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Skillful discernment and the principle of non-contradiction: Knowing how to make client-centered professional commitments among different ideas and practices

Submitted by RST on Sat, 04/06/2013 - 04:06
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Many of us who attended junior high or high school in the United States had to read and analyze "The Road Not Taken", a poem published in 1916 by Robert Frost.

It reads:

1. The Road Not Taken

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

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

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

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

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

 

 

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

 

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

 

 

 

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

 

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

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

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

 

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

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

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

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

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

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

 

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

 

 

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

Avoiding the perception of impropriety (#6/31)

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

What is biopsychosocial massage?

Submitted by RST on Tue, 08/07/2012 - 08:53
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Several other people have contributed greatly to my thoughts on the topic of biopsychosocial massage, and a really profound discussion along those lines is currently going on in a social media group that I'm a part of.

I'm not going to quote those other people directly here, because they were speaking in a private group, and I respect their privacy. This lack of quotations, however, should not be interpreted to mean that I fail to recognize the influence that others have had, and continue to have, on these ideas that I'm developing here. I'll be very happy to acknowledge and cite those discussions that are not explicitly private.

I am very grateful for everyone who has mentored me and contributed to my professional development, and who continue to do so to this day.

I promise you that I will pay it forward.

 

 

Biopsychosocial massage is the practice of massage in a way that builds bridges to working on a unified team with biomedical healthcare providers by participating in the shared knowledge base of biological, psychological, and sociocultural factors that influence health and illness.

That means that practitioners of biopsychosocial massage practice massage in a way that is compatible with the current state of the evidence. We don't create obstacles to being part of a unified team by making counterfactual and unsupportable claims about how massage works.

It facilitates our professional development as healthcare providers by putting the client at the center of knowledge and information. One of the most stressful situations in life is illness--by committing to a shared knowledge base and sending a unified message to the client as the rest of the team does, we do not add to the client's cognitive burden and stress load at a particularly difficult time by forcing them to do the additional work to try to sort out conflicting alternative and contradictory messages.

It means that we are honest about what we know, and what we don't know. That includes a responsibility to develop basic scientific literacy and critical thinking, in order to ground our perceptions and experiences in the larger context of what we know about the material physical universe around us. The "bio" aspect of "biopsychosocial" actually draws on many other natural sciences than just biology, and understanding the cohesive integration of the knowledge generated by all of those disciplines is crucial to an honest evaluation of what we really know about the world around us.

It means that we always need to be aware, at a very general level, of the fact that psychosocial factors can influence the state of a person's health, for better or for worse.

It means that we need to understand the difference between being a supportive layperson versus practicing psychotherapy, which--among other things--means listening supportively without giving advice or interpreting meaning.

It means we should know what the signs are that indicate someone is in greater psychological distress than we ourselves are equipped to help them with, and to have a plan for how to reach out to the larger psychotherapeutic community, either to assist them in getting help, or in our need for supervision or mentoring in processing what our clients bring to us.

It means that--no matter how we regard those particular sociocultural factors, for better or for worse--we recognize the profound effects those factors can have on the health status of our clients, and, to the best of our ability, we take those factors into account when we try to understand our clients' experiences.

It means that we recognize that the available research evidence will always lag behind immediate needs for information in the clinic, and so evidence-based practice will always remain an ideal or a goal as a result of that fact. Working practically in real life in the meantime, it means that we practice in a way that is based on the evidence, if available, and if evidence is not available then we at least practice in a way that is consistent with the larger body of knowledge about how the physical universe works.

It means that we put our responsibility to our clients above our attachment to particular ideas and claims--if claims about massage or other related topics repeatedly fail validation tests, we accept that fact, make our peace with it, and move on to what we do actually know that can be of benefit to our clients.

It does not mean at all that the subjective experience of meaning-making, or joy, or humor, or spontaneous feeling are off-limits--it simply means that we remain clear, to ourselves and to everyone else, on the differences between objective and subjective, mind-independent and mind-dependent, universal and unique, literal and metaphorical/allegorical, and fact and interpretation.

It does not mean at all that we are not open to new ideas--it simply means that, for the sake of our clients, we expect the advocates of those ideas to do the work of connecting the dots and showing how those ideas truly lead to positive outcomes for our clients, before we go on to regard those ideas and claims to actually have the status of validated knowledge.


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

 

 

 

Words have meaning: On finding a balance between hope and realism

Submitted by RST on Wed, 08/01/2012 - 09:25
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I tend to be a bit optimistic on how much work I can get done in a particular timeframe, and so I've been engaged in an ongoing struggle to put my deliverables on a more reality-based schedule. Part of this effort is sticking to scheduling and time management as tools to bring my optimistic assessments more in line with what really can be done in a particular amount of time.

Yesterday afternoon was set aside to finish another chapter of the massage research literacy book, and put it up here for your review. But real life did not consult my DayRunner before unfolding, and so things went very differently instead.

I spent the entire afternoon at a local hospital, consoling a friend who was absolutely shattered.

That's not a complaint about my friend, by the way--human needs always, always, trump sitting at a screen and writing. So, I readjust my time estimates, and begin again--that's not the problem.

The issue here is why my friend had to go through that massive shock in the first place, and--if there is any silver lining to it at all--what we can learn from it, to prevent it from happening to others in the future.

My friend's surviving parent was recently diagnosed with terminal cancer. Because of the parent's age and frailty, and because of the devastating effects that chemotherapy drugs for this condition would have on even a young and vigorous patient, my friend agreed that it didn't make sense to treat the cancer, outside of removing the tumor--no chemotherapy or radiation, just surgery.

The surgeon reported that the tumor was cleanly removed, but that there were signs that the cancer had already spread. The surgeon told my friend, based on that observation, that my friend's parent had maybe 2 or 3 years left to spend with the family and to get affairs in order.

When my friend called me, absolutely undone, it was because another doctor on the case had reviewed everything, and estimated that my friend's parent had 6 months or so remaining to live. Before that, it meant adjusting to a new normal; now, suddenly, they're blindsided into finding themselves already in a hospice situation.

To my friend--whose mind was already wrapped around a 2-3 year process of saying goodbye because of the surgeon's optimistic offhand pronouncement--the effect of the more realistic assessment was like getting that death sentence all over again.

Words have meaning, and by virtue of our work with people in sickness and in health, our words in particular are perceived as having a certain amount of authority.

Our own conflicts with healthcare professionals, insurance companies, and legislators aside--conflicts in which we experience our relative lack of authority compared to others--this is about how the client perceives us.

When you are in a situation where you are suffering, sometimes, you will grasp at any straw of hope that is offered, and run with it. It doesn't matter how the words were intended; that sliver of hope meets a need in people who feel desperate above and beyond what it means to people who are not in that situation themselves.

If we are going to become healthcare professionals, we need to recognize that fact on our clients' behalf, and step up to own our responsibility for the messages we send out to them. Optimism is a positive human trait, but we all--optimists and pessimists alike--have to adjust our messages to what we might reasonably expect our clients to hear.

If we make grandiose, sweeping claims about what we can actually achieve, then we are, obliviously, going to leave a trail of shattered clients in our wake.

If we are, on the other hand, willing to accept that massage is not a panacea or cure-all, and are willing to humbly and honestly examine exactly what massage is, and is not, capable of, then we are on track for two things:

  1. We can begin to tackle the very difficult questions of how do we leverage the positive psychological effects of hope on healing, without either taking away all hope, nor setting up our clients for a fall with false hope, and
  2. We show our commitment to the professional healthcare ethics that are a necessary step in the evolution of massage into a healthcare profession.

 

Source: Allegory of hope; Oil on canvas, Francesco Guardi, 1747, from Wikipedia: "Hope", http://upload.wikimedia.org/wikipedia/commons/2/2d/Francesco_Guardi_002.jpg accessed 1 August 2012

The Ethical Implications of Research and Education in the Massage Therapy Profession (Chunco 2010)

Submitted by RST on Fri, 06/29/2012 - 18:10
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I want to thank the International Journal of Therapeutic Massage and Bodywork for their open access policy permitting free use with proper attribution in noncommercial settings, which--along with the fair use principle--permits us to engage with the text of this article in depth.

Entries in the IJTMB are governed stylistically and ethically by the publication guidelines of the International Committee of Medical Journal Editors' (ICMJE), Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Published articles are licensed under the Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 license. Accordingly, copyright retention by authors, first publication rights for the journal, free use with proper attribution in noncommercial settings, and prohibition of derivative works are all ensured.

--Glenn M. Hymel, From the Executive Editor's Perspective ... IJTMB, Vol 1, No 1 (2008)

 

Full disclosure: Rosemary Chunco has been a supporter of the ideas behind POEM since the day I first mentioned the idea to her, and she has donated countless volunteer hours of technical and massage content expertise to bring it to fruition, as well as providing emotional support when I needed it along the way.

You should always read critically, and think about whether what you read makes sense, and that is especially true in this article, because I have a personal connection to the author.

It is my job to connect the dots and build my case to evaluate whether or not what she writes is correct, totally separate from the high esteem I personally hold her in.

Then, it is your job to read what I have written, and decide whether I was really successful in separating my evaluation of her work from what I think of her personally, or whether I am permitting my very high positive regard for her to bias what I write here about her work.

I hope you let me know in the comments whether or not I have succeeded at that task.

 

"The Ethical Implications of Research and Education in the Massage Therapy Profession", by Rosemary Chunco, LMT, BA, MSc, Owner (Private Practice), Shamrock Therapeutics LLC, Plano, TX, USA, International Journal of Therapeutic Massage and Bodywork, 2008:3(3).

Chunco sets the stage for the ethical and knowledge claims she will make in this article by grounding it in her practical experience of running her own massage practice for a number of years:

As a therapist operating my own practice, I am constantly reminded of the ethical aspects of my work in dealing with situations involving clients and the everyday running of my business. Professional boundaries and ethical practices are recognized within our profession as an important aspect of our work, as evidenced by mandatory classes on ethics in most U.S. states and also by the clearly stated ethical codes and practices set out by our professional organizations. The reasoning behind these measures is clear. Ethical declarations and a thorough understanding of them and their application are needed. They set standards of integrity. They help to define massage therapy as a profession and have significant repercussions on how massage therapists are perceived by the public.

 

From this foundation, she sets out to explore the connections between research, education, and ethics, and the meaning of those connections in everyday MT practice.

By drawing on specific points in the ethical code of each of MT's 2 major professional organizations in the US, as well as that of the NCBTMB certification board, she avoids partisanship, and focuses on what all of us--at least, those who subscribe to the ethical code of either professional organization--have in common with each other.

Whether it's ABMP's

I shall actively participate in educating the public regarding the actual benefits of massage, bodywork, somatic therapies and skin care.

and

I shall not make false claims regarding the potential benefits of the techniques rendered.

 

or AMTA's

[practitioners shall] be truthful in advertising and marketing, and refrain from misrepresenting his or her services, charges for services, credentials, training, experience, ability or results.

 

Chunco correctly emphasizes what they have in common with each other and with other professions' codes of ethics: actual benefits, not making false claims, being truthful and refraining from misrepresentations.

As she observes, this ethical value of veracity--truthfulness, accurately representing the facts--is core to the mission of a healthcare profession such as MT aspires to be.

But how do we gain that veracity about massage? She proposes:

Considering the increasing quantity—and importance—of research in our profession, and applying our understanding of professional ethics, it is apparent that keeping up to date with research findings could be viewed as an ethical responsibility. New research findings may uncover therapeutic benefits that we never learned in school. Conversely, some things we were taught in massage school have been overturned by the latest research. For example, many of us may have been taught that massage helps to release lactic acid from muscle tissue after exercise; research refutes that claim.

 

In this way, she grounds knowledge in empirical research findings, as well as describing the problem of outdated and ungrounded information that is taught in massage schools as fact.

She is touching on a huge problem here. You don't need to assume any bad intentions at all on the part of massage schools and educators in this situation--it makes perfect sense that the situation has developed because reality changed out from under us faster than we were prepared to keep up.

There was a time in the past when those explanations were the best we had for trying to figure out what was going on in the world around us.

But knowledge has moved on since then, and we were not prepared for that. So now, schools and their owners face tremendous sunk costs--costs already spent, that will never be recovered--as well as tremendous need for investment to bring the new knowledge on board, at exactly the time when the economy does not support such investment.

It is a huge problem, and you can really feel for the plight that educators find themselves in.

And yet, as difficult as the situation is, Chunco is correct: practicing MTs must, every day, confront the fact that what they were taught in school was insufficient, or even wrong, and to pass along that misinformation is to directly contradict the ethical codes of both of our major professional organizations, and of the board that certifies and attests to the integrity of our education.

Integrity means doing the right thing, not when it's easy and anyone can do it, but precisely when--although it would be easier to take the path of lesser integrity instead--you do the right thing anyway, even at greater cost. Chunco is correct in identifying that right thing as "a restructuring of existing knowledge, and that knowledge will continually evolve".

This integration of research findings into our profession’s training programs should be considered an ethical necessity.

 

"Ethical necessity" is a very strong term--and yet, entirely accurate and appropriate here. We must address the situation; to deny or ignore it is an ethical failure.

She ties that ethical necessity into what is required to actually carry it out. Our responsibilities to understand and integrate research findings run far deeper than just finding a source that says what we like, and slapping a citation onto our claims. Chunco refers to the established biomedical research literature, where others before us have encountered this challenge, to identify weaknesses in our relationship to massage research:

causism, a “tendency to imply a causal relationship where none has been established” (that is, the data are insufficient to support the claim), and data dropping...These, along with misrepresentation of findings, instances of poor research design, and an assortment of weaknesses in methodology can result in low-quality research. It follows that an uncritical acceptance of research by the massage community, and most of all by massage therapists, is a mistake, and that awareness of the ethical and methodologic issues common to any subfield of research is imperative.

 

But it's not all one-sided responsibility and burden, as she points out--there are professional benefits from being part of the biomedical healthcare team that shares a common body of translational client/patient-centered healthcare knowledge.

By sharing and communicating better with other members of the team, and by communicating a unified message to the client/patient (as she mentions with educating the public about massage), research literacy benefits us as well as putting higher expectations on us.

She deals compassionately and with integrity to common objections raised to changing practice in response to research findings:

When adherents of a specific modality are confronted with research findings showing that that modality has no therapeutic effect, I have often heard or read these three objections:

  • “More research is needed.”

  • “If the public wants it, and they believe it works, then we should supply it.”

  • “If I see results in my practice, then that’s all I need. All I want to do is help my clients.”

 

Although we frequently deal with these concerns here at POEM, she has said it in her article better and more concisely than I could do myself--I recommend you follow the link to her article and read her responses to these objections for yourself.

Chunco is clear on what needs to be done, yet she is compassionate and empathetic to the practitioners, teachers, and students who find themselves confronted with this new reality:

Having invested time, energy, and money to be trained in a modality and then being confronted with new information showing that that modality may have no therapeutic effect is undoubtedly an unpleasant and uncomfortable situation. The attachment to the modality could even go so far as to be an emotional one. Of course, the power of choice will always lie with the therapist. It is my hope that the ethical core of the therapist will make the right choice and that our profession will accept what good science is showing us; for in doing so, we are using science to raise our own levels of integrity and the universal integrity of the profession. Each of us has a role to play, and we should not view ourselves as detached. The decision that each therapist makes will affect the profession as a whole.

To conclude, it is reasonable to deduce that the link between research, education, and professional ethics is strong. Examination of our ethical codes indicates that it is our responsibility to keep up to date with research findings and to apply them in our work. The decisions that we make as a profession—from every angle and by every participant, whether it be researchers, policymakers, educators, or therapists in practice—will have a significant influence on the true ethical barometer of our field.

 

Chunco has written a very good and convincing review of the issues and a call for ethical action in integrating the volume of massage research going on into our educational system and our daily practices. As she points out, we're all in this together, and history will record the outcomes for the practice of massage from how individual therapists choose to face our common challenge.

 

 

 

My recommendations for the future of massage as a healthcare profession

Submitted by RST on Thu, 05/31/2012 - 07:19
Posted in

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.

Ethics, professionalism, and scope of practice: A bodyworker prescribes muscle strengthening exercises

Submitted by RST on Tue, 05/15/2012 - 10:26
Posted in

"Ethically Speaking: The Advice Trap", Dianne Polseno, December 21, 2002 accessed 15 May 2012

...While it's inappropriate to advise a client on such personal matters as relationship issues or financial problems, it may not be so easy to recognize inappropriate advising when our suggestions and recommendations have to do with the client's health. For example, we may want to share information with our clients about products or methods that we have personally found to be effective. Or, in contrast, we may want to caution clients about products or methods that we have personally found to be ineffective. Furthermore, our other life experiences and education may encourage us to feel qualified to offer information that we believe will be helpful, when in actuality, to do so would be stepping outside of our scope of practice. Several situations come to mind that may help explain this point. These are actual cases that have been conveyed to me in recent years:...

A bodywork professional who worked out regularly offered his clients advice on how to strengthen muscles. He had no formal education or credentials in personal or athletic training. A client, who happened to have an undiagnosed rotator cuff tendinitis, followed the therapist's advice, and it resulted in further injury to the tendon. The client may need surgery.

In all of these cases, it is understandable that the massage therapist did not intend to cause harm to the client. Yet, despite the intention to be helpful, the suggestions, feedback and advice were inappropriate and out of the scope of a massage therapist's practice. In each of the above situations, consider the following guidelines regarding scope of practice and appropriate professional behavior:...

The teaching of muscle-strengthening exercises is not within the scope of practice of a massage therapist. Professionals, such as physicians, chiropractors, physical therapists, athletic trainers and personal trainers, are qualified to do so. If a client would benefit from such measures, the safest and most ethical action would be to refer him or her to a qualified professional for the proper education.

Advice-giving is a trap that is easy to fall into and difficult to get out of. Remember that, in general, when we share comments, opinions, helpful ideas and judgments about any nonmassage matters, we are sharing "our stuff," and we have most likely moved into unethical, and perhaps illegal, territory.

 

 

 

Ethics, professionalism, and scope of practice: An MT imposes religious/spiritual beliefs and practices on clients

Submitted by RST on Tue, 05/15/2012 - 10:24
Posted in

"Ethically Speaking: The Advice Trap", Dianne Polseno, December 21, 2002 accessed 15 May 2012

...While it's inappropriate to advise a client on such personal matters as relationship issues or financial problems, it may not be so easy to recognize inappropriate advising when our suggestions and recommendations have to do with the client's health. For example, we may want to share information with our clients about products or methods that we have personally found to be effective. Or, in contrast, we may want to caution clients about products or methods that we have personally found to be ineffective. Furthermore, our other life experiences and education may encourage us to feel qualified to offer information that we believe will be helpful, when in actuality, to do so would be stepping outside of our scope of practice. Several situations come to mind that may help explain this point. These are actual cases that have been conveyed to me in recent years:...

A massage therapist, who had devout spiritual beliefs and practices, freely shared her views and ideas with her clients. At some point during the sessions, she brought this topic into the conversation, and she often encouraged her clients to adopt a more spiritual lifestyle. She had spiritual literature in her office, and she offered to help clients learn how to pray and meditate for stress reduction. Clients soon sought out other massage therapists in her area, and reported to the new therapists that they felt pressured and turned off by her approach...

In all of these cases, it is understandable that the massage therapist did not intend to cause harm to the client. Yet, despite the intention to be helpful, the suggestions, feedback and advice were inappropriate and out of the scope of a massage therapist's practice. In each of the above situations, consider the following guidelines regarding scope of practice and appropriate professional behavior:...

Discussion of religious beliefs or spiritual practices should not be brought into the client/therapist relationship by the massage therapist. Such matters are highly personal and confidential. Moreover, if the conversation in a session is directed toward this, or any other aspect of your life, it is likely that your focus is in the wrong place. The most effective sessions are client-centered, not therapist-centered...

Advice-giving is a trap that is easy to fall into and difficult to get out of. Remember that, in general, when we share comments, opinions, helpful ideas and judgments about any nonmassage matters, we are sharing "our stuff," and we have most likely moved into unethical, and perhaps illegal, territory.

 

 

 

Ethics, professionalism, and scope of practice: An MT prescribes herbs to replace prescription medication and makes a psychological diagnosis of physical pain

Submitted by RST on Tue, 05/15/2012 - 10:22
Posted in

"Ethically Speaking: The Advice Trap", Dianne Polseno, December 21, 2002 accessed 15 May 2012

...While it's inappropriate to advise a client on such personal matters as relationship issues or financial problems, it may not be so easy to recognize inappropriate advising when our suggestions and recommendations have to do with the client's health. For example, we may want to share information with our clients about products or methods that we have personally found to be effective. Or, in contrast, we may want to caution clients about products or methods that we have personally found to be ineffective. Furthermore, our other life experiences and education may encourage us to feel qualified to offer information that we believe will be helpful, when in actuality, to do so would be stepping outside of our scope of practice. Several situations come to mind that may help explain this point. These are actual cases that have been conveyed to me in recent years:...

A client went to see a massage therapist for neck and left upper extremity pain. In giving her medical history, she reported that she was taking antidepressant medication. The massage therapist, a proponent of herbal remedies, cautioned the client about the side effects of the medication, and recommended that the client experiment with an herbal antidepressant that she, herself, had found to be highly effective. The massage therapist went on to say that the left upper extremity pain could be a manifestation of the client's relationship issues with a parent; the therapist had seen this to be the case with many clients. The client, feeling angry and violated, never returned for another visit with the massage therapist...

In all of these cases, it is understandable that the massage therapist did not intend to cause harm to the client. Yet, despite the intention to be helpful, the suggestions, feedback and advice were inappropriate and out of the scope of a massage therapist's practice. In each of the above situations, consider the following guidelines regarding scope of practice and appropriate professional behavior:...

A massage therapist must never tell a client to start or stop taking medications, and recommending herbs is the same as prescribing medicine, which is out of a massage therapist's scope of practice. No judgments should be made about the emotional or psychological status of a client, and massage therapists should refrain from sharing their opinions unless they have the appropriate professional training and qualifications...

Advice-giving is a trap that is easy to fall into and difficult to get out of. Remember that, in general, when we share comments, opinions, helpful ideas and judgments about any nonmassage matters, we are sharing "our stuff," and we have most likely moved into unethical, and perhaps illegal, territory.

 

 

 

Ethics, professionalism, and scope of practice: An MT advises a client to stop seeing a chiropractor

Submitted by RST on Tue, 05/15/2012 - 10:20
Posted in

"Ethically Speaking: The Advice Trap", Dianne Polseno, December 21, 2002 accessed 15 May 2012

...While it's inappropriate to advise a client on such personal matters as relationship issues or financial problems, it may not be so easy to recognize inappropriate advising when our suggestions and recommendations have to do with the client's health. For example, we may want to share information with our clients about products or methods that we have personally found to be effective. Or, in contrast, we may want to caution clients about products or methods that we have personally found to be ineffective. Furthermore, our other life experiences and education may encourage us to feel qualified to offer information that we believe will be helpful, when in actuality, to do so would be stepping outside of our scope of practice. Several situations come to mind that may help explain this point. These are actual cases that have been conveyed to me in recent years:

A client was seeing a chiropractor for low-back problems. The client decided to also see a massage therapist at the same time, thinking that the two modalities would work well together. At the first visit, the massage therapist advised the client not to continue seeing the chiropractor until she had at least three massages to "give massage a chance, since massage therapy was less invasive." The client, confused about what to do, canceled her appointment with the chiropractor and explained the reason to the receptionist. The chiropractor is in the process of taking legal action against the massage therapist for practicing medicine without a license...

In all of these cases, it is understandable that the massage therapist did not intend to cause harm to the client. Yet, despite the intention to be helpful, the suggestions, feedback and advice were inappropriate and out of the scope of a massage therapist's practice. In each of the above situations, consider the following guidelines regarding scope of practice and appropriate professional behavior:

A massage therapist has no right to impose his or her own beliefs and judgments about whatever healing modalities that a client decides to explore. It is never appropriate to tell a client not to follow the directions of a doctor, chiropractor, physical therapist or other primary-care health provider. In the event that we are concerned about the judgment of another primary health-care provider, we must tread very cautiously if we choose to present our views, taking care to emphasize that we have no authority or professional opinion in the matter, and that our comments are based solely on our opinion...

Advice-giving is a trap that is easy to fall into and difficult to get out of. Remember that, in general, when we share comments, opinions, helpful ideas and judgments about any nonmassage matters, we are sharing "our stuff," and we have most likely moved into unethical, and perhaps illegal, territory.

 

 

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