Massage Tales, Oncology Massage, Thoughts on the profession

What Did You Notice?

She’s a climber, a dancer, a multi-sport athlete.* She biked to the clinic and will most likely go to a yoga class on her way home. She eats clean, but she’s not obsessed about it or anything. She will eat a piece of birthday cake or a cookie when she wants to.

She is healthy, and she is doing everything right. I say that every client is the expert on their own body. She is the expert-archetype. She knows her body so well, takes such excellent care of it, that she found her melanoma before it was much more than a spot just beginning to touch the dermis, the layer underneath the top layer of skin.

After the massage, as I hand her a cup of water, she stretches her shoulders and looks at me, earnestly. “What did you notice?” she says.

I stammer for a moment, surprised. What did I notice? She lives so fully and attentively in her body, I wonder why she even wants to know what I might have noticed. It seems more appropriate that she tells me what she noticed, that she educate me on how best to support and care for her.

She looks at me, that direct gaze, with the question still in her eyes. She wants something from me, something that I am not sure I even know how to give. She wants the report card.

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The report card is the after-appointment summary, where the massage therapist lists all the spots of tension, adhesions, tightness, or just plain wrong-ness that they felt in the client’s body. Supposedly, it is a tool to encourage repeat visits and to begin documenting the effectiveness of massage for this person.

I was trained to give the report card after a massage, even though it always felt wrong to me. First of all, every client will have extensive direct experience of their body and how it feels and functions. Even if I work with someone for years, I will only have a fraction of the embodied information each client has about themselves. Secondly, as the provider of the massage, it is my job to receive a report card, not to give one. I’m not here to rank or rate any human body. I’m here to support, to love, and to learn.

She won’t give up, though, this client of mine. It is a quality which makes her an excellent athlete. I suspect she was also a good student, since she seems to be following the same massage training book I was given years ago. That book includes the report card. This box must be checked before we can call the massage complete.

So, what did I notice?

I spread my hands wide. “I noticed your breathing, the rhythm of it. I noticed your pulse as I massaged your hand. I noticed that you move with ease.”

She raises her eyebrows, just a bit, then draws them close together. The vertical line between her eyes quivers a bit as she tilts her head to one side. There will be no demerits, no suggestions for improvement on this report card.

She keeps her quizzical expression as she leaves. I peek out my office door and I see her pause and shake her head at the bottom of the stairs.

I’ll be honest — I’m tired of the assumption that any interaction with a health care provider or wellness professional ends in a list of instructions on how to be a better, more complete human. I’m tired of leaving every doctor visit, massage appointment, or acupuncture treatment with a list of where I went wrong and how to correct it. I think some clients might be tired of that too.

What would happen if we started with the assumption that the human in our care is already complete? What if we also acknowledged that they are the expert on their own experience? And what if, maybe, we led with humility and curiosity, keeping expertise for later, after our client has had a chance to educate us?

What would happen if we threw out the report cards? I hope that on the other side of report cards is a land of real conversation and exchange of information, as equal partners working towards the same goal.

*- This client is a composite of several different individuals. All identifying information has been removed.

Inner World, Thoughts on the profession

Interoception

I am committed to making this blog, this website, a safe, neutral space, free of partisan ranting. I have plenty of safe places to rant in my life, and I need all of you to feel welcome in my space.

I also don’t think having agency over all aspects of my body is a partisan issue. That seems like common sense to me. So here we go:

Today I am thinking about what happens when we give over (or have taken from us) full control of our bodies. What, from a physiological perspective, happens when we are not able (or allowed) to fully sense what is going on inside ourselves? And (because the mind and body and spirit are all connected) what happens to our emotional life?

Interoception is our sense of what is going on inside our bodies. This is one of the senses we use to interact with and interpret the world. Interoception is the sense that tells us when we maybe should not have eaten at the sketchy buffet, or that we’ve probably had enough caffeine for the day.

In addition to physiology, interoception helps us associate bodily reactions with emotions. This is the sense that helps you associate your racing heart with either the terrifying new boss or the delightful new love.

Interoception can be so easily interrupted by outside forces, and by the workings of our own minds. How many times have you ignored that prickle at the back of your neck because it seemed “silly”?

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Every time this happens, our sense of interoception takes a hit. It may not seems like much, but this sense plays a key role in identifying and regulating emotions. According to research published in Frontiers in Psychology, “There is compelling evidence demonstrating links between poor or disrupted awareness of sensory information, or interoceptive awareness, and difficulties with emotion regulation.”

Meaning, if we keep denying the evidence of our own bodies, we run the risk of losing it. More or less.

There’s a lot of talk lately (still, for as long as I can remember) about the proper use and care of bodies like mine. Uterus-having bodies, specifically. I am fortunate to have the support and practice to hear this talk and let it fade away. I have over a decade of massage therapy training and work that taught me to trust the evidence of my own body.

Today I’m thinking about those who don’t have that good fortune. Those whose bodies have relentlessly been under attack — wrong size, wrong color, wrong shape, wrong place, etc. I see you navigating through the world that wants to transplant your interoception with someone else’s, and I am in awe of your resilience.

Today, I just want to say that if you need a safe space to listen to and make peace with the wisdom of your own body, I am here. My office is quiet and my door is open.

Thoughts on the profession

The Other 40%

I recently got back home from the International Massage Therapy Research Conference in Alexandria. If you’re not familiar, basically this is a nerd conference where massage therapy nerds can nerd out together. It is exactly up my alley, and I left feeling mostly inspired, energized, and just a little bit smarter.

On the surface, most of the conference was about pain. Chronic pain, the opioid epidemic that grows from (mis)treatment of chronic pain, the efficacy of massage as a treatment for all kinds of pain. For me, however, one other theme emerged from the conference, and that theme was: Health Equity.

During the first panel, three presenters talked about integrating massage therapy as a way to address the opioid epidemic. The first presenter threw out a sentence or two about cost, and quickly moved on to other things. The second presenter talked about integrating massage therapy and other integrative practices into the VA healthcare system, and the positive results that followed.

Yay, massage, right?

But as I sat there, I grew more and more uncomfortable. What about people who didn’t have access to either money or the VA healthcare system? What about the many (many) people in chronic pain who don’t have the extra income to spend on massage therapy, or other integrative practices that are not included in health insurance? What about the many (many) people in chronic pain who have no health insurance?

I struggle with this at some level almost every day. I am a sole practitioner, trying to make my living with a private massage practice. I do not take insurance, for a number of reasons. My services are out of reach for some people. I have an uneasy compromise, in that I offer a sliding scale to anyone who tells me they need it. But still, just the location of my office puts me out of reach for some people who don’t have access to a care.

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And, being a human, I do not want to suffer this dilemma alone. I want the entire massage therapy profession to spend more time thinking about equity, about creative ways to make our services available to more people.

Let me clear: I am not talking about volunteering. The truth is that we live in a world that often equates value with money. The things we value are the things we pay for, and in order for massage therapy to be valued, it needs to be paid for. We are healthcare professionals who should be compensated, just as a physician, physical therapist, or nurse practitioner would be compensated.

Later in the conference, one of the speakers put up a colorful pie chart which showed the factors that really influence health outcomes. In her chart (and others I have looked up since,) clinical care (doctor visits, etc.) accounts for only about 10% of health outcomes. The largest pieces of the pie chart were health/lifestyle behaviors (30%) and socioeconomic factors (40%.)

Socioeconomic factors. 40%.

The speaker completely ignored this part of the chart. It sat there on the giant slide projected over her shoulder, and she didn’t mention it. Instead, she spent about a third of her presentation talking about health behaviors, and the influence we could have on these behaviors.

I get it. It feels good, and doable, to talk about influencing smoking cessation or encouraging movement. We can wrap our heads around health behaviors.

Socioeconomic factors are big and tough and scary. To really look at these things, we have confront things like institutionalized racism, housing disparities, and a long American history of devaluing humans based on their perceived otherness. We may even have to confront our own unconscious biases and prejudices. It will get messy, and there will be no such thing as uncomplicated success.

But we ignore that 40% of the pie at our peril, and the peril of our fellow humans. As several of the speakers at the conference said, we don’t just have an opioid epidemic in this country. We have an epidemic of epidemics. Pain. Opioids. Dysfunction. So many ways that people are suffering, often needlessly.

I have been reviewing the Health Equity Report for Louisville. In most of the report, the maps for different diseases are darkest in areas of economic disparity. We can not, must not, ignore this. It is inspiring to talk about integrating massage into total care, to research the effects of integrated care, but if we do not also consider how to bring integrated care to those darkly shaded areas of the health equity map, we are just watching ourselves move around a mirrored funhouse.

I don’t have an answer. Right now, what I have is frustration and emerging awareness of my own blind spots. Also, a resolve to never unsee what I am seeing now. I am seeking to educate myself, to listen, to work even more with groups who are trying to address health inequity in my own city.

I have no answers, just open eyes and ears willing to listen. So, tell me, what do you think we can do to address health inequity in our neighborhood?

MLD, Modalities, Oncology Massage, Thoughts on the profession

Absolutely Maybe

I have spent the weekend at a conference doing one of my favorite things — talking to other nerds about nerd things. The weekend started with discussion of the adaptations of lymphatic drainage protocols for specific types of plastic surgery, and ended with speculation on the titles of our future TED talks.

Mine is: “The Metaphor is Everything.”

But that’s not what I wanted to talk about today. Today I want to talk about certainty. Or, more accurately, capital-C Certainty.

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The end of the first day of the conference featured a panel of super smart guests, ready to talk about their particular view of oncology massage. It was a house tour of the neighborhood where you’ve always wanted to live — a chance to peek into the day-to-day lives, the medicine cabinets, and the private closets. (Metaphor. See what I mean?)

The first speaker made an entrance. She strode out from the wings of the stage and solemnly said her name and her specialty, then went on to spend her allotted time sharing images and stories of her work. I found the images and stories fascinating. I found her approach challenging.

After she introduced herself, she talked about the specific training she received, similar to mine, as it turns out, and talked about the danger of deviating in any way from the tenets and protocols of that training.

Here is where I admit that I have been deviating from the tenets and protocols of that training pretty regularly. I have a whole new kind of clientele — young, healthy people recovering from plastic surgery. For them, the exact protocol is often not as effective as some critically reasoned deviations.

I found myself becoming more and more uncomfortable as she spoke. She has been doing this a long time. She has gotten great results with some really challenging cases. She knows what she is doing. She is certain of it.

That is what made me uncomfortable. The certainty of it.

There are so many things in this profession that we were “certain” of — that massage increases systemic circulation, that mechanical pressure can change certain body tissues from solid to a more pliable gel, that we should never touch people who have cancer. Thank goodness enough open-minded, curious, smart people have challenged these and other certainties and proven them mistaken. Because of these people, who were uncertain, we can reach more people and provide much better care and education about these bodies we live in.

Certainty is a hard stop. It is the period at the end of a sentence and “The End” written at the bottom of the page. Certainty freezes us in time. I don’t want massage therapy to become dusty and desiccated like those life-size dioramas that used to terrify me at the Natural History Museum.

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We are, like the bodies we work with, living and growing. We may be educated, we may be experienced, we may be confident — but I hope, for own future growth and the benefit of our clients, we never become certain.

On Writing, Oncology Massage, Thoughts on the profession

Beyond Stillness

I am currently re-reading The Emperor of All Maladies by Siddhartha Mukherjee. It is a fascinating, novelistic, nerdtastic telling of the history of cancer. There are so many facts and nuggets in it that are buried in the larger story, and are breathtaking in their own right. Today, I am thinking of one of those nuggets.

In my edition of the book, Mukherjee states (somewhat erroneously) that the root of the word “metastasis” means “beyond stillness.”

Let’s put aside, for the moment, the actual root of the word, and consider the breathtaking poetry that is “Beyond Stillness.”

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Metastasis, as we currently understand it, is the movement of a disease from one part of the body to another. In cancer land, this can exponentially increase the dangers of a particular disease process. Every cancer patient hopes to be free of metastasis, leaving the rest of their body intact and functional. (As much as it can be after systemic treatments like chemotherapy, anyway.)

We shorten metastasis to “mets” in talking about progression of cancer. Breast cancer with bone mets. Lung cancer with brain mets. This short, sharp, easier to say word that contains within it layers of fear, anxiety, and potential physical pain.

Which brings me back, to beyond stillness. With cancer metastasis, the disease has moved beyond the stillness of a body at rest in wellness. It has moved beyond the stillness of an in situ tumor which yields obediently to removal or treatment. The disease moves beyond stillness into a kind of strobe light-illuminated motion, where the confirmation of movement comes through the flashes of a PET/CT scan.

And what exists beyond stillness?

Is it the growth of the opposite, a kind of frantic and endless motion that never quite rests, never quite allows the body to rest?

Or can we find, beyond stillness, another level of stillness — something even more quiet? Is the movement beyond stillness like the movement from the parking lot at the top of a hiking trail to the spot a mile or so down the trail, where all the city noises are erased and the senses can expand into this new space?

The simple etymology of metastasis, mistaken though it may be, leads to a particular kind of poetry. This is the poetry of words that lead into a compassionate and loving meditation on life, disease, and death. This is the poetry of breathing and being in a vulnerable, human body.