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Community outreach

Seattle-area Veterans Appreciation Dinner event on Saturday, 18 May 2013 at 1 PM


Inspired by and modeled on the years-long tradition of community Elders Dinners provided by the health sciences students in the Medicine Wheel Society at the University of Washington, the first Veterans Appreciation Dinner by the Project for Open Education in Massage will take place on Saturday, 18 May, 2013. The weekend preceding the official Memorial Day holiday weekend was chosen in order not to conflict with the many other events commemorating the importance of the holiday.

Onsite chair massage will be provided as one of multiple massage continuing education opportunities associated with this event.

More details will be announced as they are finalized, and this post will be updated frequently as those details are determined.

Event: Veterans Appreciation Dinner

Date: Saturday, 18 May 2013 

Time: event prep begins 9:00 AM, dinner served to guests at 1:00 PM, cleanup and debriefing 3:00 PM

Location: TBD

Tickets for dinner available at: TBD

Signup for chair massage available at: TBD

 

 

A webpage for the Canandaigua VA Medical Center in New York State shows a student on her clinical rotation for the Finger Lakes Community College massage therapy program.  

Source: http://www.canandaigua.va.gov/images/StoryMassage.jpg accessed 31 March 2013

If your client, your friend, your relative, or you may be experiencing domestic violence

 


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.

 


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.

 


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

 

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.

Looking into the abyss (#26/31)

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

Exploring ethics and effectiveness: Can we accept this invitation to be part of an integrated public health team? (#19/31)

One of the most desired professional goals consistently expressed by massage therapists has been for massage to become part of an integrated healthcare team. Such an integration has to be in the best interests of the client/patient, as recognized by other members of the team, for that integration to come about.

A recent article in the Maternal and Child Health Journal seems to provide an opportunity for complementary and alternative medicine (CAM) providers to work with public health providers to reduce the occurrence of vaccine-preventable disease. That's a major public-health priority, since these diseases are on the rise lately all around the United States.

 
Downey's team looked at the usage of CAM, and at two other factors to determine the relationships among them.
 
The two other factors they looked at were:
  • whether children between the ages of 1-2 received the vaccinations recommended by best-practice guidelines, and
  • whether children between the ages of 1-17 contracted vaccine-preventable diseases.
 
They based their information about the relationships among those factors on the records of pediatric medical insurance claims in Washington state who reimburse for CAM therapy under Washington law.
 
To measure CAM usage, they looked at claims for reimbursement for services for the children or their families by:
  • chiropractors,
  • naturopaths,
  • acupuncturists, or
  • massage practitioners.
 
To measure the rates of vaccination among children 1-2 years old, they looked at claims for vaccinations.
 
To measure the rates of contracting vaccine-preventable diseases among children 1-17 years old, they looked at medical claims for the following diseases:
  • diphtheria
  • tetanus
  • pertussis
  • polio
  • measles
  • mumps
  • rubella
  • Hemophilus influenzae type B
  • hepatitis B
  • chickenpox.
 
From the insurance reimbursement records, they found that:
  • Children were significantly less likely to receive each of the four recommended vaccinations if they saw a naturopathic physician (diphtheria/tetanus, measles/mumps/rubella, chickenpox, or H. influenzae type B).
  • Children who saw chiropractors were significantly less likely to receive each of three of the recommended vaccinations (measles/mumps/rubella, chickenpox, or H. influenzae type B).
  • Children aged 1–17 years were significantly more likely to be diagnosed with a vaccine- preventable disease if they received naturopathic care.
  • Use of provider-based complementary/alternative medicine by other family members was not independently associated with early childhood vaccination status or disease acquisition.
  • Pediatric use of complementary/alternative medicine in Washington State was significantly associated with reduced adherence to recommended pediatric vaccination schedules and with acquisition of vaccine-preventable disease. Diagnosis with vaccine-preventable diseases among children through age 17 years was rare. However, pediatric use of naturopathy was associated with significantly more diagnoses, and chickenpox was the diagnosis most frequently made.

 

They propose, in light of these findings, that:

  • Interventions enlisting the participation of complementary/alternative medicine providers in immunization awareness and promotional activities could improve adherence rates and assist in efforts to improve public health.

 

Here's an opportunity to be part of the team working toward a shared public-health goal--to promote best practices in pediatric immunization against vaccine-preventable disease.

Can we accept it?

Do we want to accept it?

What would it take on our parts, and what support would we need from other massage stakeholders?

The most hated people that you've probably never heard of (#16/31)

may well be the Rohingya people of Rakhine State in western Burma (the country also known as Myanmar).

Photograph by: Saurabh Das / Associated Press in the Los Angeles Times at http://framework.latimes.com/2012/06/19/pictures-in-the-news-451/#/0 accessed 16 August 2012

Source: Picture is a composite of a Google Maps image and the map of Rakhine State at http://upload.wikimedia.org/wikipedia/commons/2/22/Rakhine_State_in_Myanmar.svg accessed 16 August 2012.

 

The BBC sums up their plight quite succinctly in an article titled "Bangladesh accused of 'crackdown' on Rohingya refugees":

Persecuted

They are among the world's least wanted and most persecuted people - Burma denies them citizenship and refuses to let them own land.

It does not allow them to travel or even marry without first seeking permission.

And they are not welcome in Bangladesh either, where at least 200,000 now live as illegal immigrants, without rights to employment, health care or education.

 

and you can read more BBC coverage at "Burmese exiles in desperate conditions".

Amnesty International has developed a report, "Myanmar: The Rohingya Minority: Fundamental rights denied", although since it dates from 2004, it is out of date with recent developments--such as the ongoing violence in their home state in Burma, or Bangladesh's refusal to permit philanthropic organizations to help the refugees who have fled to their country.

Still, it gives a good general overview of the problem, grounding it in its historical, political, and sociocultural roots.

This document reports on the situation of the Rohingyas, a muslim ethnic minority in Myanmar who are subjected to multiple restrictions and human rights violations - among them, restriction of mov[e]ment, forced labour, forced eviction and land confiscation and various forms of extortion and arbitrary taxation.

 

Most people in the United States have never heard of the Rohingya people, so if you haven't heard of them before now, you're certainly not alone.

They certainly are hated, though: many Burmese Buddhists claim the Rohingya are not Burmese at all, but rather are Bangladeshi intruders in Burma; Bangladesh, on the other hand, does not want to accept them, either.

Meanwhile, the violence and a multitude of other affronts continue to happen.

Some sobbed quietly while others pleaded and raised their arms to heaven. Their children looked on with glassy stares, utterly exhausted after days at sea in an open boat. Soon they would be on the water again, escorted by a Bangladeshi coast guard vessel and pushed back into the waters of Burma where they knew violence still raged.

"The Mogh [ethnic Rakhine people of Burma] slaughtered my brothers. They will kill us all … please help us!" screamed a woman carrying a baby only a few months old, before she was hustled away by border guards.

The sectarian violence in Burma that has sent boatloads of refugees fleeing to Bangladesh in recent weeks – and being firmly pushed back – has once again turned the spotlight on the plight of Burma's Rohingya minority.

There is no place the Rohingya people can call home. Burma passed a law in 1982 – criticised as discriminatory by human rights groups – that effectively rendered them stateless. Waves of ethnic violence since 1991, some of it state-sponsored, have pushed more than 250,000 Rohingyas into Bangladesh, where they live in squalid, makeshift camps with little or no access to healthcare or education. --The Guardian, "Burma's Rohingya refugees find little respite in Bangladesh" accessed 16 August 2012

 

MDG : Burma

Source: "Nozir Hossain shows the scar he received while trying to protect himself on the day his sons were killed." Photograph: Syed Zain Al-Mahmood for the Guardian. At http://static.guim.co.uk/sys-images/Environment/Pix/columnists/2012/6/26/1340709910115/MDG--Burma-008.jpg accessed 16 August 2012

 

 

 


The situation is all very sad and distressing, but what does it have to do with massage?

This: massage practitioners are currently engaged in passionate debates over the future of massage, as well as over its very nature.

Is massage a personal service, or is it self-expression, or is it a business, or is it a healthcare profession?

If it's a personal service or self-expression or business, then that's one thing--personal services carry no fiduciary duties of equality of access.

But if massage truly aspires to become a healthcare profession, then questions of human rights and accessibility lie at the very core of the discussion. We need to figure out where we stand on these questions, and why.

There is talk in the air that Rohingya refugees will be resettled here in Seattle, but no groups have arrived yet, and as far as I've been able to find out, plans seem still to be up in the air.

This, then--if massage is truly becoming a healthcare profession--would be the perfect time to plan a program in advance, to extend access to massage to this group of traumatized refugees, rejected by other groups from their homeland, who are undergoing the stress from the massive adjustment from refugee camps to modern US society, as well as the aftereffects of the trauma to which they have borne witness.

What do you think we can do for people in this situation? What should we do? What will it take on our part?

 

 

You can save a life: How to help a client who may be suicidal

Kelli Wise has issued an August Blog Challenge, and this post is part of the my response to the challenge.

Can I write 31 blog posts in 31 days?

 

We'll see. I'm getting a late start, coming in on the 5th of August, but I think that's not going to be a problem. As she said, there are no blog police enforcing this goal.

 

Can I keep those blog posts to less than 350 words?

 

No, I can't--asked and answered. What I will aim for is to stay on point, and provide valuable information, rather than just indulging my long-windedness.

You'll be the ones to let me know how well--or not--I have succeeded at that task.

 

 


The people who wrote the Talmud, a Jewish religious text that dates from about the years 200-500, clearly wanted to convey a strong and unambiguous message to their audience about how they regarded the importance of human life.

One of the most famous lines reads:

מי שהציל נפש אחת - כאילו הציל עולם ומלואו

Whoever saves a single life is considered to have saved the whole world.

--Talmud, Sanhedrin 37a accessed 5 August 2012

 

The idea is that, by saving that one person's life, you also save the lives of that person's future children, and all the other people whom that person--thanks to your intervention--will be around for in the future.

You don't have to be religious to appreciate how profound that point is--the same point holds, taken from a systems science point of view as well, when you consider how many points of contact exist among people, and how many opportunities those contacts provide us to influence one another.

Most of the time, the effects we have on other people are not immediately life and death in the moment--but, occasionally, they can reach that point.

Whether or not we want to practice massage as healthcare providers, we can learn what to look out for as warning signs, and what we--in both our capacities as MTs and as caring human beings--can offer in the way of help to someone who may be at risk for suicide.

 

 


The first thing we need to do is to be clear on our role and our scope of practice. We have no business practicing psychotherapy in our role as MTs.

The Massage Therapy Body of Knowledge (MTBoK) states that clearly:

The following are NOT included in the Scope of Practice of Massage Therapists:
...
• Psychological counseling.
• Hypnotherapy.
• Guided imagery intended for counseling or psychotherapeutic processing.
...
• Intentional use of techniques to evoke an emotional response in the client

--MTBoK pp. 9-10 accessed 5 August 2012

 

If you have additional training in psychotherapy, that's a different matter.

But MTs in general do not have the training to practice psychotherapy, and our trying to analyze the cause of another person's pain, or telling them what they should do, is grossly inappropriate in our role.

What we can do is:

  • Listen in a caring, attentive way;
  • Reassure the person that you are there for them, and that you won't turn away from them in their pain;
  • If needed, actively help the person to find resources in their community who can take a more active role in intervention than we are able to.

 

 

 


Although most of us are taught something about it in massage school, the very first time that someone breaks down emotionally on our table when we are practicing unsupervised can be a terrifying occasion for the MT. A large part of that fear on our parts lies in the responsibility we feel for taking care of that person and keeping them safe.

The good news is that in the vast majority of cases, an emotional breakdown or release in response to feelings that arise in response to a massage are not a danger sign. As the MTBoK explains:

Understand that emotions may surface for a client/patient during a massage, that this is normal and that emotions are not harmful.

--MTBoK pp. 27 accessed 5 August 2012

 

 

So how do you tell the difference between normal distressed emotions versus a danger sign that you don't want to miss?

There's no one-size-fits-all formula I can give you that covers every situation perfectly. You have to use your best judgment to act in the client's best interest in the unique situation you find yourself in.

The MTBoK, correctly, draws an important distinction in the knowledge they expect of an entry-level MT:

Differentiate between emotional and psychological processing (outside scope of practice for massage therapists) and handling emotions (in scope of practice).

--MTBoK pp. 27 accessed 5 August 2012

 

In a very general way, a part of what MTBoK calls "handling emotions" is knowing what you would expect to see in a normal emotional release during or after a massage.

Two important things that you would look for are:

  1. that the client does not lose touch with their surroundings, and
  2. that they feel better after the release has passed.

 

It's ok to gently check in with your client.

"Are you all right?" and "Is there anything I can do to help?", gently asked in a way that does not appear that you need for the client to compose themselves, is one way to be supportive.

Standing by silently and calmly is another way that you can support your client.

Being prepared in advance with tissues and with drinking water to offer are other ways of tangibly being there for them.

The message that you want to send is that it's safe and ok to experience and show these feelings in your presence--that you do not need for the client to deny their feelings, or seek to please you by acting as though things are different than they really are.

 

 


Most emotional releases that occur in massage sessions are self-limiting and not dangerous--but when should you actually be concerned?

If the client seems confused about where they are, or if they seem to lose touch with their surroundings in some other way, that may well be something to be concerned about.

If the client seems to feel worse, rather than relieved, after the emotional release, then that may also be something to be concerned about.

There are other warning signs that someone may be considering suicide.

The Mayo Clinic has posted a guide for laypeople--not specifically for healthcare professionals--but something that anyone can use to prepare how to handle the situation, if necessary:

Suicide: What to do when someone is suicidal. When someone you know appears suicidal, you might not know what to do. Learn warning signs, what questions to ask and how to get help. accessed 5 August 2012

 

You can use this guide to familiarize yourself in advance with the warning signs to look out for, and to make a plan about how to react, if you ever should need to do so. This is not practicing psychotherapy; it's being helpful, supportive, and caring as you aid someone to reach out for more specialized professional resources that can help them.

Additionally, you can line up a mentor or trusted colleague in advance, whom you can call on for help when you are not sure about situations that arise in your practice. There is no shame in not always having all the answers; we are all lifelong learners, no matter where we find ourselves.

The important thing is knowing how to reach out for help if you ever do need it. Making a plan in advance about what to look out for when emotional releases occur during a massage session, what to do if you ever find yourself in a situation that you think is more than just a normal emotional release, and knowing what resources are available for help for you or for your client, can be some of the most important things you may ever do in your practice.

You may never need them--most people won't ever face this situation. But if you ever do, then having made a plan in advance, and knowing who is in your community who can be of help--both to your client and to you--can lead directly to your saving a life. And saving a life, when you consider all the future events that will cascade from that person's effects on others, is as if you saved the world.

It's just that important.

 


 

Learning, success, and learning success

UPDATE, 22 July 2012, 8:53 AM PDT: This post has undergone major revisions to correct scientific inaccuracies since its original, in response to feedback from Christopher Moyer.

But the post (and the WSJ story it is based on) are not scientifically accurate. Normally that might not matter so much, but we're scientists and we like to understand things and get things right, so it matters to you and me.

 

This.

He has summed up POEM's very reason for being--helping stakeholders in the community of massage to figure out how to get things right--and he took the time to engage with my post and to spell out the problems with it, so that I could correct them.

cheers, Chris!

 


Do you want to learn more about massage and how it fits into foundational human knowledge about the material physical universe, but fear you can't, because bad educational experiences in your past have locked you into an inescapable path?

That's not an issue at POEM--you're not going to be judged on your past education here, nor on how other people may have criticized you in the course of that education.

I originally included a story from the Wall Street Journal to reinforce that point--which still stands--but Christopher Moyer pointed out that the article was problematic and scientifically inaccurate in how it discussed intelligence, and that I, too, had propagated those errors in my original post.

Since here, we're all about getting it right, I've reworked the post to address the issues he raised, but I still want to ultimately keep the focus on this point:

Don't worry about whether you liked school or not, or whether they told you that you'd never do well because you aren't smart, because here at POEM we think the most important thing is a commitment to learning and we will help anyone who is motivated to understand what we are doing.

 

 


Neil deGrasse Tyson, an astrophysicist and science educator, interviewed in a recent Wall Street Journal article about recovering from educational failure, describes his views on people's capacity to learn as related to their attitudes about learning itself.

His views align nicely with our approach here, but before we get into just how that's true, we need to clarify inaccuracies in the article's lead-in:

Where do helpless students get the notion that intelligence is fixed? In part from our culture, which bombards them with the idea that IQ tests measure how bright they are.

Many people think of intelligence as static: you are born with lots of brains, very few, or somewhere in between, and that quantum of intelligence largely determines how well you do in school and in life.

 

Moyer points out that:

In fact, general intelligence *is* quite static. It is also true that it largely (a vague word here, but I'll agree to it for now) does determine how well people do in school. It also determines, to a lesser degree, how well they succeed in other areas of life. We may not like that, but it's well supported by mountains of solid evidence. The opening of the post suggests that those are not true.

 

He's correct, but that does not undermine my larger point, because general intelligence is not the only criterion involved in learning. And it is learning that we are concerned with here, not just general intelligence.

But the article does need to make that point more clearly than it did--it fails to explicitly point out that we are changing the topic from general intelligence to other factors that support learning. And I need to make that clearer in this post as well.

From this point on, we are setting general intelligence aside, and focusing on those other factors supporting learning instead.

The article continues:

The astrophysicist Neil deGrasse Tyson has never liked this view. "I hardly ever use the word intelligence," says Mr. Tyson, who directs the Hayden Planetarium in New York. "I think of people as either wanting to learn, ambivalent about learning or rejecting learning."

 

There is a lot of implicit subtext here, and since it is not stated explicitly, it runs a large risk of promoting misunderstanding. We'll clarify those implicit assumptions, and then bring it back to how it relates to our educational philosophy.

As Moyer points out:

"The astrophysicist Neil deGrasse Tyson has never liked this view."

As noted previously by me and then also by you, who cares? I don't like it either, but it's a fact. The implication here, of course, is that NDT, whose claim to fame is that he is really smart, must be rejecting the importance of intelligence because it isn't very important. In this case, he's wrong, especially if the content (say, astrophysics, or physiology) is complicated.

 

"Who cares?" is shorthand for at least three implicit references that he knows, and that he knows I know, so he doesn't spell them out every time he uses them--he's referring to the naturalistic fallacy, the moralistic fallacy, and the is-ought confusion.

In this case, the naturalistic fallacy would be that since nature, genetics, and material physical reality, in combination, are the source of general intelligence, then they would always do what is good and right, and never do anything else--they would dependably ensure that everyone has equal opportunity and capacity in general intelligence. Unfortunately, it doesn't work that way.

 

The moralistic fallacy sounds a lot like the naturalistic fallacy, and it is, in fact the converse of the naturalistic fallacy: it's what you get if you reverse the direction of the relationship, either by changing the direction of the arrow, as in A, or by swapping the entities with each other, as in B.

In this case, the moralistic fallacy would be that since equal opportunity and capacity in general intelligence is good and right, then we can expect nature, genetics, and material physical reality to provide it.

A

B

 

The is-ought confusion results when people confuse how things ought to be with how things really are in fact. People ought to be equal in opportunity and capacity in general intelligence; in reality, people are not equal in opportunity and capacity in general intelligence.

If general intelligence were the be-all and end-all in learning, we'd find ourselves confronted with a quite insoluble problem

Fortunately, that's not the case--general intelligence is one factor among several others in learning; those others include:

  • abilities,
  • motivation,
  • interests, and
  • personality.

 

We can create a lot of positive change in those aspects, and those are what we focus on from here on out.

As Moyer points out, although the article does not make it sufficiently explicit, Neil deGrasse Tyson also switches the emphasis to those other factors:

Next: ""I hardly ever use the word intelligence," says Mr. Tyson, who directs the Hayden Planetarium in New York."

Well that's fine, and appropriate; in his role as a public educator, it is not his job or even a good idea to try to sort people according to aptitude. Rather, the task is to present the information as accurately and effectively as possible, which is also the job at POEM. So this part is cool, but opening with the implication that intelligence isn't stable and isn't that important is misleading. It's both of those things.

 

So we say it explicitly, in order not to be misleading: we are focusing on those factors other than general intelligence here.

deGrasse Tyson's words sum up our philosophy here at POEM very well--if your experiences have been so bad that, as a result, you totally reject learning, then--unfortunately--we have nothing to offer you here, other than the hope that you will encounter enough good experiences along the way to convince you to give it another look someday.

If you do actively want to learn, then that's an easy win for all of us--all the content here is intended to give you ideas to think about in your learning journey. You don't have to agree with everything presented--it would actually be most surprising if you did--but in pushing back, thinking about, organizing, and expressing your viewpoints, learning will certainly happen, and you'll share that learning with the rest of the community.

And if you're ambivalent about learning, please give us a chance to meet you halfway and to build bridges to where you are. I hope it works for you, but if you give it a try and it's really not for you, we at least appreciate your efforts and your willingness to try, and hope that someday you find what you're looking for.

From the same WSJ article, although we'll mentally substitute "learning capacity" for "intelligence" to avoid the previous confusion, and to keep the focus on where we work:

A growth mind-set can be learned. In a 2007 study by psychologists from Columbia and Stanford, nearly 100 seventh graders (most of them struggling in math) participated in an eight-week workshop on studying. The subjects were secretly divided into two large groups. Both groups received instruction on how to use their study time most effectively and how to organize and remember new material.

But then came the difference: One of the groups read aloud an article titled "You Can Grow Your Intelligence." It explained research on how nerve cells in the brain make stronger connections after we learn something new. Students in the other group spent that time reading an article about how memory works and learning new strategies for recalling material.

Most of the students went into the sessions generally believing that intelligence was fixed for life, but the group that read about the brain's growth emerged from the experience with much stronger notions about improving intelligence with effort. That group generally showed greater motivation to do well in math class in the weeks and months after the experience.

As the researchers noted, someone's theory about intelligence may not make much difference when times are easy. But when failures accumulate, those who believe that they can improve their basic abilities are far more likely to weather the storm.

 

If you believe that you can improve your basic abilities, wherever you find yourself along your learning journey, then your chances of being successful are higher than if you believe there is nothing you can do. Here at POEM, we are in the process of building tools to help you take charge of your learning and build that success.

Moyer agrees with that point, and so we end on the optimistic note he raises:

That's great and definitely true. Practice, dedication, and routine exposure can and do improve concentration, effective habits, interest, and so on. They may even have a small but real effect on intelligence with enough time. (It is stable but not entirely immutable.)

 

 

 

 

Stepping up: Protecting human rights as well as our good name

There's a pretty good article on MSNBC on local efforts to combat prostitution and human trafficking working under the guise of massage in Bellevue, just across the lake from Seattle.

Lavon Watson, a licensed therapist has been leading a drive to clean up the unlicensed trade saying it puts people and his livelihood at risk.

"Any local police department could do the same thing that Bellevue is doing now and find the same problem," he said.

 

It's not just massage where the Seattle area has a problem; local refugee communities have forced labor problems as well--sometimes in the sex trade forced prostitution, other times in the clothing or food industries.

Efforts such as this are a real opportunity for us:

  • to face down a real problem that tarnishes our name in the eyes of massage stakeholders,
  • to stand up for ourselves as real healthcare professionals,
  • to join our efforts with others commited to supporting the human right to live and work free of slavery.

 

The article falls down a little bit in not giving you enough information to act upon, so I'll include a few representative links here where you can start to find out how to take action. These are certainly not the only ones, and the more you reach out, learn, and make contact, the more you'll come across efforts in the massage industry to end human-trafficking efforts that are being carried out in our shadow.

If you know of any other resources you'd recommend, please mention them in the comments, and I'll compile a list of them.

Defending Our Good Name accessed 7 June 2012

National Certification Board for Therapeutic Massage and Bodywork brochures accessed 7 June 2012

Oklahomans Against Trafficking Humans (OATH) accessed 7 June 2012

 

 

 

Source: http://media.king5.com/images/foot_massage.jpg accessed 7 June 2012

 

UPDATE, 7:02 PM PST: I thank Colleen Hayman in the comments over at Facebook for giving me an indicator that perhaps I had not made my position totally clear. She wrote that she was sad to see this on POEM, and that I was conflating human trafficking with prostitution. She stated that

'Protecting human rights' would include protecting the legitimate work of sex workers and not conflating it with the horror of human trafficking!! Education *always* helps.

 

I don't think we're quite as far apart as my post originally made it sound, and this is my response to her. I hope it clarifies the points I made very briefly above. UPDATE, 8:06 PM PST: Colleen has convinced me that my use of the term "sex trade" is unnecessarily inflammatory; I'll use clearer and more precise language from here on out, but I don't believe in sanitizing the record after the fact, so I'll leave occurrences of the term in this response as I originally wrote it.

I think that perhaps I was not clear in making my points, and I am glad that you can bring up disagreements. I would hate to think that people don't care enough to raise them, nor that they think I am unreceptive to talking about them.

We can talk openly about those disagreements, and perhaps we have some common ground. I will also update the post to clarify the points where I wasn't clear. I really appreciate the feedback, since that's the way I can know if I am communicating well, missing the mark, or something in between.

I think that many of the problems in the sex trade come precisely from legal efforts at driving it underground, at least here in the US.

From my own personal perspective as someone very interested in public health, I think that we really need to talk honestly and on evidence-based grounds about licensing the sex trade (including what we in the US can learn from how other countries deal with the trade), and how that mitigates a lot of the harm currently perpetrated under it here in the States.

I know that some of my allies are diametrically opposed to that viewpoint, and that's their prerogative. I don't think the idea of eliminating it is particularly realistic, and we will probably never agree on that. That's all right; we can work together on the things we agree on (the monstrosity of forced labor), and agree to disagree on the rest. No doubt I come across as way too small-l libertarian to them on the issue of legalizing the sex trade here, and that's ok, too.

But we do need to draw a crystal-clear line between the sex trade and massage, if we care about becoming a healthcare profession. We need to assure our clients that we are not blurring those boundaries in any way.

So my viewpoint, more clearly explained than I did before, is this, I would say:

  • in the long term, we need, as a society to come to terms with how we regard sex and sexuality, and that includes a serious evaluation of how we deal with prostitution in this country, and how our efforts to eliminate the trade criminalize it, and make the problems worse;
  • however, that needs to be totally separate from massage, since massage, as an evolving healthcare profession, has obligations to its stakeholders, and the boundary-blurring that comes from mixing massage and the sex trade fails to meet those obligations;
  • whether or not that discussion ever takes place, it is a long-term solution at best. In the short- and medium-term, there are many people who are forced into labor through economic and physical coercion. Those people need immediate help, and that cannot wait until society finds its optimal treatment of the sex trade.
  • forced labor is not unique to the sex trade by any means. In one of the refugee communities I work with, I hear that there are sweatshops in Seattle sewing apparel for major companies. Another of the refugee communities has people who owe a great deal of money for coming here, and they have to work it off in awful conditions in the food trade. So while the sex trade is entangled with massage in a unique way, historically, it is certainly not the only industry in which human trafficking and forced labor are actively being carried out in the US.

I hope that that makes clearer what I was trying to say, and I hope that--as I perceive--we are not as far apart on that particular question as my original piece made it sound.

But if we still disagree, I thank you for letting me know about it, and engaging with me on the issue. I will check out the link you provided.

 

 

My recommendations for the future of massage as a healthcare profession

UPDATE, 7 March 2013: fixed to address the problem that Mended pointed out. Still not finished, but I'll leave it up so as not to inadvertently hide Mended's comment as well. Consider this a work-in-progress, rather than a finished piece. 


Elsewhere, I was asked what I thought massage needed to do in order to evolve into a healthcare profession.

Since that was a semi-closed forum that not everyone can access, I'll repeat those ideas here, and I've added some concrete examples of how to carry out those ideas.

  1. clearly and unambiguously distinguish ourselves from both prostitution and "cure cancer with baking soda"-style alternative medicine--perhaps through a tiered system with clearly-distinguishable names;

    Example: Getting involved in advocacy efforts to help get people out of "the life" of prostitution and human trafficking. Defending Our Good Name is a project in Washington state that educates massage therapists and others about the scope of the problem of human trafficking in the sex trade, how it operates in ways that affect the perception of legitimate massage practitioners, and what steps people can take to become involved in addressing the problem. Other organizations in the Seattle area, such as International Rescue Committee in Seattle, API Chaya (Asian & Pacific Islander Women & Family Safety Center), Refugee Women’s Alliance, and YouthCare, are also involved in coalitions that work to detect situations where people are unlawfully forced to work for others, and provides resources for them to escape. To make professional contacts with such groups, and to support their advocacy efforts, is a grass-roots way of emphasizing the professionalism, caring, and community involvement of massage practitioners.

  2. establish a minimum basic level of anatomical and physiological education that is not just memorized, but actively understood and applied, that you cannot graduate from massage school without demonstrating;

     
  3. have an open-source repository of evaluated evidence on massage that any stakeholder can access without a middleman, and that demonstrates the effectiveness of massage in a way that puts it outside of the opinions of other providers by demonstrating it objectively, and

     
  4. actively participate in the healthcare system building efforts that are currently going on, rather than withdrawing from it into our own little isolated silo.


     

Then, once all that is established, continue to work diligently to guard it from being watered down--because it will be a lot of hard work, and there will always be those who want the title without doing the work.

The germ theory is too Western

Laura Allen embodies the very ideas of transparency and accountability when she says that anyone is free to quote anything she says anytime and anywhere, and I believe I'll take her up on that.

Over on her Facebook account, which you may or may not be able to see unless you're already friends with her, she writes:

It's a concern to me that three times in the past couple of days, I have seen stories on here about employers who don't want the massage therapists to change the sheets for every client. That is so unethical, not to mention a health hazard. If you are working in such a place I suggest getting out immediately and reporting the owners to the massage board AND the health board. As one person said to the owner who was mad about her changing the sheets, would you want to check into a hotel and sleep on the sheets the last person used? I don't think so. And if the guilty owner happens to be reading this, do us all a favor and get the hell out of this business.

 

Clear, concise, and correct. And if the guilty owner was reading the post, they didn't choose that hill to (metaphorically) die on; Laura's commenters were 100% supportive of the bright shining biomedical and ethical line in the sand that she drew.

It occurred to me that there could be correlation between the type of massage practiced and its underlying conceptual model, with the degree of sanitation and hygienic practices adhered to.

For example, if you truly believe that disease is caused by a bad wind entering the body, or by negative thinking, or by karma, then that's not really much of a motivation for paying attention to getting rid of germs on surfaces.

And an interesting followup question is, if you do believe in one of those conceptual models, and you are scrupulously diligent about observing good hygiene, then why do you go to that trouble?

I mentioned that that would be a fascinating study that I would probably never get around to carrying out, but if someone else did, I would love to read about it.

Well, ask and you shall receive, I guess.

One of Laura's commenters told a story from her own experience, that is a perfect case study of the correlation I was thinking about:

I had an MT friend who worked in a chiro's office and he reused disposable acupuncture needles. He was quite careless with them and they'd often fall on the carpet where you wouldn't notice them until you got off the table, barefoot, and get one in your foot. When the MTs in his office complained, he waved them off for being too "Western." In China, they reuse needles from person to person. At least, he bragged, he only reused them on the same person. Eventually he agreed not to do acupuncture in the massage rooms so massage clients didn't get stuck by stray needles. Sheesh.

 

/facepalm

There are so many issues here, that it's difficult to know where to start.

Disease transmission by infected reused needles, or Hygiene 101, is only the first one.

To get back to our topic from needles, I'm sure the POEM commenters can name several conditions that can be passed from one person to another by dirty bed linen.

Sources: Left: http://www.stanford.edu/class/humbio103/ParaSites2004/Scabies/scabies.jpg accessed 29 April 2012, Right: http://www.stanford.edu/class/humbio103/ParaSites2004/Scabies/scabies1.jpg accessed 29 April 2012

 

And although this may come as news to the chiropractor in the story, in resource-poor areas of the world, they don't share needles because they *want* to; they do it because they have no other options.

Every time something like that reinforces the perception of MTs as elitist, classist, ethnocentric, and generally oblivious, it just makes more work for the rest of us to dismantle that perception.

So here we go, gradually chipping away at it:

First of all, the session is about what the client wants and needs, not about forcing the client--with or without full disclosure and informed consent--to settle for what people in resource-poor environments are compelled to make do with. The chiropractor in the study is not practicing in a client-centered way; his practice is centered on something else, where infection control is not a priority.

Second, in chiding others for being "too 'Western'", he probably sees himself as all diversity-oriented, and transcending elitism and ethnocentrism.

Nothing could be further from the truth.

He is claiming, in effect, that Chinese people don't value their own lives and bodily integrity enough to care about basic biomedical best practices. Where he got the idea that he gets to speak for them is unclear, but his claim positively advocates poorer medical care based on nationality and ethnicity.

This violates Ethics 101 in a big way.

If Chinese people do reuse needles, what could be the explanation?

Unlike the chiropractor in the story above, who implies they are choosing to do so when they have better options, I think that looking at the availability of resources is a useful source for possible explanations.

According to the Wikipedia article "List of countries by GDP (nominal) per capita", the US per capita annual income ranges (depending on the reporting source) from $47,153-48,387.

The per capita annual income in China ranges (depending on the reporting source) from $4,428-5,414.

The per capita annual income in Ethiopia ranges (depending on the reporting source) from $300-360.

I'll leave as an exercise for the readers to evaluate whether Chinese people and Ethiopian people reuse acupuncture and injection needles because:

  • they don't care about their own lives and health, or about each other, and consider infection control "too 'Western'", or whether
  • unused needles are much harder to come by in environments where the average person earns 11% (China) or 0.007% (Ethiopia) of what the average American earns.

 

 

 

And if you consider it a do-or-die cost issue--if your business, in the US context, is so iffy that you need to operate it in the American context with Chinese or Ethiopian standards of practice and margins on clean linens, unused acupuncture needles, or any other compromise on infection-control best practice, then your business is not dying.

It is already dead, and you just haven't acknowledged the fact. If you cannot afford to practice infection control, it's over. Deader than the parrot in the Monty Python sketch.

 

I'll heartily second Laura's recommendation:

And if the guilty owner happens to be reading this, do us all a favor and get the hell out of this business.

 

and I'll add some of my own.

Recommendations for educators:

  • The history of massage is an important thing for students to know about, but infection-control trumps it every time.
  • If you don't have time in the curriculum to teach both about how people used to believe humors or bad winds caused disease, AND what we know now about how to prevent infection in a massage therapy practice, so that the students not only rotely deliver the correct answer on tests, but really show that they understand and can apply it in context, then the curriculum resources have to be devoted to infection control at the expense of pre-modern concepts of illness and disease.

 

Recommendations for students and practicing MTs:

  • Check to see if your school is teaching (or did teach, if you've graduated) proper infection-control practices.
  • Make sure that you know how to protect clients by reporting unethical and unsafe practices to the correct regulatory authorities in your area.
  • If not, make sure that you get all that information somewhere else, and use it in your practice--it's just that important.

 

Recommendations for clients:

  • The time in a session is time that you have paid for, and you should not feel hesitant to ask questions about the care or service you are receiving.
  • A client-centered healthcare professional will be happy to answer any questions you may have. Hospitals in the US, UK, and elsewhere are now actively promoting campaigns (as shown in the buttons below) to ask your provider whether they've washed their hands before examining you. MTs who want to be part of an integrated healthcare team will not balk at following the same infection-control best practices as other members of that healthcare team.
  • Don't hesitate to ask what infection-control procedures your MT uses.
  • When you are getting on the massage table, take a moment to look at the linens you will be lying on--do they look clean and unused, or do they appear to be re-used?
  • How many layers of linens are on the table? If it's more than one, the establishment may be cutting corners by stacking sheets to save time between clients. The problem with stacking sheets is that mere layering will not prevent transmissible conditions from crossing those layers. Don't accept sheet-stacking from your MT; insist on a single layer of clean and unused linens every single time. This is your time and your care; it is reasonable that you expect it to be conducted in a way that looks out for your best interests.

 

Sources: Left: http://www.jcrinc.com/Common/Images/custom/products/HHB-05.jpg accessed 29 April 2012; Center and Right: http://www.healthcareinspirations.com/hci_fe03_single_quantity.html?&prodid=513 accessed 29 April 2012

 

These are steps we can take, and encourage our clients to take, to show that we are serious about developing into a healthcare profession that will accept the responsibility of self-regulation and client protection that comes along with that status.

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