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


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

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

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

Event: Veterans Appreciation Dinner

Date: Saturday, 18 May 2013 

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

Location: TBD

Tickets for dinner available at: TBD

Signup for chair massage available at: TBD

 

 

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

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

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

Many of us who attended junior high or high school in the United States had to read and analyze "The Road Not Taken", a poem published in 1916 by Robert Frost.

It reads:

1. The Road Not Taken

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

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

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

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

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

 

 

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

 

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

 

 

 


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

 

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

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

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

 

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

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

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

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

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

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

 

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

 

 


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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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!

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

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

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

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

 

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

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

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

 

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

 

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

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

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

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

 

 

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.

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

Avoiding the perception of impropriety (#6/31)

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

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

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

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

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

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

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

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

 

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

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

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

 

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

 

 

 


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

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

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

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

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

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

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

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

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

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

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

 

 


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

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

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

What is biopsychosocial massage?

Several other people have contributed greatly to my thoughts on the topic of biopsychosocial massage, and a really profound discussion along those lines is currently going on in a social media group that I'm a part of.

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

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

I promise you that I will pay it forward.

 

 


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

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

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

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

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

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

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

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

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

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

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

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


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

 

 

 

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

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

Can I write 31 blog posts in 31 days?

 

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

 

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

 

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

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

 

 


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

One of the most famous lines reads:

מי שהציל נפש אחת - כאילו הציל עולם ומלואו

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

--Talmud, Sanhedrin 37a accessed 5 August 2012

 

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

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

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

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

 

 


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

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

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

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

 

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

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

What we can do is:

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

 

 

 


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

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

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

--MTBoK pp. 27 accessed 5 August 2012

 

 

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

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

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

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

--MTBoK pp. 27 accessed 5 August 2012

 

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

Two important things that you would look for are:

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

 

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

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

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

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

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

 

 


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

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

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

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

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

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

 

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

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

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

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

It's just that important.

 


 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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