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No blame, no shame: How we got here is not as important as finding ways to fix the problems

Submitted by RST on Mon, 09/24/2012 - 09:56
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The world has shifted out from under us.

And although we're not the only ones it's happened to, that's cold comfort as we have to go through the disruption that shift causes us.

That disruption can cause us to lash out in pain sometimes. Additionally, it's very easy to decide that someone else is that cause of all the problems, and to paint them as a cardboard cut-out depiction of a villain.

Although those reactions are understandable, we're not going to indulge in them here. No matter how intense our feelings of distress, we are going to behave better than that. We are going to start with the principle that we need to fix the problem, rather than fighting with each other over the past.

As humans, we often share meaning with each other by means of stories. There is a traditional story in Buddhism which carries some of the meaning I'm trying to convey here:

The parable of the arrow (or 'Parable of the poisoned arrow') is a Buddhist parable that illustrates the skeptic and pragmatic themes of the Cula-Malunkyovada Sutta (The Shorter Instructions to Malunkya) which is part of the middle length discourses (Majjhima Nikaya), one of the five sections of the Sutta Pitaka.

..

"It's just as if a man were wounded with an arrow thickly smeared with poison. His friends & companions, kinsmen & relatives would provide him with a surgeon, and the man would say, 'I won't have this arrow removed until I know whether the man who wounded me was a noble warrior, a priest, a merchant, or a worker.' He would say, 'I won't have this arrow removed until I know the given name & clan name of the man who wounded me... until I know whether he was tall, medium, or short... until I know whether he was dark, ruddy-brown, or golden-colored... until I know his home village, town, or city... until I know whether the bow with which I was wounded was a long bow or a crossbow... until I know whether the bowstring with which I was wounded was fiber, bamboo threads, sinew, hemp, or bark... until I know whether the shaft with which I was wounded was wild or cultivated... until I know whether the feathers of the shaft with which I was wounded were those of a vulture, a stork, a hawk, a peacock, or another bird... until I know whether the shaft with which I was wounded was bound with the sinew of an ox, a water buffalo, a langur, or a monkey.' He would say, 'I won't have this arrow removed until I know whether the shaft with which I was wounded was that of a common arrow, a curved arrow, a barbed, a calf-toothed, or an oleander arrow.' The man would die and those things would still remain unknown to him."

— Cula-Malunkyovada Sutta: The Shorter Instructions to Malunkya" (MN 63), Majjhima Nikaya

--Quoted in Wikipedia, "Parable of the arrow" accessed 24 September 2012

 

Granted, we're not totally subscribing to this principle, because understanding how we got into a situation is sometimes useful in figuring out how we're going to avoid a similar situation in the future.

So we'll temper that story's strong pronouncement a little bit, and go with the idea that--for our purposes--most of the time, the most important aspects are not assigning blame for anyone's past actions, but accepting that we have a problem in the present, and committing to assessing and describing the problem, so that we can proceed to address and resolve it.

Ralph Stephens is correct that a lot of current instructors are unqualified. But no child aspires to be an unqualified teacher when they grow up; the situation is the result of historical forces, not the goal. Back when we were in an economy that could not supply MTs fast enough to meet demand, "see one, do one, teach one" looked like a reasonable way to promote instructors to graduate students to address that gap faster.

Things have changed, but that doesn't mean that past efforts were the deliberate result of bad intentions. It just means that those earlier solutions are no longer working for us, and we need to fix them.

Similarly, he's right when he points out the risks of monoculture (systems with little or no diversity) when students have only 1 or 2 teachers for their entire curriculum. But I'm willing to bet my right kidney that no school owner ever said, "Let's deliberately expose our students to a single-point-of-failure system.".

That that turned out to be the effect is an indicator that we need to modify the course we're on, but it doesn't mean that small school owners are to blame for all our problems. Once again, it's an artifact in the present of a solution tried to address a problem in the past, and although we need to fix it, we don't need to cast aspersions on all small schools.

(UPDATE, 11:29 AM PDT: I've modified the next paragraph to make clear that what I originally stated as though it were a fact is actually my impression of the situation. I thank Matpardini for bringing my attention to my original overstatement.)

It's my understanding, although I don't actually have the evidence to back it up for sure, that many small schools have a good track record, as measured by pass rates on licensing exams. If this is true, then I believe that it further underscores the point I'm making that, if we are going to look at the issues, it's only fair to include the good aspects they bring to the table as well as we consider what needs to be done in massage education. And if I am mistaken, then I think that that means I am mistaken about that particular fact, but I stand by the moral principle that we should look at all aspects of the situation. Not that it means we're not going to fix a problem--I still believe we need to do that--but to avoid falling into the trap of bogging down in blaming an oversimplified depiction of a group of stakeholders of massage.

If we're going to actually address the problems we're facing in massage education, I suggest the following first principles to ground the discussion in:

  1. We need to understand how we got to the present situation, so that we don't fall into the same problems in the future, but right now our highest priority needs to be recognizing and addressing the immediate problems, for the sake of clients and students who don't have the time to wait. We have serious structural problems that we need to commit to fixing.
  2. We recognize that no one individual or single group of MT stakeholders is to blame for the current situation--that it's the result of historical and structural forces in a period of massive disruption--and although we need to speak frankly about the problems to find a solution, we are not going to indulge in blaming and shaming of anyone. It hinders our efforts to find solutions. We start from the principle that--unless someone actively demonstrates a very, very good reason to modify that assumption--that everyone is coming to the table in good faith and with the best of intentions, and deserves the benefit of the doubt.
  3. We acknowledge that there are critical problems that need fixing, and we recognize as well that fixing these problems is going to cause further disruptions that MT stakeholders will have to bear the brunt of. We start from the principle that we are all in this together, and that we are operating from a client-centered perspective, and that any change that causes disruption needs to occur for a good reason that supports this client-centered mission.

 

These principles will, by no means, guarantee that the road ahead of us will be smooth, nor that we will succeed. It's possible to do everything right, yet still fail, and I'm not going to lie to you about the reality of the situation.

But, I argue, they do provide us the best possible basis for frank, honest, open, and transparent discussion of issues that we cannot afford to remain in denial about any longer.

Source: http://www.lexphoto.co.uk/laosblogimages/buddha%20park%20archer.jpg accessed 24 September 2012

The Seven Deadly Sins of Ralph Stephens

Submitted by RST on Sun, 09/23/2012 - 09:48
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Hmmm--that title sounds like I'm accusing Ralph Stephens of committing seven deadly sins. :)

But the more precise and accurate title, "The Seven Deadly Sins of Massage Education In The Way It Is Currently Practiced, As Described By Ralph Stephens", doesn't exactly roll off the tongue, does it?

There are many things that Stephens and I disagree on, often to the point of having diametrically opposite assessments of a situation, and recommendations about how to proceed.

However, it is a positive joy to engage with someone who remains professional and civil, even in strong and passionate disagreement on the issues, and I thank him for the high level of good-faith discourse that he brings to collegial discussions about shaping the future of massage.

And in this post, we don't even have to be concerned with how we handle disagreement, because I am going to argue that he is dead-on with his assessment of the problems in massage education.

 

The full title of Stephen's article in Massage Today is "The ELAP Project vs. The Seven Deadly Sins of Massage Education".

The ELAP (Entry-Level Analysis Project) is a very important topic, and deserves a dedicated post at some future point. For the moment, we'll concentrate just on the problems in massage education that Stephens has identified, and what I think we need to be talking about as a result.

So right now, we'll address only the part of his article from the heading "The Seven Deadly Sins" to the end.

There is a German expression, "Er nimmt kein Blatt vor dem Mund"--literally, "he doesn't hold any (flowers and) leaves in front of his mouth". In other words, Stephens speaks his mind, and is willing to call it as he sees it.

Colleagues, here comes the real truth of the situation that no one has had the courage to put on the table until now. 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.
  2. Deliver the curriculum in a disjointed "modular" system that prevents sequential learning and integration.
  3. Have just one (or maybe two) instructors teach the entire curriculum.
  4. Use stock courses off the shelf that serve a variety of career programs, instead of courses designed specifically for a massage therapy program.
  5. Enroll students who lack the interpersonal skills or the cognitive, physical, and emotional resources to be competent and ethical practitioners.
  6. Keep students in a program whose performance is marginal, just to get their Federal Student Aid disbursements (tuition).
  7. Allow students to graduate who cannot perform a competent massage, or create a secure therapist/client relationship.

The (ELAP) is a further diversion from the long and challenging work that will be needed to address these "sins." 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.

 

Let's stipulate for the moment that we're going to put off the discussion of ELAP for a dedicated post.

Other than recognizing a need to engage in a little more discussion of ELAP, I would argue that Stephens is exactly right in his identification of major problems in massage education as it currently stands.

He continues with recommendations:

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.

We must take up these challenges for the sake of the massage seeking public and for the lineage of our profession. Want to be part of the solution? Get involved. Thank you for your caring for our profession.

 

I wholeheartedly join Stephens in his call for these goals, and the posts that follow this one will explore in depth how we can address the challenges and obstacles that lie in the way of our solving these problems.

 

Source: http://upload.wikimedia.org/wikipedia/commons/0/03/Hieronymus_Bosch-_The_Seven_Deadly_Sins_and_the_Four_Last_Things.JPG accessed 23 September 2012

 

Massage in a biopsychosocial model (#29/31)

Submitted by RST on Wed, 08/29/2012 - 12:16
Posted in

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

Reality bites (#28/31)

Submitted by RST on Tue, 08/28/2012 - 10:45
Posted in

Or, as the Buddha famously put it: Life means that suffering exists.

An important question is what do you do about that suffering? We all are confronted with that question, because no one escapes suffering as a part of life.

You can't change that fact, but you can choose what you do in response to that fact.

Some ways of reacting to suffering in life are constructive--others, not so much. You can choose to blame others, or to "kill the messenger". Lots of people make that very choice.

But if you choose that path, and you find it is not making you any happier, at least there are other alternatives you can change to.

Kat Mayerovitch has a blog post up about relations with biomedical healthcare practitioners--mainly physicians--at Miracles, Medicine, and Manners.

Take a moment to go read the whole post--it's definitely worth it.

One of the best things about it is that she doesn't just recommend what not to do; she also suggests ways to proceed more constructively--to build bridges, not to burn them.

She provides practical suggestions for starting to work together with physicians in a client-centered way. She also provides a well-deserved shout-out to Laura Allen and the Massage Therapy Foundation for creating Working with Physicians: a Massage Therapist's Guide, and making it available on an open-access basis as an e-Book for free download.

You don't have to approve of every single thing about the modern American healthcare system to find and work with sympathetic allies in it toward goals that you share.

It won't change the basic nature of modern reality, but finding and working with supportive allies and companions along the way can definitely make a big dent in the suffering.

 

Source: http://upload.wikimedia.org/wikipedia/commons/4/42/FlameDance.jpg accessed 28 August 2012

 

 

cheers, to Kat, Laura, and the Massage Therapy Foundation!

Campbell 2012: Skin cancer education among MTs (#27/31)

Submitted by RST on Mon, 08/27/2012 - 09:39
Posted in

I can't really say much about the article itself until I get to the University later this week, and can get behind the paywall, but the abstract certainly served its purpose--it alerted me that this is a potentially interesting and very useful article, and that I should go to the effort to get the entire article and read it.

Campbell SM, Louie-Gao Q, Hession ML, Bailey E, Geller AC, Cummins D. Skin Cancer Education among Massage Therapists: A Survey at the 2010 Meeting of the American Massage Therapy Association. J Cancer Educ. 2012 Aug 23. [Epub ahead of print] PMID: 22915212

Massage therapists encounter skin on a daily basis and have a unique opportunity to recognize potential skin cancers. The purpose of this study was to describe the skin cancer education provided to massage therapists and to assess their comfort regarding identification and communication of suspicious lesions. An observational retrospective survey study was conducted at the 2010 American Massage Therapy Association Meeting. Sixty percent reported receiving skin cancer education during and 25% reported receiving skin cancer education after training. Massage therapists who examine their own skin are more likely to be comfortable with recognizing a suspicious lesion and are more likely to examine their client's skin. Greater number of clients treated per year and greater frequency of client skin examinations were predictors of increased comfort level with recognizing a suspicious lesion. Massage therapists are more comfortable discussing than identifying a potential skin cancer. Massage therapists may be able to serve an important role in the early detection of skin cancer.

 

Once again, we have an invitation to up our game, to commit to the shared body of knowledge of the client-centered healthcare team, and to contribute in a specific way to that team and to the client's well-being.

What are some concrete steps we could take--individually, through our organizations, both ways, or some other way--that would demonstrate that we are serious about wanting massage to become a healthcare profession, and to take steps toward accepting that invitation?

Is this something that we really want to do? What are the risks and benefits of doing so?

 

Source: Left: Wikipedia, "Skin cancer" http://upload.wikimedia.org/wikipedia/commons/4/4f/Basal_cell_carcinoma.jpg accessed 27 August 2012; Center: Wikipedia, "Skin cancer" http://upload.wikimedia.org/wikipedia/commons/3/35/Squamous_Cell_Carcinoma1.jpg accessed 27 August 2012; Right: Wikipedia, "Skin cancer" http://upload.wikimedia.org/wikipedia/commons/6/6c/Melanoma.jpg accessed 27 August 2012

 

The images above show the 3 classic types of skin cancer. Reading from left to right, what are the names of the skin cancers in the photographs?

Reading from left to right, do the types of cancer you see in the images get more common or less common in occurrence in the general larger population?

Reading from left to right, do the types of cancer you see in the images get more deadly or less deadly?

If you saw a skin lesion on a client during a session, and the lesion looked exactly like one of the types of cancer you see in the images, what words would you choose to talk to the client about what you saw?

 

 

Looking into the abyss (#26/31)

Submitted by RST on Sun, 08/26/2012 - 06:56
Posted in

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

Silence is not always consent (#25/31)

Submitted by RST on Sat, 08/25/2012 - 07:53
Posted in

Many times, on the Internet, people assume that if someone states something, and no one contradicts that statement, then everyone agrees with what is said.

Sometimes that's true--and sometimes, the lack of contradiction results from a realistic assessment that there is no point in discussing the matter further.

Honest discussion only works when all parties approach the discussion in good faith, and are willing to honestly re-assess their positions to see if there is somewhere that they could be mistaken. If such a mistake is found, people need to be willing to correct that mistake.

If someone is not willing to engage in honest discussion, there is no shame in deciding that it's a waste of your valuable time to engage in less-than-honest discussion, and to simply walk away. After all, that time you'd burn up on "Is so!" "Is not!" "Is so!" "Is not!" is time you could spend:

  • Working with a client on resolving pain, anxiety, or other symptoms;
  • Enjoying time with your loved ones that will later be the stuff of which fond memories are made;
  • Reading a fun or awesome or life-changing book;
  • Watching a movie you've always wanted to get around to;
  • Making music that has never existed before and never will again, but is absolutely transformative in the moment, or
  • Any number of wonderful other activities--or restful non-activity--just waiting for you.

 

How do you know whether someone's interested in engaging in honest discussion?

You don't, always, but there are some red flags to warn you that they aren't.

Someone who wants to engage in honest discussion will connect the dots in their position for the people they're speaking to.

When you ask an honest question and then someone won't take the time and effort to connect the dots in their argument for you--when they say they "don't have the time to debate the research", or they point you to books by their favorite gurus and say "it's all there, just read it for yourself"--that's a big neon sign that their mind is already made up, and no amount of evidence will influence what they've decided to believe.

Not always, of course--some people eventually give up their adamant resistance, and actually examine the evidence for themselves.

You can't always tell who's going to do that, and who's not.

And sometimes, there is value in speaking out, even if there is no hope of honest discussion.

You may just want to go on record as someone who doesn't believe that statement--nothing more, nothing less.

You may recognize that there are many others reading without commenting, and you may want to point to the evidence for their benefit, rather than for the person who refuses to discuss it. You never know, and can never know, the effects of the seeds you're sowing--but you are having an effect, whether you see it or not.

You're the best judge of your situation, and you're the one to decide whether any given situation makes sense for you to engage in it or not.

But there is no shame in looking at the situation, deciding that it's hopeless, and resolving that the absolute best use of your time is to walk away from it, and spend your time and energy elsewhere. There are many other places on the Internet where learning and honest discussion is truly valued; there are lots of people there who want to hear what you think, based on the evidence, and to discuss with you what it all means.

Refusing to waste your time engaging in bad-faith arguments does not mean you agree to incorrect claims someone else is making--silence does not mean consent.

Are you mandated? (#23/31)

Submitted by RST on Wed, 08/22/2012 - 22:08
Posted in

I always looked forward to my trip over the bridge to see my client, Mrs. Ford, in her skilled nursing facility in West Seattle.

Mrs. Ford had a long history of smoking before the stroke that took away most of her ability to speak and to move, so she was quite frail and had difficulty breathing. Despite the fact that she couldn't talk to me, and that she was mostly paralyzed, she was a sweet, cheerful lady, who managed to communicate a lot of meaning without being able to speak.

We worked out a system, much like "20 Questions", where I'd ask a yes-or-no question, and--based on the answer to that question--I'd choose the next question to ask. Depending on the quality of her sigh in response, I knew the answer was "yes" or "no", and then we'd proceed to the next question, until I was sure she was comfortable, securely positioned, and ready for her massage.

It was a laborious method, but it met her communication needs in the absence of her being able to speak.

Since I was so used to communicating with her in this way, I was totally blown away one day when, lying supine on the table, she grabbed my wrist in a death grip, and pulled me close to her face.

In a breathy whisper, she slowly forced her lips to form the words "Shheee's.......hurrttingg......mmmeeeee."

One of the nursing assistants had been abusing her, knowing that she was unable to defend herself.

 

 

Do you know what the laws are in the state regarding your status as a mandated reporter--one who is required to report cases of suspected abuse or neglect of a member of a vulnerable population?

Are you considered a mandated reporter?

If so, what populations are you responsible for making reports about, if you suspect that someone is being abused or neglected?

What counts as abuse? Physical? Sexual? Emotional? Financial? Neglect?

RAINN (The Rape, Abuse, and Incest National Network) provides information pages about the laws in different states.

They also provide this information:

  • Who Must Report?
  • Standard of Knowledge
  • Definition of Applicable Victim
  • Reports Made To
  • Contents of Report
  • Timing/Other Procedures
  • Other
  • Source/Applicable Statute(s)

 

They seem pretty good, but it would also not hurt to check them against other information sources, such as the local chapter of your professional organization, for example.

The reason I'm not sure it's right is that, for my state (Washington), it lists MTs as mandated reporters for elder abuse, but not for children.

It's not impossible that that's the way the law really reads, but I want to double-check that before assuming.

In a way, it doesn't matter, because I am not about to sit on my hands and say, oh, well, a child's being abused, but I'm not required to report it, la la la. So it won't change what I would ever do if I did learn that a child was being abused.

But on the other hand, it does seem odd that elder abuse reporting is mandated, but child abuse is not.

So for the moment, at least, I'd treat this source much as I treat Wikipedia--a good portal or jumping-off place, but not the be-all and end-all of necessary information that I depend on to get exactly right.

 

 

What happened with Mrs. Ford was this: I asked her daughter what she might be talking about, because I did not fully understand. Her daughter suspected she knew who her mother was talking about, and confirmed it with her mother.

We then went to the director of the skilled nursing facility to report it.

It turned out that this nursing assistant had a checkered track record, and was on probation. Abusing Mrs. Ford was the last straw, and the nursing assistant was let go after an investigation of the accusation.

I continued to work with Mrs. Ford for a couple of years after that, and when I returned to school, she was the only client that I kept on working with while trying to adjust to the grad school environment and the course load.

I stayed her MT until she passed away.

But except for that one time, she never tried to speak verbally to me again.

 

Source: National Committee for the Prevention of Elder Abuse, "Preventing Abuse to Elders" http://www.preventelderabuse.org/images/img03.jpg accessed 22 August 2012

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

Submitted by RST on Thu, 08/16/2012 - 13:47
Posted in

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?

 

 

Avoiding the perception of impropriety (#6/31)

Submitted by RST on Fri, 08/10/2012 - 08:10
Posted in

Since my massage practice at the Refugee Clinic involved working with many clients who did not speak English, and since translators weren't always available, I took a course on medical translation, in order to help me better translate from the limited Khmer language I had studied in school into the language of real-life healthcare situations with clients.

All translation is not created equal. One of the things I learned is that, in legal translation, there is no special obligation to ensure that the client understands the translation at the concept level of meaning.

An English-speaking defendant is told certain things, but--except for that defendant's lawyer, or advocate--no one in the court system takes the extra time and effort to ensure that the client actually understands the ideas and meaning of the words. If the defendant hears the words, the obligation to communicate is fulfilled, as far as the court is concerned.

Legal translation operates on a similar principle--the non-English-speaking defendant must be given the same opportunity to hear in their language what the English-speaking defendant would hear in English. There is no time or extra resources in the system to ensure that someone sits down with the defendant, and--acting as a culture broker--ensures that the defendant actually deeply understands what is heard.

That culture-broker role, someone who understands both sides of the translation well, has a foot in both worlds, and actively helps the client bridge those worlds, is much more characteristic of medical translation than it is of legal translation.

There, where the client/patient is the highest priority, and understanding can be, literally, a life-or-death matter, people do invest the effort to bridge that gap and promote true understanding, because the results can make such a difference in the quality and impact of care that the client/patient receives.

Garcia-Castillo D, Fetters MD. Quality in medical translations: a review. J Health Care Poor Underserved. 2007 Feb;18(1):74-84. PMID: 17337799

Despite a growing number of U.S. citizens who do not speak English fluently, little literature attends to issues of accurate translation of medical documents. We conducted a systematic review of the World Wide Web and electronic library resources to identify sources on translating clinical and medical research documents. We identified and carefully examined 44 relevant articles. Each article was coded with 5 to 10 key words that were used as a guide when we searched the articles for issues salient to assuring quality in medical translations. We divided these into two major categories, mechanics/practicalities of translating medical documents and extrinsic factors influencing medical translations. The results of this review confirm that medical translation is a complex process involving far more than mechanically converting one language to another. Attention to translation procedures can improve the quality of care for limited English proficient patients.

 

Just as good quality of translation can improve access and care for underserved clients, unawareness of cultural issues involved in medical translation and care can lead to serious problems in delivery of healthcare services:

McCabe M, Morgan F, Curley H, Begay R, Gohdes DM. The informed consent process in a cross-cultural setting: is the process achieving the intended result? Ethn Dis. 2005 Spring;15(2):300-4. PMID: 15825977

This report is based on the experiences of Navajo interpreters working in a diabetes clinical trial and describes the problems encountered in translating the standard research consent across cultural and linguistic barriers. The interpreters and a Navajo language consultant developed a translation of the standard consent form, maintaining the sequence of information and exactly translating English words and phrases. After four months of using the translated consent, the interpreters met with the language expert and a diabetes expert to review their experiences in presenting the translation in the initial phases of recruitment. Their experiences suggest that the consent process often leads to embarrassment, confusion, and misperceptions that promoted mistrust. The formal processes that have been mandated to protect human subjects may create barriers to research in cross-cultural settings and may discourage participation unless sufficient attention is given to ensuring that both translations and cross-cultural communications are effective.

 

These are the kinds of issues we care about, as evolving healthcare providers, but the priorities in the legal system are different. Understanding those different priorities is key to understanding why legal translators make decisions the way they do, and why those decisions are different from the ones medical translators would make in their role as culture brokers.

 

 

 

Still, I was happy to see in my legal translation overview, that the specialty is not totally impervious to what the defendant perceives and understands.

In that class, I was introduced to the concept of avoiding the appearance of impropriety, and to practical applications of what that principle means in real-life practice.

"Impropriety" means behaving inappropriately, and the appearance of impropriety is when it looks as though someone is behaving inappropriately, even though their actual behavior may be totally innocent.

The example given in the legal translation class is that--even if they are in reality good friends outside the courtroom--once they get into the courtroom, the lawyers don't stand around laughing and joking with the judge on breaks.

The reason for this is that, even if the conversation is totally innocuous (like picnic plans for the upcoming weekend), if the prosecutor and the judge are joking around, the client could reasonably interpret that friends support friends, and as a result, the judge is biased in favor of the prosecutor and against the defendant as the trial proceeds.

As a result of situations like this, professional codes of ethics have been developed to offer guidance on how is the appropriate way for professionals to behave.

Avoiding even the appearance of impropriety in the mind of a reasonable person is one basis of those codes. Some of the behaviors they prescribed by may seem nit-picky and unnecessary--recently, a social-worker friend of mine discovered at the grocery checkout line that she had left her wallet at home, and one of her clients, who happened to be behind her in line, offered to lend her the money.

Instead of accepting the money, she thanked the client graciously and then left her groceries at the checkout, and went home to get her wallet.

The reason is that she works with very poor clients, who are underserved by our system. They spend hours waiting in line for things that most of us in the middle-class take for granted--if, indeed, those things are available at all to them.

If she is seen in public accepting money from a client, then other clients who might see that transaction take place, or hear about it from others, could--very reasonably--interpret that to mean that the client was purchasing access to special favors from my friend.

The sticking point is what "in the mind of a reasonable person" means. That standard is open to interpretation; like abductive reasoning to the "best" explanation, we can't define a one-size-fits-all definition for it. Life would be so much easier if we could do that, but people are so complex and diverse that it's not possible.

 

 

Last week, I had to reschedule an appointment with an older, frail, client in the early stages of Alzheimer's disease because of car trouble I was having. The expensive car repairs are coming at a most inconvenient time, but that's just the way it is.

My client offered, of his own initiative, to help me finance the purchase of a car to replace the one that's giving me such trouble.

As tempting as the offer was, and as much as it would help me out to have assistance in financing the purchase of a replacement vehicle at this inconvenient time, I think everyone reading this post can see what my answer to my client had to be, and exactly why that is so.

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