violence to control another person. A victim is a person to whom a violent act is directed.

Many abusers grew up seeing violence as the way to express anger or as the method used to get control. Because of this, violence is what he or she uses as an adult to express anger or gain control.

Domestic violence is never okay--no one ever deserves to be abused. It is never the fault of the victim.

Who is abused?

Domestic violence happens to people from all different kinds of backgrounds. It happens to people of all ages, races, cultures, sexual orientations, religions, economic levels, and educational levels. Both men and women can be victims of domestic violence.

What is abuse?

Abuse falls into three categories: psychological, physical, and sexual. An abuser may use any or all types to try to control the victim.

Psychological Abuse

Psychological abuse may include name-calling or teasing, controlling the victim's activities and relationships (hobbies, friends, etc.), controlling the victim's appearance (clothing, hair style, etc.), not allowing different opinions, threatening harm or violence, or threatening suicide if the victim doesn't cooperate with demands.

Physical Abuse

Physical abuse can include punching, pushing, biting, slapping, pulling hair, kicking, pinning down, or choking.

Sexual Abuse

Sexual abuse can include any unwanted touching or fondling, physically attacking breasts or genitals, any unwanted sexual contact, including oral, anal, or vaginal intercourse, or the use of force during sex.

Why don't victims leave?

Many victims feel they have no control over the violence because it happens no matter what they do. Victims may be isolated from others, often because of the abuser. If they do have contact with people, they often don't talk about the violence due to feelings of shame and fear.

A victim may feel he or she is the only one being abused and no one else would understand. Or, the victim may believe all relationships are violent and so the abuse is normal and acceptable.

A victim may stay with the abuser for many reasons:

Fear

• Lack of physical protection.
• Fear of retaliation against victim or family.
• Fear of losing custody of children.
• Losing financial support.
• Fear of losing one's job.
• Having nowhere to live.
• Being alone.

Social and cultural reasons

• Family tells victim to stay.
• Family sees it as a private issue.
• Abuse may be viewed as acceptable in some cultures.
• Family tells victim to make the best of it.
• Others won't believe the abuse happens.
• Religious beliefs (that it is wrong to break up a marriage.)
• Cultural beliefs (that it is wrong to get help.)

Beliefs of victim

• Feels helpless to change the situation.
• Believes things will get better.
• Feels deserving of the abuse.
• Feels sorry for the abuser.

What is the battering cycle?

There are usually three phases to domestic violence, called the battering cycle. The cycle continues until the abuser or victim gets out.

Phase 1

Tension builds up. There is an increase in criticism and insults.

Phase 2

Abuser explodes into violence for little or no apparent reason.

Phase 3

Abuser apologizes and says it will never happen again, or acts as if the violence never happened. The abuser is often very charming and attentive to the victim during this phase, and promises to change or attend counseling.

How are children affected by domestic violence?

Children are impacted by domestic violence, either by witnessing the abuse or by being abused themselves. Children who witness abuse may learn that violence is normal, and is an appropriate way to solve problems.

Children affected by domestic violence may show any of the following traits:

• Anxiety and fear.
• Shame.
• Depression.
• Guilt, because they feel the violence is their fault or because they can't stop it.
• Confusion about the love and anger they feel for the abuser.
• Afraid of being left by one or both parents.

 

---

Children may experience physical problems resulting from emotional stress, including:

• headaches
• bedwetting
• rashes
• hearing or speech problems
• sleeping or eating disorders
• learning problems

 

They may also develop behavioral problems at school or at home or act withdrawn.

 

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Develop a safety plan

If your partner is abusive, it's important to develop a safety plan for you and your children in case the violence happens again.

Make copies of important papers including:

• social security cards
• birth certificates
• restraining orders
• bank account statements
• insurance policies
• your marriage license, if you have one

 

Hide them with a close friend or relative.

Hide extra clothing, money, ATM and credit cards, and an extra set of keys with a close friend or relative.

Open a checking account separate from the abuser.

Remove weapons from your home.

Set up signals with neighbors, friends, and relatives that will let them know you are in danger. A signal could be a code word to use on the phone to indicate trouble, or closing a curtain in a certain window. Ask a neighbor to call police if violence begins.

Identify a safe place to go, and practice how you will get there. Make plans to take your children with you. Prepare older children to leave and call police from a neighbor's house if you can't get away.

During an incident:

Call 911 for help.

Get out if possible. If you must leave without your children, come back with the police to get them.

If you can't leave the situation:

Avoid rooms with only one exit.

Avoid the kitchen, bathroom, bedroom, and garage.

 

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Computer safety

If the abuser can access your computer, they can find out what Web sites you have visited, what documents you have written, even what e-mail you have sent. The safest thing to do is to use a computer at the library instead of your computer at home.

---

For more information

Domestic violence is a serious health concern for you and your children. Please speak with your doctor if you are affected by domestic violence.

For help, please call:

• National Domestic Violence Hotline
  • (interpreter services available)
  • 1-800-799-7233
  • www.ndvh.org
• Group Health Behavioral Health Services
  • Western Washington: 1-888-287-2680
  • Eastern Washington: 1-800-851-3177
• Group Health Consulting Nurse Service. Call 24 hours a day toll-free
  • 1-800-297-6877.
• Northwest Network of Bisexual, Trans, Lesbian & Gay Survivors of Abuse
  • 206-568-7777
  • www.nwnetwork.org

 

The Group Health Resource Line can provide information about community resources and support groups in your area. Call the Resource Line toll-free 1-800-992-2279 or e-mail resource.l@ghc.org.

You are not alone. No matter what your loved one has told you, abuse is not your fault. You have a right to live without being hurt.

Psychosocial and cognitive approaches don't require that you become a clinical psychologist but that you have a broad concept of the influence of those factors and that you account for them in your encounters with your patients. Know the literature and be able to give management advice based on evidence. When people come to see you they want a plan. Have a plan that is defensible and that works toward their goals. Address concerns, fear avoidance, other stress, and unhelpful beliefs with compassion, understanding, empathy, and informed knowledge.

Understanding why people hurt is part of our professional responsibility and should change most everything we do on a daily basis away from traditional methods and towards methods defensible with modern science.--Jason Silvernail accessed 5 August 2011

Since I'm advocating massage in a biopsychosocial model, it's my job to connect the dots and explain what I mean by that.

A biopsychosocial model of health and illness is one that takes into account the role of biology (and other sciences), psychological factors, and sociocultural factors, as well as the interactions among those different factors, in seeking to understand what health and illness really are.

An example of a biological factor in health could be increased cortisol in the bloodstream in response to chronic stress. The interaction of that biological factor with the increased daily stress in modern society would be an example of interactions among biological factors and sociocultural factors.

An example of a psychological factor in health could be a man who is less likely to seek professional treatment for pain than a woman is, because of his perception that stoically enduring pain is what men do in the society he grew up and lives in. The increased structural damage that can occur as a result of ignoring symptoms and delaying treatment is an example of the interactions among psychological factors and biological factors.

An example of a social factor in health could be the relative stigmatization of mental or behavioral illness, as compared to how more clearly structural conditions are regarded. This stigmatization can drive psychological conditions underground--say, for example, if someone did not get needed psychological treatment because they didn't want it to show up in their medical record. That would be an example of interactions among sociocultural factors and psychological factors.

Biopsychosocial massage is client-centered. That means that the psychological and social factors in the client's unique experience, as well as the universal biological factors we are all subject to, is the center of where we focus our attention and caring. It doesn't mean that we accept everything in someone else's experience is literally true. It does mean that we recognize that, for them it feels true, and for that reason alone, it is important in where we meet the client in the therapeutic encounter.

Biopsychosocial massage welcomes self-expression and the art of massage. It is clear, however, that sometimes our need for self-expression can come into conflict with clients' immediate healthcare needs, and--when that happens--we recognize that, in order to act as healthcare professionals, our ethical fiduciary duty is to put the clients' needs first, ahead of ours if necessary.

Biopsychosocial massage is wholistic, integrative, and evidence-based. That means that it does not draw upon supernatural explanations of mechanisms, and it builds upon foundational knowledge in the sciences to evaluate and validate the evidence for or against particular claims of effectiveness or mechanisms.

Since our encounters with clients will always run ahead of the available high-quality evidence, we don't limit ourselves only to what has been rigorously validated by studies and nothing else. We take our professional experience into account, and we actively seek to understand and incorporate the clients' preferences, whenever possible, in treatment. But in all these cases, in developing our approach to caring for the client, we remain clear on what is evidence, what is speculation, what is science, what is art, what is literal, and what is metaphor.

Understanding the material physical universe around us, and the centuries of cumulative human knowledge about that universe, give us powerful tools to draw upon. That understanding, combined with the caring that characterizes so many people who choose to go into massage as a career, is the heart of biopsychosocial massage.

Neil deGrasse Tyson sums it up almost perfectly:

I am driven by two main philosophies, know more today about the world than I knew yesterday. And lessen the suffering of others. You'd be surprised how far that gets you.

--Neil deGrasse Tyson

That quotation demonstrates the core of massage in a biopsychosocial model.

Source: http://healthskills.files.wordpress.com/2008/10/biopsychosocial.jpg accessed 7 August 2012

It's not easy to face the realization of having been misled.

And the misleading does not have to be intentional; it could have been done with the best intentions in the world.

But those good intentions don't change the facts that, as a result, the student is launched into real-life practice operating with poor information, is bringing misinformation into the relationship with the client, and is being publicly evaluated on the basis of that misinformation by other potential partners in a unified healthcare team.

It could have happened to any of us--the field of massage is notorious for promoting teachers out of the ranks of students who have simply passed the class they're now expected to teach. Biomedical physicians have nothing on massage when it comes to "See one, do one, teach one".

No blame, no shame: one set out to create that situation; it just evolved that way, undirected. And there was an unspoken social contract that allowed it to continue, because the need for teachers was so high.

But the social contract has changed out from under us, and the current situation is no longer sustainable in light of the responsibilities expected of healthcare professionals.

Ralph Stephens names the problem as the very first one in his list of the educational "seven deadly sins":

Standardizing the number of hours or the curriculum content (ELAP) will not improve educational outcomes as long as our massage educational institutions are allowed to:

1. Employ unqualified instructors.

...

Two things are needed to "heal" the problem, money and moral conviction. ABMP, AMTA and FSMTB must be persuaded to give substantial and ongoing financial support to COMTA and AFMTE to assist them with their respective missions. COMTA because we need a strong accrediting agency dedicated to the field of massage therapy. That is the natural place for educational standards to live. AFMTE because their Teacher Education Standards Project (TESP) is the trail that the entire education sector must follow if we are to truly "elevate" the profession from the sad state in which it currently exists.

These organizations also need to take a public stand - an unequivocal position - that the operational practices listed in the "Seven Deadly Sins" are no longer acceptable in the massage therapy field; that we expect better from our schools and programs. They may not have the force of law, but such moral courage on the part of community leaders, consistently stated, can and will instigate a change in institutional behavior.

Stephens is right about going forward--but what about all the students, practitioners, and teachers who are coming to grips with the fact that much of what they were taught is exaggerated, counterfactual, or simply wrong?

It takes a great deal of courage on their part to stare unflinching into that abyss, and to engage with what's needed to collect, assimilate, organize, and share good information.

The upheaval and disruption in the process is causing a great deal of moral distress and pain in people who are re-evaluating where they are, and how far away they are from where they need to be.

One thing that they do not have to worry about here is being blamed for having been taught wrong.

The policy here is, "no blame, no shame": it is not someone's fault that they did not get the education they deserve, and if they are trying to fix that situation, they deserve--and will have--our support in that journey.

The Buddhist concept of samma-vaca--"right speech"--is a useful guide to discourse here at POEM.

It's often summarized as, "Is it true? Is it kind? Is it necessary?".

We'll examine those questions in a slightly different order than they're usually posed.

"Is it true?": The standard at POEM is that we will not pass along misinformation here.

Massage stakeholders can depend on POEM for accurate information about massage.

If someone is making a factual error, it's ok to correct that error civilly and professionally. That means focusing on the facts, not on the person--no personal attacks, just connecting the dots on what the facts are.

Not everything is a matter of fact, of course--there is no scientific answer to the question "Is chocolate or vanilla better?"--and interpretations, creativity, and imagination are welcome topics for discussion, as long as active misinformation doesn't ride along.

"Is it necessary?": There is a wide consensus that something is rotten in the state of massage education, so yes, having a portal to the shared body of biomedical knowledge that members of a unified and client-centered healthcare professional team all draw upon to varying degrees is an absolutely necessary--and as-yet unmet--niche that POEM is being developed to fill.

"Is it kind?": Absolutely: everyone who participates here can expect to be treated kindly. Kindness does not mean letting misinformation go uncorrected; it means that misinformation will be corrected in a civil, professional, and kind manner, without attacking the person.

When someone does not have access to good and high-quality information, because of gaps in their education, the kind and considerate thing to do is to offer them a bridge to obtain that information.

Giving them an opportunity to correct themselves is far kinder than leaving them--and their clients--to the consequences of misinformation.

We're in really deep waters here, as a result of a number of historical, social, political, and cultural factors all coming together and synergizing.

But if POEM has any say at all in the matter, then we will get through these difficulties, because we'll support each other in learning and growing along the way.

Source: http://www.education.noaa.gov/images/article_ocean_floor_2.jpg accessed 26 August 2012