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Respect for others

Massage in a biopsychosocial model

[reposted from Massage in a biopsychosocial model (#29/31)]

 

 


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

What Seth said

Seth Godin writes, on the natural human tendency to deny facts we don't like:

The problem with Orwellian talking heads, agitprop, faux news and Ballmer-like posturing is that they take away a foundation for a genuine movement to occur, because once we start denying facts, it's difficult to know when to stop.

 

Still, it's understandable--when reality seems overwhelming, the temptation to deny that reality, and avoid the pain of dealing with it, can be very strong. Barrett Dorko also has an excellent take on that phenomenon and this article, over at SomaSimple.

We've got a lot of massive problems in massage--for example, at the same time that we have the chance for a place at the healthcare professional table under Obamacare, and that we say we want to be taken seriously as professional members of the healthcare team, our major credentialing organizations grant recognition to courses that take money for teaching claims like "body cells carry emotional memory", "craniosacral therapy moves skull bones", and "all past traumas are stored in the fascia".

Anyone who had a decent education in anatomy should be able to debunk those claims after the first day of the first class.

Yet our major professional organizations visibly sanction the teaching of claims like these and grant CE credit for them, at the same time we say we want to be real healthcare professionals.

Our walk doesn't match our talk, and the problem's not going to go away just because we refuse to face it.

If we refuse to face it and discuss it in a civil and professional way in an attempt to reach solutions, history's going to make us eat the decisions that others make for us about these problems.

And if we claim we want to incorporate the latest neuroscience findings into massage as a healthcare profession, and we start that process off by being Neurophysiology 101 denialists, how, exactly, is that supposed to work?

No one's denying the fact that this shift to accepting facts and material physical reality is going to cause a great deal of disruption and moral distress. The world has entirely shifted out from under us, and the old social contract that we were comfortably used to just does not work any more.

That fact is going to cause an unforeseeable amount of pain and distress, and we need to be extra kind to each other as a result.

But denying reality is not a sustainable choice anymore, and the only real question is whether we'll make the change in time to make use of these new opportunities, or whether our process will make us too late to accept the invitation, and we'll totally miss out.

Godin provides an aspirational ideal to assist in that process:

Transformational leaders don't start by denying the world around them. Instead, they describe a future they'd like to create instead.

 

We can't change the larger universal material physical reality that confronts us. What we can change is how we react to it, and that reaction--what we commit to--will sow the seeds for the future we want to create.

Source: "13 Plus Myths of Massage Therapy", by Lee Kalpin RMT http://www.massagetherapypros.ca/wp-content/uploads/2012/03/Myths-of-Massage-Therapy.jpg accessed 3 October 2012

Sometimes evidence shows that the old ways actually are the best

While cherry-picking--the act of suppressing evidence that doesn't support our own particular biases--is something to be avoided, berry-picking, on the other hand--carrying out our searches for information in a way that is not strictly linear and that incorporates cognitive questions, by allowing those searches to evolve and change in response to what we initially come across--is not only to be encouraged, but can be absolutely delightful in the unexpected directions it leads us.

This morning, berry-picking took me in a most unexpected direction. On the way to looking up something else, I came across this:

Risks of consuming fermented foods

Alaska has witnessed a steady increase of cases of botulism since 1985. It has more cases of botulism than any other state in the United States of America. This is caused by the traditional Eskimo practice of allowing animal products such as whole fish, fish heads, walrus, sea lion, and whale flippers, beaver tails, seal oil, birds, etc., to ferment for an extended period of time before being consumed. The risk is exacerbated when a plastic container is used for this purpose instead of the old-fashioned, traditional method, a grass-lined hole, as the botulinum bacteria thrive in the anaerobic conditions created by the air-tight enclosure in plastic.--Wikipedia, "Fermentation: Risks of consuming fermented foods accessed 3 October 2012

 


Slightly off-topic, but interesting (I think!), in a berry-picking way, since we care about calling people by the names they want to be called: Did you notice that the paragraph used the word "Eskimo", and did that perhaps seem a little strange to you, because you've heard that you shouldn't use the term "Eskimo" when you mean the Inuit people, since the word is derogatory or pejorative or insulting?

You're not wrong, if you remember hearing that--the word "Eskimo" probably does, historically, have connotations that are belitting and insulting, and Native American and First Nations people have spoken out explicitly and firmly against the use of the word.

At the same time, there is no good inclusive replacement term that includes the Yup'ik peoples of Alaska--if you just say "Inuit" instead of "Eskimo", that's fine if you mean only Inuit people and no one else.

But if you mean Inuit people together with Yup'ik people, then there really isn't a well-known acceptable term that means both. So often, you will see Alaskan Native American (more so) and Canadian and Greenlandic First Nations and Inuit people (less so, or maybe even not at all, per Lee Kalpin's comment following this post) compromising, and using the term in order to be inclusive, despite the connotations that go along with the word.

 


What's happening in Alaska?

Alaska has witnessed a steady increase of cases of botulism since 1985. It has more cases of botulism than any other state in the United States of America.--Wikipedia, "Fermentation: Risks of consuming fermented foods accessed 3 October 2012

 

Botulism is a condition that paralyzes people and animals who eat food contaminated with botulin toxin, or who have an open wound through which the bacteria that produce the toxin (Clostridium botulinum) can enter the body. C. botulinum is an obligate anaerobic bacterium, meaning that it is obliged to grow in an environment without air--oxygen is deadly to it.

VERY IMPORTANT WARNING

This is why you absolutely never, under any conditions at all, give honey to babies under 1 year old--they don't yet have the immunity to fight off the bacteria that produce the toxin.

After 1 year of age and older, people can fight off the actual C. botulinum bacteria themselves, so the bacteria can't gain a foothold in their systems to begin pumping out the toxin.

But if the neurotoxic poison produced by that bacteria has already contaminated the food somehow--as opposed to the bacteria themselves--then that toxin can produce botulism in anyone.

 

Facial paralysis which spreads through the body is a typical symptom of botulism; very bad cases can actually cause death by paralyzing the muscles needed to breathe.

The 14-year-old in these pictures from Wikipedia show the paralysis that's typical of severe botulism. Although he appears dead, he was actually fully conscious, yet unable to move. His eyelids were drooping and his eyes were paralyzed, and the pupils were fixed and dilated. We hope he made a full recovery--Wikipedia doesn't tell us how his story turned out--but even if he did, it would require a long, slow, difficult path to rehabilitation.

 

"A 14-year-old with botulism. Note the bilateral total ophthalmoplegia [paralyzed eyes] with ptosis [drooping eyelids] in the left image and the dilated, fixed pupils in the right image. This child was fully conscious."

Source: http://upload.wikimedia.org/wikipedia/commons/b/b4/Botulism1and2.JPG accessed 3 October 2012

 

From 1950 to 1997, 105 confirmed outbreaks of foodborne botulism involving 214 persons occurred in Alaska (there were no confirmed cases during 1947-1949)...All cases occurred in Alaska Natives. The average annual incidence among Alaska Natives increased from 3.5 cases/100,000 population during 1950-1954 to 10.7 cases/100,000 during 1995-1997 [in other words, right about 3 times as many cases as you'd expect, based on history].--State of Alaska Public Health Epidemiology Report: Botulism in Alaska--A Guide for Physicians and Health Care Providers, 1998 Update accessed 3 October 2012

 

Source: State of Alaska Public Health Epidemiology Report: Botulism in Alaska--A Guide for Physicians and Health Care Providers, 1998 Update http://www.epi.hss.state.ak.us/pubs/botulism/fig_1.gif accessed 3 October 2012

 

The Rose Urban Rural Exchange, in its own words, "aims to strengthen relationships between urban and rural Alaskans by building mutual respect and understanding, and fostering a statewide sense of community through cross-cultural immersion.".

They have a website where they promote cross-cultural understanding by presenting pictures and reports of daily life, festivals, and other events.

In a post, "The Best of the Whale", one of their writers, Bogdan, presents pictures from Ilisagvik Inupiaq Culture Camp, where elders and others share a meal of traditional foods.

Notice the blue plastic container, and the Ziploc plastic bags--we're going to get back to those in a moment.

 

Source: http://ecci-2012.s3.amazonaws.com/thumbs/20120814_ecc_grp_iic_awi_70_502ab33f88f97.JPG.poster.jpg accessed 3 October 2012

 

Bogdan describes the scene:

The most desirable food served at the blanket toss festival is fermented whale meat and blubber (mikiaq). Elders particularly like mikiaq, because it is easy to chew. To keep the audience interested and at the site, mikiaq is served last, after all the other food items have been distributed.

 

Mikiaq is

raw whale blubber that has been left to soak and ferment in the whale's blood.

 

Fermentation occurs when, under anaerobic conditions (reduced or no oxygen), you convert sugars (carbohydrates containing carbon [C], hydrogen [H], and oxygen [O] atoms as building blocks) like the kinds of glucose here:

Source: http://upload.wikimedia.org/wikipedia/commons/0/06/DL-Glucose.svg accessed 3 October 2012

 

 

 

into ethanol, the kind of alcohol in drinks such as beer, wine, and spirits, a process which rearranges those atoms into this arrangement:

Source: http://upload.wikimedia.org/wikipedia/commons/3/37/Ethanol-2D-flat.png accessed 3 October 2012

 

Greenlandic to English Dictionary

nuna iterssaliorpâ: digs a hole in the ground, p. 180 (Old orthography)

qasaerdlâq: a seal which has been put by whole and left to ferment, p. 211 (Old orthography)

 

Back in the old days, fermenting the mikiaq was accomplished by digging a hole in the ground, and leaving it there for as long as it took the process to occur naturally.

Nowadays, just like most of the rest of us reading this, circumpolar peoples have access to modern conveniences like the blue container and the Ziploc bags you saw in the photo from the festival.

Plastic bags, containers, and utensils, no matter how bad they are for the environment, have some convenient qualities that make them so widespread in food preparation. One of those properties is the ability to keep food fresh for longer periods of time.

It does this by sealing the food away from exposure to air that would cause it to decay faster. In other words, it promotes an anaerobic environment.

And that's where the connection to the increased cases of botulism lies.

This is caused by the traditional Eskimo practice of allowing animal products such as whole fish, fish heads, walrus, sea lion, and whale flippers, beaver tails, seal oil, birds, etc., to ferment for an extended period of time before being consumed. The risk is exacerbated when a plastic container is used for this purpose instead of the old-fashioned, traditional method, a grass-lined hole, as the botulinum bacteria thrive in the anaerobic conditions created by the air-tight enclosure in plastic.--Wikipedia, "Fermentation: Risks of consuming fermented foods accessed 3 October 2012

 

Fermentation in a grass-lined hole, while still an anaerobic process, is less efficient at keeping the oxygen out, since air will circulate in and out of the hole and between the blades of grass. The C. botulinum bacteria have to overcome the deadly oxygen in that air, if they are going to establish a strong enough foothold to produce enough neurotoxin to make the mikiaq dangerous to the people who eat it.

A plastic container, on the other hand, does a much better job of keeping out the oxygen. Less oxygen in the container means a more welcoming environment for C. botulinum, where they can start to churn out neurotoxin.

As plastics have come into wider and wider use in the general population, and as they have made their way to more remote areas, where the convenience appealed to people, they took the existing risk of botulism, and--by providing a better anaerobic environment--sent the cases of botulism much higher than had been the case when mikiaq used to be fermented in the traditional grass-lined hole.

 


What all this means is that--contrary to what you may have heard--evidence-based practice does not mean that you have to give up traditional practices just because they are traditional, and adopt modern practices just because they are modern.

It means that instead of a top-down simplistic rule-based approach (either "Old = Good! New = Bad!": the "Argument from antiquity" fallacy, or the other way around, "Old = Bad! New = Good!": the "Argument from modernity" fallacy), we take a bottom-up approach of examining the evidence itself, and then deriving more nuanced and accurate rules that we can turn around and apply. Which, in turn, means that everything, traditional and modern alike, gets examined to find out:

  • what works in the way it claims to,
  • what doesn't work in the way it claims to, and
  • the mechanisms for why that is the case.

 

Once we better understand the answers to those questions, we can better decide which practices fit better into our client-centered model of service, and why they do so. This example was a perfect demonstration of how sometimes evidence supports the traditional practice as objectively better, as measured on the basis of outcomes (number of cases of botulism), than the modern practice.

 

Source: http://upload.wikimedia.org/wikipedia/commons/e/e2/PSM_V37_D324_Greenland_eskimo.jpg accessed 3 October 2012

What Seth said

Denying reality is not a sustainable choice anymore, and the only real question is whether we'll make the change in time to make use of these new opportunities, or whether our process will make us too late to accept the invitation, and we'll totally miss out.

Godin provides an aspirational ideal to assist in that process:

Transformational leaders don't start by denying the world around them. Instead, they describe a future they'd like to create instead.

 

We can't change the larger universal material physical reality that confronts us. What we can change is how we react to it, and that reaction--what we commit to--will sow the seeds for the future we want to create.

Massage in a biopsychosocial model (#29/31)

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)

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!

Looking into the abyss (#26/31)

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

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

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

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

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

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

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

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

  1. Employ unqualified instructors.

...

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Silence is not always consent (#25/31)

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.

Everyday science in the world around us: Making chocolate (#24/31)

There is no better, there is no more open door by which you can enter into the study of natural philosophy than by considering the physical phenomena of a candle.--Michael Faraday, The Chemical History of a Candle

 

Michael Faraday was right. Everywhere we look, the world around us contains so many possibilities for understanding natural philosophy (the old name for science), because we use it in our lives in so many ways every day.

Faraday was focused on the numerous processes at work in a candle; we're going to take the same approach in a somewhat different venue. And if, in addition to reading along, you replicate the steps described here, at the end, you're going to have a treat to reward yourself with.

Interestingly, you can find chocolate massage at some spas, so there is actually an even more direct connection between chocolate and massage than we're exploring here.

Source: http://thedailybasics.com/wp-content/uploads/2012/02/chocolate-massage-tineye-marriot.jpg accessed 24 August 2012

 

Our connection to it here in this post is just as a very nice part of the larger material physical universe that we're engaged in; maybe we'll talk about chocolate massage some other time.

 

 


Making vanilla-cream-infused chocolate balls

To make chocolate balls, we have to decide what we're going to do about their inside and their outside.

For this recipe, we're going to have a ganache inside--a smooth, soft mixture of chocolate and cream, infused with fresh vanilla.

The outside will be, for simplicity's sake, premade hollow chocolate shells. The reason I'm going premade on this is that I don't want to discuss tempering chocolate yet--that's a big enough topic that I want to treat it later on its own.

Here are all the ingredients that I'm going to use in this recipe.

The cream in the background, and the chocolate buttons in plastic bags and the vanilla pod lying on a saucer in the foreground are going to become the inside of the chocolate balls.

 

The hollow chocolate shells lined up in plastic trays in the center of the picture are going to become the outside of the balls. I buy mine at a nearby chocolate store; depending on where you live, this may or may not be an option.

Later, we're going to talk about how to make them entirely from scratch. But as I mentioned, there is enough to learn about that process that I want to get back to it later, so that we can quickly get to making some confections now.

Ingredients to start:

  • 8 ounces chocolate buttons or other kinds of chips or shaved or chopped chocolate for the ganache
    • Either dark or milk is ok, whichever you prefer. White may work every bit as well as milk or dark does, but since I don't have very much experience with white chocolate, I can't speak to it out of real experience.
    • You don't have to seek out buttons, but you do want as much surface area (the "amount" of exposed surface [Wolfram MathWorld, "Surface Area" accessed 24 August 2012]) as possible exposed, so that when you add the boiling cream, it melts reasonably evenly. You don't want to pour boiling cream over a chocolate slab. If you start with a block of chocolate, chop it or shave it so that you have lots of smaller pieces, exposing more surface area for the cream to contact.
    • You'll have ganache left over from this much chocolate for other uses--more chocolate balls, cake frosting, other treats.
  • 2 ounces extra chocolate for sealing off the filled chocolate balls
  • 1 cup pasteurized heavy whipping cream
    • This proportion of cream to chocolate is not absolute. When you try it, see what you think about the resulting ganache. If you find it too liquidy, you can fix that by adding more chocolate. If it's too stiff for your taste, you can make it more liquid by adding more cream to  the mixture. This proportion is a good first approximation, but feel free to vary the proportions to get the ganache to be the way you like it.
  • 63 hollow 3/4" chocolate shells
    • 3/4" inch is a very good size, since we're putting a creamy filling inside a crisp chocolate shell. If the person eating the chocolate eats it in two bites, the filling has the potential to leak out (especially later, when we're going to be doing other, very liquid, fillings, such as liqueurs). This small size is convenient for people to just pop in their mouths and eat in one bite, so there's no danger of the filling leaking out uncontrolled.
  • 1 vanilla pod
Microbiology of this photograph

The chocolate in the center and the foreground, for all practical purposes, do not support microbes, and are safe for storing at room temperature. They're best used within 18 months from manufacture, for the sake of taste, but as long as they're stored in a hygienic way, straight chocolate is a very safe food.

The biologicals in this photo, the vanilla pod and the cream, are where any practical risk of food spoilage is going to come in. Before it's been used in cooking, the dried vanilla pod can be stored at room temperature in a dark place out of direct sunlight for at least 6 months--some sources say for up to a year. If it dries out, or has visible signs of stinky mold, then you have a problem, but most of the time, it should stay moist and workable for 6 months.

After you've used it to make a ganache, you can reuse it a few more times, but it needs to be fairly soon--the cream that it is boiled in will determine its remaining shelf life. Before it's ever used, you should store it at room temperature; after boiling it in cream, you should store it in the refrigerator, and any reuse should take place soon after.

The cream is a good source of bacterial growth, because it's a great food source for them, but we're going to thwart that by boiling it, killing any microbes that may have been in it. Of course, others can establish themselves later, so we'll definitely practice safe food handling practices with it. The cream is the most immediate weak link in the food safety chain of chocolate confections, and it's the one around which we'll plan our safe food handling.

The reason I put such emphasis on safe food handling is this: Not only is it a matter of professional ethics; it is also one of respect.

A couple of years ago, I read of a benefit being put on at the Dkhw’Duw’Absh (Duwamish tribe) longhouse cultural center, to raise funds for their legal struggle for federal recognition of their tribal status.

The tribe is suing the federal government for recognition--asking to reverse a 2001 Bureau of Indian Affairs decision that the tribe had gone extinct.

--Duwamish tribe, "Duwamish Fight for Federal Recognition" accessed 24 August 2012

 

I emailed them to ask if they'd be interested in having me set up my massage chair at the event, and donating all money I earned from massage there to the legal fund that the benefit was set up for. They liked the idea, and so I showed up at the agreed-upon day and time.

While setting up my massage chair and learning my way around the center, I talked to others working at the event.

The woman managing the kitchen mentioned that they often used the longhouse dining room to put on philanthropic and other service events, but no matter what the event, anyone working in the kitchen has to have a food-service license that shows they are trained in the basics of safe food-handling. No exceptions.

Even if it's charity, anyone eating there has the right to expect that the people serving them a meal are doing it at a professional level of standards. No one, even at a charitable event, is expected to settle for less-than-professional quality of service.

As the woman explained, "It's a matter of respect.".

It's out of that spirit of respect for anyone that we served food to that I present the food-safety information here. Taste and enjoyment are very important, but keeping each other safe to continue to enjoy it is a foundational principle.

 

 

 


Step 1: Prepare the vanilla for infusion

Vanilla pods are really fruits of the vanilla orchid. The shiny textured pods contain the tiny black seeds of the orchid. We're going to include both the contents of the pod and the pod itself in our infusion.

 

The first step is to slice open on side of the pod and flatten it out. Then you can scrape out the seeds and other contents of the pod. They're seen on the right side of this saucer, beside the knife.

 

The seeds and the pod are going to go into the cream to bring to a boil on top of the stove.

Once the pod is used in this way, it still retains a great deal of flavor. You can reuse the pod 5 or 6 more times, but remember that--now that you have cooked it in cream--you need to store it in the refrigerator, rather than at room temperature, and you need to use it sooner than the 6-month-or-more shelf life a dried pod would have.

 

This is also your opportunity to put other flavorings in the ganache. I've just suggested vanilla here, but you're certainly not limited to that--you can put in other herbs and flavorings, to suit your taste. Your imagination is the limit here, as long as it's something you can safely eat or drink.

 

 


VERY IMPORTANT SAFETY NOTE: Never use essential oils of any quality less than food-grade essential oils for flavoring, whether you're making chocolate or any other food.

Because I as an MT, as well as the MTs in the reading audience, work with essential oils, it is critical that we be very clear on that distinction. We may often use the term "essential oils" to refer to topical products that we apply to clients' skin.

We must always make sure not to confuse the essential oils we use in massage with food-grade essential oils that we use in cooking or other ways of making food--no exceptions at all.

Many of the essential oils that we use in massage or aromatherapy are actively harmful or toxic if eaten or drunk.

Never, ever eat or drink any essential oil unless you are absolutely positive that it is a food-grade essential oil and nothing else. When purchasing it, unless you are absolutely positive from the label, never hesitate to feel free to ask the merchant you are purchasing from if it is food-grade essential oil, and safe to use in food and drinks.


 

 

 

 


Step 2: Infuse the flavorings in the cream

Put the seeds and the pod in the cream (plus any other flavorings if you've decided to use them), and bring them to a boil on top of the stove.

 

 

When the cream comes to a boil, we're going to pour them over the chocolate, so have the chocolate nearby and ready to go when the cream is ready.

 


Step 3: Melt the chocolate in the boiling cream

When the cream is boiling, pour it over the chocolate and stir to mix it thoroughly.

 

 

As the chocolate begins to melt, you'll see small chunks start to appear in the cream.

 

It will get browner and more evenly spread out as the hot cream comes into contact with the surface area of all the chocolate, melting it more and more.

 

When it's thoroughly melted, and you can't see any more white cream visible, then--if all has gone well--the shiny glossy surface of the mixture tells you that an emulsion of liquid melted chocolate suspended (or dispersed) in liquid cream is present.

This emulsion is the completed ganache.

 

Put the ganache aside to cool. Chocolate has a very low melting point; you've probably experienced having chocolate melt from just holding it in your hand. Chocolate's melting point is very close to human body temperature, so you don't want to put this hot chocolate in the chocolate shells right away.

 


Step 4: Fill chocolate shells with ganache

Once the chocolate has cooled to the temperature that you want to work with it at, you'll fill the chocolate shells with the ganache.

 

How do you know that the ganache is at the right temperature? You want it to be cool enough to put in the chocolate shells without melting them, yet not so cool that it becomes solid, stiff, and difficult to work with.

As you're working, you may find that the chocolate grows colder and becomes harder to work with than you want. You can always pop it in the microwave for 15-20 seconds, to make it more liquid again without heating it up too much.

What do you fill the shells with? You can using a frosting piping bag (my teacher's preferred method) or a food-grade syringe (my preference).

Fill up the shell's interior, but only up to the interior rim. You don't want to fill them up all the way, because you need to leave room to add a solid chocolate barrier to seal the creamy ganache inside.

 

 

 


Step 5: Sealing off the chocolate balls

Melt the remaining 2 ounces of chocolate to use to seal off the hole in the ganache-filled chocolate balls.

You can apply the chocolate with a piping bag or syringe to close off the balls in the same way you filled the balls, if you like, but I like to do this part by hand.

Of course, I make sure to wash and scrub my hands thoroughly before this step--20 seconds (time to sing the "Happy Birthday" song twice) under warm water, washing, scrubbing, and rinsing all exposed surface areas of the hand, shows care and respect for the well-being of the people to whom you're going to present these chocolates.

Dry your hands thoroughly before dipping them into the chocolate--not only is that an important part of handwashing hygiene, but you don't want to introduce water into your chocolate.

It sounds funny to say that melted chocolate is a very dry liquid--it sounds like a contradiction in terms. And yet, if you think about what "wet" means, it starts to make sense.

Melted chocolate is the same material as solid chocolate--it has just changed physical state, but there has been no chemical change. It's still exactly the same material.

When it was solid, it didn't have water in it. Adding heat to melt it gives the chocolate molecules energy to get further apart from each other. Because they don't hold on to each other as tightly as they did when it's a solid, it's softer and more pliable. But there's still no water in it, any more than there was when it was solid.

But if you add water to the melted chocolate, a chemical change occurs. It's no longer the same compound as it was, and it's not going to work the same way it did before the water was added.

Joe Pastry's blog shows what chocolate looks like when it seizes.

Source: Joe Pastry, "How to 'Un-Seize' Chocolate" accessed 24 August 2012

 

You can avoid this problem by not letting water get into your melted chocolate.

However, if water does get in, don't panic and throw away perfectly good chocolate!

It can't go on to become tempered chocolate or anything like that, but you can make chocolate syrup out of it by adding more liquid (more water, cream, and so forth). Seized chocolate changes from its original form, but it can be salvaged.

Joe Pastry's blog shows what the process looks like, and you can find detailed directions at the blog itself.

Source: Joe Pastry, "How to 'Un-Seize' Chocolate" accessed 24 August 2012

 

But let's try not to need to salvage the chocolate by not getting water in it in the first place.

After you've melted the 2 ounces of chocolate, you can dip your clean, dry finger in it to dab melted chocolate onto the open hole of the filled shells.

Dab enough melted chocolate to close the hole completely.

 

Remember, pure chocolate doesn't support microbial life. The cream, on the other hand, does, although it's temporarily free enough of microbes, since we boiled it. But other microbes can live in it after it cools, so sealing it off from the outside world, using pure chocolate, protects it from that possibility.

If you seal the ganache off totally, these chocolate balls can be stored safely at room temperature for several days.

 

The melted chocolate used to seal off the chocolate balls wil grow solid as it cools. If you're in a hurry, though, you can take advantage of the fact that changes in temperature can accelerate changes in physical state. You can stick them in the refrigerator or freezer to accelerate the melted chocolate turning solid.

You'll notice that there is unevenness and asymmetery in the finished balls, where I dabbed them with my finger to close them. That's fine; they're homemade--they shouldn't look as perfectly spherical as ball bearings, or as machine-produced chocolates.

 

 

As soon as the chocolate seal is solid, you can eat them, although some people prefer to wait a day or so, as the infusion continues to diffuse flavor in the ganache.

The best flavor is within 1-3 days of making them, although as mentioned, they'll actually last longer than that--either at room temperature, or in the refrigerator.

For serving them, though, the plastic tray the shells come in is very floppy, and can lead to dropping the chocolates.

Before moving the filled and sealed chocolate balls anywhere (whether to the refrigerator to speed up the sealing, or to the table for serving), I always slip a baking tray or other support under the plastic tray, or else I transfer the chocolates to a serving plate. I don't try to move the plastic tray unsupported, as that always ends in tears.

If you try this, I hope you enjoy it, and that you let us know in the comments how it turned out for you.

 

 

 


What flavorings do you like in chocolate?

Did you try making these chocolates?

Please tell us in the comments.

 

 

Are you mandated? (#23/31)

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

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