Our stories

The best, most healing thing you can do is just listen. Don’t say “I know how you feel”, because you don’t. Don’t interject your feelings, don’t say you support the war or don’t support the war, because you don't know how we feel about it. Don’t say it’s just like "Call of Duty", because it’s not. "Om" and "kumbaya" don’t help.

The worst thing you know here is maybe a car accident or a mugging—that's not comparable. Put all your possessions and all the people you care about in one house, and then set it on fire and watch it burn while people are shooting at you from all around—then maybe you understand. And if you can go through all that without the memories tormenting you, then you’re stronger than any soldier.

Just listen, and say, "I wish I could have been there for you to help and support you".

--"Jason", veteran of tours of duty in Afghanistan and Iraq, wounded twice and now living on a disability pension

Source: http://1.bp.blogspot.com/-MX0OVAYrN1E/T0Lx4qkaGYI/AAAAAAAAAxA/0PWxeTFsPug/s1600/O+Brother+Where+Art+Thou-01.jpg accessed 10 March 2012

In the 2000 film, O Brother, Where Art Thou, filmmakers Joel and Ethan Coen borrowed the basic plotline of Homer's Greek epic story-poem the Odyssey: a small number of men, led by a charismatic main character, confront massive obstacles in a determined journey home from a traumatic experience.

Of course, in that film the journey was played for laughs. so much of the shocking violence and intense struggle of Homer's original story was watered down--even though the Odyssey's emphasis on building relationships and telling stories to one another was retained.

However, the film does resemble the original epic in one respect that's easily missed.

Odysseus and his shipmates are on their way home from the Trojan War (covered in Homer's other epic story-poem, the Iliad), an arduous experience that they surely spent time recounting during their many years' voyage back to Greece.

But in the same way that the characters in the film don't spend much time talking about their experiences in prison--it begins with them escaping from their chain gang--even the characters in the Odyssey aren't shown having those discussions about the Trojan War.

It's reasonable to assume they did have them, but Homer--with his fine eye for what ancient Greek audiences would have found sufficiently dramatic--concentrated on the high points of encounters with monsters, sirens, disasters, and politics back home.

Everyday conversations among the rank-and-file soldiers ended up on Homer's cutting-room floor. Even today, we're accustomed to the idea that such "ordinary" drama as how one is affected by the violence of war doesn't rise to the level of entertainment.

But for those of us lucky enough not to have known war, just because we're not typically shown such ordinary drama in our entertainments doesn't stop those events from being extraordinarily consuming for those who lived them.

Over the ten years of the Odyssey, the crew had a lot of time to talk, decompress, tell each other their stories, and deal with what had happened to them, and to those they cared about, during the war.

Even as recently as World War II (1941-1945 for American combat involvement), getting to and from battle took days or weeks on board troop carriers traveling to battle and then traveling home.

Source: http://upload.wikimedia.org/wikipedia/en/d/d0/USS_McCawley_landing_rehearsal.jpg accessed 10 March 2012

On the voyage home to people who had not seen what they had witnessed, the troops could talk with each other about it. They could validate each other's perceptions, express their feelings to one another, and, generally, prepare to reintegrate into a very different world from what had been their recent reality.

That process began to change during the Vietnam War, and it is now literally possible for returning veterans to be back in their home country within hours of having been on the battlefield, and back home to their friends and loved ones--few, if any, of whom have shared their experiences--within days or a couple of weeks.

Returning home from war can now be trivially easy, in the physical and logistical sense only. Someone else makes the arrangements, and soon you're on a plane heading home.

But what often goes unrecognized is that, in the relative ease and convenience of returning home compared to the case in previous wars, the opportunities for sharing stories, building and reinforcing relationships, and hearing your experiences validated by others who witnessed the same kinds of things you did--these are all lost in transit.

Like its simpler relative the dilemma (δι-/di, "two" + λημμα/lēmma, “premise, proposition”), a trilemma is a difficult decision point.

The difference is how many problematic options you have to choose among. Odysseus was confronted by a dilemma (two options) in trying to find his way home from war with his ship and his crew. As Wikipedia describes it:

Scylla and Charybdis were mythical sea monsters noted by Homer; later Greek tradition sited them on opposite sides of the Strait of Messina between Sicily and the Italian mainland. Scylla was rationalized as a rock shoal (described as a six-headed sea monster) on the Italian side of the strait and Charybdis was a whirlpool off the coast of Sicily. They were regarded as a sea hazard located close enough to each other that they posed an inescapable threat to passing sailors; avoiding Charybdis meant passing too close to Scylla and vice versa. According to Homer, Odysseus was forced to choose which monster to confront while passing through the strait; he opted to pass by Scylla and lose only a few sailors, rather than risk the loss of his entire ship in the whirlpool.

Sometimes, a trilemma (τρί-/tri, "three" + λημμα/lēmma, “premise, proposition”) is nothing more than the addition of one more monster to choose among.

But often, the special nature of a trilemma lies in the nature of the relationships among the options themselves, and what those relationships do to the decision-making process.

There's a saying in the software industry that illustrates these relationships among options to choose from:

"Fast, cheap, and good: pick any two."

What that saying means is that the combination of any two of those options automatically excludes the third.

So if you want your software to be released fast, and to be of good quality, you can't have it be cheap, because you will have to put a lot of expensive extra resources into getting good quality in a short time.

You can have your software be good and cheap, but in that case you can't have it fast--instead of investing those expensive extra resources, you will have to demand a lot of extra work in quality assurance on the part of the regular team, and that extra work will necessarily take a great deal of time.

Or you can skip that quality assurance, and have a fast release of cheap software, but in that case, you skimp on quality and sacrifice good.

That's a classic example of the nature of a trilemma--not usually so much that you have to choose one of three bad options, but that you have 3 desirable options that conflict with each other, and you have to choose which option to sacrifice in order to keep the others.

But what if you're in a much worse situation, and rather than getting two out of the three things you want--a frequent enough situation in the course of normal life--two of the three things you want have gone away, and it's a struggle just to hold on to the last one remaining?

In a workshop in Seattle yesterday, sponsored by the Veterans Training Support Center at Edmonds Community College and led by Lori Daniels, we talked about what we civilians back here at home can do to be supportive of veterans returning from war and dealing with physical and psychological trauma.

Lori presented a view of multiple dimensions of loss experienced during trauma, such as, among others, the physical loss of friends to violent death, as well as multiple losses on an emotional level. She brought up the book Loss of the Assumptive World: A Theory of Traumatic Loss by Jeffrey Kauffman as a useful resource.

I'm paraphrasing her interpretation of a book written by someone else and that I haven't read myself, but I think this description is pretty faithful to our discussion yesterday.

Kauffman writes about the loss of self-worth that happens in trauma, describing it as a trilemma facing the person who has experienced the trauma, although I would be surprised if he actually uses the word "trilemma".

He states (again, paraphrased and filtered through 2 different people) that, as humans, we tend to share 3 foundational assumptions about the world around us:

1. The world is organized in some capacity, and events in that world happen for a reason;
2. The world is benevolent and good, and good things happen to good people and bad things happen to bad people; and
3. The self is worthy of being loved and accepted.

He proceeds to describe how trauma "annihilates" (Lori's term for his description) 2 of those assumptions:

1. Trauma is random and unpredictable; uncontrollable and unorganized; and
2. Bad things happen to good people.

It is impossible to prepare emotionally and psychological well enough for that—we're just not wired that way.

So something has to be done on a psychological level in order to bring the system back into order.

In the old days, in the company of others who knew what each other had been through, there used to be an opportunity to validate each other's perception over time in the sharing of stories. Now, when you can be home within hours of being on the battlefield, that particular opportunity is no longer there, and other opportunities have to be found or created.

Kauffman describes how, if a trauma survivor contains the experience and feelings inside without disclosing, or if that survivor gets shut down by others for disclosing, then they have to contain experience and solve the conflict among the three foundational ideas all by themselves.

Their task is to navigate the ordinary world with this trauma experience behind them. But there is now an inherent conflict in the 3 ideas, because what they've seen makes it clear that bad things do happen to good people.

That realization means facing the prospect of the horror that is a chaotic, unpredictable, uncontrolled world around us, where bad things happen to good people, and undeserved good things go to bad people, for no reason at all.

But the image of the world as a reasonable, organized place, where the correct things happen to the appropriate people can be regained--but that restoration comes at a tremendous price.

If the trauma survivor lets go of the assumption that their self is worthy, they can regain the other two assumptions in that way.

If you judge yourself as unworthy, someone who failed by making the wrong decisions, that bad things happened to good people only because you yourself blew it, then you can regain other two assumptions, recapturing the idea of a fair world, by sacrificing the idea of yourself as worthy of love and acceptance.

A large part of recovery, then, is the problem of how to bring back the worthiness of one's own self while still managing to navigate a random and crazy world around us.

Again, this is not my original interpretation. I am paraphrasing Lori's presentation of Kauffman's work, and any errors in representation here are totally my fault and not theirs, since I have not read the book for myself in order to interpret and present it. I will put it on the task list, so that my informed interpretation can serve as a resource here at POEM in the near future.

My interest in taking this series of free workshops (and I will put an enthusiastic plug in here for them as they are an excellent and fully-open resource; if you're anywhere near enough to Seattle or Lynnwood to attend, I recommend them whole-heartedly) is in learning how MTs can be of more effective service to returning veterans, and in making that knowledge freely and openly available here at POEM.

Lori is an experienced social worker; she has training and a scope of practice that is not the same as ours, so I asked her several questions about how we could translate this information into something MTs can use knowledgeably, ethically, and within our scope of practice.

The first question I asked was when she said we can provide a service by letting them tell us about their nightmares. I asked what an MT needs to know in order to make sure that we could do that without exceeding our scope of practice and bordering on practicing psychotherapy ourselves.

She responded that we are not practicing psychotherapy if we just listen supportively, without trying to structure the discussion. or to interpret it, or to try to draw out disclosure from the veteran.

If they bring it up of their own accord, during an assessment/history or during a massage, we can reasonably and ethically:

• Reflect their disclosure back in a sympathetic and non-judgmental way: "That must have been a very difficult thing to have lived through."
   
• Reassure them that they are safe in disclosing to you--not only will you not betray their confidences and secrets, nor will you reject them for what they went through, but also that they don't have to worry about protecting or shielding you.
  
  Only tell them this if it is actually true, however.
  
  If you really need to believe in a benevolent world to the degree that you are going to meet their self-disclosure with a response like "everything happens for a reason", then it is better to work with different populations.
  
  This is, after all, a population where many of its members need to find their way back to self-acceptance after already sacrificing their own self-worthiness to the ideal of a benevolent world.
  
  If they disclose to you, and then experience that you can't handle it, or that you are judging them, then you can actually contribute to a setback on their part.
   
• Refer calmly and matter-of-factly to our own limitations in scope of practice for being able to help them: "What you're telling me is very moving, and I can see that it's having a profound effect on you. I want to help and be supportive of you, but what we're talking about is outside of what I have been trained to help you with. Have you ever thought about talking to someone who is in a position to help with issues like these?"
  
  Of course, you'll find your own words, but the point is that you are not shying away from either what they tell you (you are not rejecting them), or from your own professional limitations (scope of practice).
  
  What you need to have prepared in advance is a list of resources in your area they can draw upon.
  
  Sometimes, people are skeptical of professional therapists for various reasons, so it is a good idea to include informal peer-support groups, as well as professionals, on your resource list.
  
  You can also have brochures in your office, so that if someone doesn't yet (or ever) feel safe disclosing to you, they can discreetly take one for possible use later on.
   
• Never let anyone just "dump and run", because that reinforces isolation and feelings of unworthiness.
  
  Don't solicit disclosure (because that would be practicing psychotherapy without a license), but if someone does disclose, then acknowledge it, communicate that you appreciate their trust in you, that you do not judge them, and that you want to be supportive (including referring to someone else with a different scope of practice, if that's appropriate).
  
  Don't just let them disclose, and then hurry past it in an awkward way, or laugh it off and change the subject, because what you have communicated then is that you don't want to hear it--and that reinforces their previous injury to their self-worth.
  
  The big secret of trauma survivors is the feelings of unworthiness that accompany the event.
  
  By letting them tell you their nightmares, or other disclosures, if they bring it up and want to talk about it, you can help them to start chipping away at that secret, by letting them know they don't have to keep it anymore.
  
  If it's more than you can help them deal with while staying in your scope of practice, don't be afraid to say so.
  
  It is perfectly ethical to say I care, I want to help, I can do this but not that because I am not trained for it, but if you like, I can help you to look for help from people who are in a position to help you in ways that I can't.

We have the privilege of (literally) reaching people, many of whom--veterans or not--will be trauma survivors.

By learning how we can use our touch skillfully and ethically, we have the potential to be of great service to an increasing number of people living with the aftereffects of trauma.

I hope more of us step up to that challenge, and I hope we share our stories with each other about how we are doing so.

Source: Still picture from the film "now, after (a PTSD/VA autobiography)" by Kyle Hausmann-Stokes, available at http://www.youtube.com/watch?v=NkWwZ9ZtPEI accessed 11 March 2012

(I recommend this film most highly, but before you watch it, you should know that it contains very violent scenes of death and dismemberment where the person's face is visible. You should consider, before you watch it, whether a film with such vivid potential triggers is right for you or not. There is no shame at all in deciding that such a film is too violent for you personally, and deciding not to watch it for that reason.)

The metaphor of a three-legged stool is often used to describe the three major components of evidence-based practice (EBP), because a stool with three legs can be steady and supportive, even when the ground beneath us is uneven.

The three major components of EBP are:

• research evidence;
• clinical experience and judgment; and
• client/patient wishes and preferences.

The research evidence in massage component is being slowly yet steadily addressed, here and at many other sites. Client/patient wishes and preferences can be understood by skillful active listening to clients/patients themselves. But how do we share our clinical experience and judgment with each other, and ask for advice when we need it, in a way in which we can trust the information that we're getting?

That continues to be a challenge, and over on Facebook, a group of MTs is starting to address the challenge. A Facebook group, "What Works Best for You (WWBY)" has been created for that purpose.

If you want access to what the founder, Claude Ratliff, describes as:

the benefit of rational, intellectual, and science based discussions of massage treatment

please do join us for some awesome questions, answers, and sharing discussion there.

In the short time WWBY has been in existence, I have learned so much there from experienced clinicians.

The rules for joining the group are very simple:

• you have to be on Facebook in order to see it;
• you approach the discussions in a rational and evidence-based way; and
• negative attacks and condescencion will not be tolerated.

If this is what you're looking for in a discussion group with other MTs, you'd be most welcome there. On Facebook, message Claude Ratliff or Lee Kalpin to request to be added to the group.

Source: http://www.clker.com/clipart-three-legged-stool-outline.html accessed 28 October 2011

Touch and caring are often inseparable.

--Gloria Joachim

This is a sort of review of an article, where I engage with it, and in the process share my experiences in the clinic, both as a practitioner, and as a patient in the hospital for a month, recovering from a blood clot, surgery, and complications.

Even more important, I summarize the important practical points for your application in massage, and as massage skills are so foundational to our field, I'm including the ability to give a great foot massage as a foundational concept.

Gloria Joachim, a family nurse practitioner who was an assistant professor at the School of Nursing, University of British Columbia, Vancouver, at the time she wrote this article, and who is now emerita there, published this article in 1983 as a guide for nurses in how to provide effective foot massages for their patients. Although cutting-edge research articles go out of date very quickly, articles about tried-and-true techniques, such as the ones Joachim discusses, are timeless.

Some of the information will be out of our scope of practice as MTs; I'll indicate when that is the case.

Massage claims in the Joachim article

More than just a component of complete care, foot massage has physiological and psychological benefits for the whole person.

--Gloria Joachim

Joachim makes the following claims in her article about the benefits of massage:

• While massaging, the nurse can
  • assess the feet,
  • stimulate circulation,
  • decrease edema, and
  • provide a local form of passive exercise.
• As the feet and body relax, heart and respiratory rates decrease.

Except for the "stimulate circulation" claim, which is a little vague, these claims are fairly well-supported by the evidence, and none of them is particularly controversial.

Joachim finds that the the therapeutic relationship between the nurse and patient is enhanced when the patient is relaxed, because they are both more self-expressive (which lets the nurse know what's going on with them), and more open to health education and good information from the nurse. The example she provides is educating a client with regard to a diagnostic test or special diet, considerations that are outside our scope of practice, unless we have additional training in a field that permits us to counsel clients about those topics, as recognized by the regulatory authorities in the region we're practicing in.

What Joachim does not state, but what I found from my own experience as a patient in the hospital, is that the massage also helped me cope with the fear, anxiety, and loneliness that accompanied that month-long stay. There is a fairly solid body of literature for anxiety, and the effect of massage on fear and loneliness in long-term hospital patients could probably be studied in the same way.

Recommendations for timing of foot massage

She finds that before the patient has hospital procedures done (where procedures mean such things as surgery, imaging, and other specialized protocols), as well as bedtime, are excellent times for the nurse to perform massage for the patient to promote relaxation.

She states that:

On these occasions a foot massage can decrease the need for pain and sleeping medications.

which are two good hypotheses for further study, and for both of which there is some existing literature already that tends to support it, although that literature is not especially strong. These would be most worthwhile to study further.

Recommendations for sequencing of foot massage

Joachim recommends that massage follow complete foot care, although depending on the nurse's intention, there may be reasons to do the sequence differently.

Here are a couple of questions for the spa practitioners out there: although nursing foot care is different from spa foot care, there is a certain amount of overlap as well.

• Is there a standard sequencing for massage and other foot care? Does massage precede foot care, or follow it, or does that simply depend on spa personnel scheduling, rather than sequencing considerations?
• How much evaluation is given to the clients' feet before spa foot care is carried out? Are there any warning signs of problems that spa personnel are trained to look for, and alert the client to, if found?

Joachim recommends that before the massage, you (here, she means a nurse, but this is valid for MTs as well) examine the feet for:

• swelling,
• color,
• ulcerations,
• areas indicating pressure,
• toe deformities,
• cleanliness,
• odor, and
• condition of the nails and skin.

She takes for granted here that her audience of nurses knows what signs to look for and what to do if they are found; specifying them for reference for MTs would be a very valuable POEM sub-project, and I'm putting it on the to-do list.

Contraindications for massage

She advises that the presence of any of the following conditions are contraindications for foot massage:

• skin lesions,
• blood clots,
• fractures,
• or extreme arthritic pain.

This is not an exhaustive list, but they are the ones she mentions.

Pre-massage foot care

Joachim recommends using warm water to clean and soak the feet before beginning the massage. While this is not specifically out of scope for an MT, it's not the usual practice outside of a spa, and it may not be common practice in most spas, apart from other foot care, either.

Remember that Joachim is working with ill patients in a hospital, rather than healthy young clients who are going to get up from the table after you are finished massaging.

It's easier and less complicated for an MT to skip this part of Joachim's routine. If you did decide you wanted to offer this as a service as part of your massage, it's vitally important that you are clear on both of the following points:

• Make sure that your massage area and your practices protect your patient against slipping on the floor.
• Make sure to dry the foot surfaces and in between the toes well and thoroughly to protect against fungal infection.
• Make sure that anything you offer in the way of washing or cleaning your client's feet fall squarely within your scope of practice in the regulations governing the area or region in which you practice.

NEVER:

• Offer to trim the client's toenails, unless you are specifically trained in another field, such as beautician or nurse, and you are practicing as a member of that field. MTs do not have the specific knowledge and training to safely cut toenails for members of the public, especially in conditions that may be found in ill or elderly clients. Joachim's advice on nail-trimming is meant for nurses, and is totally out of scope for us MTs.

Positioning for foot massage

Joachim instructs the nurse to help the patient find a comfortable position, usually lying supine in bed. She advises putting a small pillow under the patient's knees to create a pelvic tilt, a standard technique taught in massage schools. She also recommends a pillow under the head, as her patients usually are in a hospital bed rather than a massage table.

She advises standing at the foot of the bed, although the patient may want to sit, and in that case, sitting and supporting the foot on your knees is a good position for foot massage.

Preparation for foot massage

In my experience, the warning not to touch a client with cold hands is widely taught in massage school, and Joachim advises washing your hands with warm water before touching. This is good advice if you have access to a sink; if you don't, you can also rub your hands together briskly, although that method seems to be less effective.

Joachim recommends centering as a way to promote your ability to pay attention to your client. She describes the technique of centering in this way:

Take a moment to achieve a calm feeling and block out external problems; this is called centering. This necessary step enables you to give your full attention to the patient and to the work of massage.

She stresses the need to be attentive to feedback from the patient during massage about what feels good and what doesn't. In my experience, this checking-in and watching for verbal and other bodily cues is taught fairly standardly in massage schools.

Her advice not to initiate a great deal of conversation with the patient during massage, but to be prepared to respond appropriately if a patient gains any benefit from talking, is also consistent with what MTs learn in school. 

She recommends rubbing lotion or baby oil as a massage lubricant between your palms, and holding one foot

gently but firmly to let the patient feel your presence before you begin.

Foot massage sequence

1. Hold the foot in both hands; Joachim advises "gentle but firm" pressure.
   
   (image posted provisionally while obtaining permissions)
    
2. Make thumb circles over the entire sole of the foot.
   
   (image posted provisionally while obtaining permissions)
    
3. Use your fingers to spread out and stretch the skin of sole at the ball of the foot.
   
   (image posted provisionally while obtaining permissions)
    
4. Holding the foot in one hand, use the knuckles of your other hand to stroke the sole up and down the length of the foot.
   
   (image posted provisionally while obtaining permissions)
    
5. As you did in the previous step, use one hand for support, and work with the other hand.
   
   This time, you'll use the support hand to stabilize the base of each toe in turn, while using the work hand to rotate that toe back and forth.
   
   As a nurse, Joachim uses the opportunity this part ofthe routine provides to look between the toes for signs of any conditions that need to be attended to.
    
6. Once again, you'll use one hand as a support hand to lift the foot very slightly, enough to get your work hand underneath.
   
   Use the work hand to cradle and knead the heel and ankle between your thumb and forefinger.
   
   You can also use your fingertips to make circles on the heel.
   
   Here, she makes the point that you can and should use greater pressure on the heel, because this skin is very thick. Remember from our study of the skin that the thickest areas, the sole of the foot and the palm of the hand, have an extra layer of skin, the corneum lucidum, that thinner skin elsewhere on the body does not possess.
   
   (image posted provisionally while obtaining permissions)
    
7. Cradle the foot firmly between both hands for a moment before repeating this sequence on the other side.
   
   (image posted provisionally while obtaining permissions)

Once you've done the massage on one foot, repeat the sequence on the other foot.

Finish the entire foot massage by cradling both feet firmly and quietly before releasing.

In their own words: After the massage

Joachim's description of various ways that patients respond to foot massage contains a great deal of important information:

Following foot massage, patient response varies. Some wish to be left alone to enjoy the relaxed feeling. Some like to walk because "it feels like walking on air." Others, because they feel so cared for and nurtured, want the nurse to stay and be close to them...Having given a foot massage may make the nurse special to the patient and foster invaluable rapport. Using this knowledge therapeutically enables the nurse to meet the patient's needs more fully. For example, an anxious or suspicious man may now trust his special nurse to know that he fears he may never be well again.

She's correct about the power of massage to foster rapport, but a nurse is better trained than we are to handle what can come out of that connection. In my experience, some MTs report that they have received enough training to teach them how to deal with transference, while others report that they haven't had the training they need to cope with situations that have arisen in their practices.

The massage field needs to promote education around these issues, given the power of this connection that Joachim describes.

I've actually experienced how she decribes, in understatement, that massage is "much appreciated" by patients. I've told this story here before, and you can find the original post by clicking on this link.

In 2002, I had a blood clot in my superior mesenteric artery that caused 3 feet of my small intestine to die, requiring emergency resection. Due to complications, including developing fluid around my lungs, I spent almost an entire month in the hospital.

It's hard to describe what it feels like to come so close to death, and then to have to work my way back slowly away from the edge of the cliff. "Alone", "frightened", "vulnerable"--these certainly all were part of it, but they're insufficient to depict the experience. My family, friends, and graduate program were wonderfully supportive, but no matter how much they were there for me, there are some things you just have to go through alone.

While I was in the hospital, I was moved to a floor that had a volunteer MT come in once a week to offer patients a massage. I remember it was Wednesdays when she made her rounds.

The first Wednesday, she came around and offered a free hand and foot massage, which I gratefully accepted. It's not that I was touch-deprived, not exactly--but the touch I was getting in the hospital was almost universally invasive touch--blood draws, infusions of dye for CAT scans, IVs for feeding and painkillers. Although there was lots of touching, I was definitely "good touch"-deprived. Her simple offering of a hand and foot rub turned into one of the best experiences in my life.

The next Wednesday, she returned, and once again, it was the high point in a week that had very few other good experiences.

The next Wednesday, I waited eagerly, my anticipation heightening from minute to minute for another of the massages I had grown to love. When it finally dawned on me that she wasn't coming this time, I cried and cried inconsolably.

Let me be 100% absolutely clear on this point--she did nothing wrong. She had not promised me that she would be back the next Wednesday; she did not stand me up. I am not reproaching her for anything she did at all.

It was only in my own head that we had an appointment that day. I had become used to her coming around on Wednesdays, and--because there was so little else good in my immediate daily life at that point--I had grown dependent on her being there for massage.

She did absolutely nothing wrong at all--but because I remember how absolutely crushed I felt when she wasn't there that last Wednesday, I've begun taking extra steps in the clinic to make sure that--in addition to doing nothing wrong--I actively do something right.

The point of that story is that I grew to need and depend on a simple hand and foot massage so much that I am very careful about letting hospital clients/patients, with no specific massage appointments, know whether to expect me from week to week. That crushing disappointment I felt is how valuable and meaningful that gesture had become to me, as I lay in that bed.

The paradox of what she calls the "essential nonessential function" of massage is just that value and meaning. Although it's not a life-saving measure in the strict sense of "essential function", never underestimate how much you have to offer to clients and patients through the simple and straightforward act of providing a great foot massage.

 

In my case, the nerve damage from a roadside explosion causes me to develop numerous trigger points in the muscles of my back. I have to get injections to relieve them--anywhere from 16 to 20 injections per week for three consecutive weeks, and they usually return within three to four months.

I know massage treatment has definitely improved my quality of life and overall comfort when I have been able to afford it. But since most massage therapists in my home area charge anywhere from $80 to $150 per one-hour session, it is a financial burden that is extremely hard to bear on a fixed disability income.

--"K.", 25 years old, Iraq war veteran