Julie Onofrio – Massage School Notes

Trauma Aware Teaching Checklist

August 4, 2020August 4, 2020 by Julie Onofrio

This checklist has been prepared for higher educators as a tool to reflect on their teaching and courses, regardless of modality. The six principles of trauma-informed care developed by SAMHSA (Substance Abuse and Mental Health Services Administration) are a foundational concept in the trauma field. In this checklist, they are adapted to the field of education to assist teachers in creating more trauma-aware classrooms. For additional basics on trauma awareness, please view these slides: https://bit.ly/olctraumaslides.

Safety

A sense of safety is a baseline for learning. If we are poised for an incoming threat (whether real or perceived), our systems are built to scan for and prepare for said threat. Higher order thinking will take a backseat to self-protection. Unsafe learning environments are a barrier to teaching and learning. All students will be harmed by unsafe learning environments, but they are particularly damaging for our learners with trauma histories. Trauma strips away our basic sense of safety and of being at home in our bodies. Creating safe and welcoming classroom environments benefits all students and teachers.

Do your students feel safe in your classroom? Do you? Consistently and clearly communicate any safety concerns to your campus leaders and community. Remind them that a sense of safety is a precursor to learning.
We can make assumptions about students’ perceptions of safety. We can also ask them. Have you surveyed your students about how they feel in your class?
Students should not be required or expected to disclose trauma to you in order to receive attention to their safety. Be mindful of how you talk to your students about safety, and let students know that disclosure is their choice. Respect students’ privacy.
Consider that the concept of safety varies for different populations (and within populations). What it takes for a White man in your class to feel safe might be very different than what a Black woman needs to feel safe. If you are from a non-minoritized population, continue to educate yourself and listen to the needs of minoritized communities.
Work with your students during the first week of class to set community guidelines for the course.
Pay careful attention to course discussions, whether online or in-person. Do you have a plan in place to keep students safe while encouraging creative and divergent thinking?
Make clear to students how, when, and why they can contact you to report any concerning incidents in class (including those that arise from your own behaviors).
Your ability to create trauma-aware courses rests heavily on the extent to which you manage your own well-being. Reflect upon the impact of trauma and toxic stress in your life. Trauma is treatable and resources are available.
Read: Racial Battle Fatigue in Higher Education, Chapter 5: “Traumatic Pedagogy: When Epistemic Privilege and White Privilege Collide” by Tapo Chimbganda.

Trustworthiness and Transparency

Can students learn without trusting their teacher or each other? Possibly. But certainly, a trustworthy learning environment is much more efficient in support of the teaching and learning process, in addition to being trauma-aware. People who’ve experienced significant trauma are often hesitant to trust others. They might be particularly wary of trusting authority figures who they may feel have failed them in the past. Working to earn and keep our students’ trust will benefit all learners.

In order to enter into a trusting collaboration with your students, you will need to reveal something of yourself as a fellow human being to them. Michelle Pacansky-Brock’s model of Humanizing is an excellent guide. What humanizing elements are included in your course? Can you add one or two to boost the trust factor?
Trust rests on the truth. The truth is often uncomfortable, sometimes extraordinarily so. Tell it anyway. Tell it to yourself, your colleagues, your leaders, and your students. Make telling the truth a rigorous, serious, daily practice in your life.
Telling the truth does not mean ignoring our students’ needs. For example, when providing feedback on assignments, we can be honest with students about their areas of opportunity without belittling or embarrassing them. Focus on strengths. Be kind and direct. Encourage your students. Quality feedback should leave students feeling hopeful and motivated, not discouraged.
Being trustworthy and transparent includes healthy boundaries. Set clear, consistent, professional boundaries in your relationships. You can be human, real, and honest with your students while maintaining boundaries.
Many of us never learned healthy boundaries in our home environments or elsewhere. If the concept of boundaries is new to you, seek out resources including readings, workshops, and therapy. Develop a working definition of what boundaries mean to you. For me, a boundary is a flexible but firm guideline that I set for myself to guide my choices, relationships, and behaviors. I cannot set boundaries for others because I cannot control anyone’s behaviors but my own.
Be transparent in your decisions about course development, assignments, and grading. Let students “behind the curtain” and invite their feedback when possible. When in doubt, ask your students for their feedback.
If you screw up (and you will, because you are a human being), name it, apologize, make it right, and move forward.
Read: Brene Brown’s “The Seven Elements of Trust.”

Peer Support

You are an expert in your field with valuable information to share with your students. You are a leader in your course. And, it’s also true that your students know things that you don’t know, and they are also potential leaders in your course if you create space for them to step into that role. It is imperative that you create structures for your students to connect with their peers and to lead themselves and one another. This can happen both synchronous and asynchronously in any modality.

Begin the course with ample time for students to connect with one another. This might happen in an introductory discussion or activity. Prioritize connections over reviewing the syllabus. Put first things first.
In an online course, consider a tool like FlipGrid or VoiceThread to allow students to see and hear one another, if they so choose. But remember, forcing students to be on camera is not trauma-aware.
For online students, synchronous sessions can be a powerful tool to build peer connections. Use them mindfully, and create options for students to engage with you and one another.
For BIPOC learners, LGBTQ students, and learners with disabilities, the opportunity for peer connections may be even more critical to their success. Does your course acknowledge the needs of these populations? Consider connecting these students to campus groups or resources outside of your class. Post that content in a course toolbox for easy access.
Encourage (but don’t require) students to find a course “buddy” with whom they’ll exchange contact information. This is especially important for online students who can be prone to isolation.
Whether or not you choose to tackle formal group assignments, have students working with their peers regularly.
Read: Sharing is Caring: 50 Collaborative Google Apps Activities.

Collaboration and Mutuality

The old model of higher education teaching was that of a sage on the stage. The professor might have even stood behind an actual podium, communicating a sense of distance and separation between them and their students. They were the only leader in the classroom, and students were often seen and treated as beneath the teacher. Most educators are now moving away from this rigidly hierarchical model toward a more collaborative, learning-centered approach.

Reflect on your philosophy of education. To paraphrase Yeats, do you see teaching as the filling of a bucket or the lighting of a fire? Or perhaps, the creation of space for students’ existing fires to burn more brightly?
Review your course and note places where students have input on course content, discussions, and assignments. If there aren’t any, add some. Where can you shift some authority from yourself to your students?
Do we want to help students be able to work as part of high-functioning teams in their future? If so, we need to model and teach that in our classrooms. Consider how making students partners in your courses teaches them critical success skills for life, community, and their future careers.
Ask students to set and share their learning goals at the start of the class. Revisit these periodically. Encourage students to edit their goals. Goals are meant to evolve.
If issues arise over late work or other challenges, ask students, “What do you think should happen? What is your suggestion?” to involve them in the decision-making process.
Teach students how, when, and why to advocate for themselves. Encourage help-seeking by answering students questions and then asking them, “Does this answer your question? If not, please let me know.”
Recognize that just as you are teaching your students, your students are also teaching you. Rethink teacher-student dichotomy.
Read: Paulo Freire’s Pedagogy of the Oppressed.

Empowerment (Voice) & Choice

One of my favorite teaching quotes comes from Thomas Carruthers: “A teacher is one who makes himself progressively unnecessary.” We can help our students to find and use their voices, to speak truth to power, and to become more confident thinkers, writers, creators, and citizens. People who’ve experienced trauma were often in situations where their rights and choices were taken away from them. Trauma-aware classrooms empower students.

Balance choice with structure. Choice is an important element to empower students to be more self-directed. Too much choice can cause students to become confused. Get to know your students and their unique needs.
If you’re new to infusing your course with choices for learners, start small. Overwhelming yourself will overwhelm your students. Pick one assignment or topic through which you can offer students a few choices.
Some less-confident learners might get anxious about choices. They might ask you to tell them what to do. If they’ve never had choices in their learning before, they need to be taught how to make these choices. Consider meeting with those students 1:1 to help them process their options.
Scaffold choices in the classroom by offering a “most popular” choice option. Again, for less confident learners, this lets them make a choice but provides them more structure.
Consider choice in the context of Gerald Grow’s Staged Self-Directed Learning Model (SSDL). Recognize that learners will have different levels of confidence with choice. Aim to meet students where they are and provide the appropriate level of direction/facilitation.
Begin lessons by asking students to share what they already know about a topic. Create space for ALL students to share, either in a Zoom chat or in-person via think-pair-share type of activities. This will set the tone for the lesson by showing students that the foundation for learning is their own existing knowledge.
Craft assignments in such a way that students are encouraged to utilize their own life experiences to learn and consider course content. Remember, students know things.
Empowering students is not about forcing the issue. Remember, we want to give students choices. For example, requiring students to do a research project on the impact of COVID-19 on their community might be empowering for some and traumatizing for others, particularly for those in communities that are disproportionately harmed by this pandemic. Make sure there is a backup choice that would be less personal for students who so choose.
Create spaces for all voices in the classroom. Do not ask minoritized students to speak on behalf of entire populations of minoritized people. Ijeoma Oluo’s book, So You Want to Talk About Race, includes excellent, practical guidelines on holding important conversations about race.
It’s okay to be nervous about releasing the illusion of control in the classroom. Learning and living are messy. You aren’t alone in those feelings.
Read: “Does offering students a choice in assignments lead to greater engagement?”

Cultural, Historical, & Gender Issues

If you wish to be trauma-aware, you must acknowledge anti-Blackness, all forms of racism, misogyny, ableism, and bigotry toward LGBTQ folx. To deny any form of oppression is an example of retraumatization. You are not asked to be perfect in your awareness; you are going to fail and fail often. You are asked to keep trying and to fail with greater awareness. You are asked to interrogate your own privilege and to act to dismantle that privilege. You are asked to think and feel deeply about how trauma impacts each of us differently. There is a tension here, because trauma does not care how much money or privilege we have. Anyone can experience trauma at any time. That said, money, privilege, and power also protect people from all manner of trauma. Both are true.

Do your own work. Seek out existing resources on all types of oppressions and bigotry.
Consider incorporating discussions of race into your classroom. Seek support for this work. Does your institution have a space for you to talk about your experiences with other educators?
Cite Black women. https://www.citeblackwomencollective.org/ Include many diverse voices in your assigned readings and course content.
Recognize that minoritized individuals have immense intelligence, wisdom, strength, and creativity as both individuals and communities. As Whitman said, we contain multitudes. That said, be extremely cautious of conversations around grit, which can often discount systemic forces like racism and place blame on individuals. You will see this arise in the trauma literature under the topic of “resilience.” Resilience can sometimes be used to ask trauma survivors to practice a “chin up” mentality. This can lead to retraumatization. Remember, trauma is something that by definition is unbearable, and it is also true that we have personal and community resources that can help us bear it.
Read Dena Simmons’s “If we aren’t addressing racism, we aren’t addressing trauma.”

Closing Thoughts on Creating a Simple and Sustainable Trauma-Aware Teaching Practice

This is a long list. Our time and energy are limited. We must develop practices that we can sustain. We cannot fill from an empty cup.

When I read, I underline a lot of important ideas. But some ideas jump off the page, and those will get some other type of annotation next to them, such as an * or a !. Read through this checklist, and notice what jumps off the page at you. What ideas grab you? Which feel most critical to you? Pick one or two. Start there, and start slowly. Becoming a trauma-aware educator is not something that can happen in a day, a week, a month, or probably even a year. It is a lifelong practice. Start where you are.

I read somewhere once that the point of making a mistake is to learn how to make more. I think of that often, recovering perfectionist that I am. We are all only human. Do your best with this challenging work, accept that you will make mistakes, and then through facing those mistakes with humility, you will have the chance for true alchemy: transforming your mistakes into lessons, growth, and service.

Take care of yourself. Take care of each other.

Please share this document freely. I ask that you do not edit or adapt so that I can ensure the integrity of the document and its content.

Original Google Document

Muscles of the Shoulder Pictures

December 5, 2015December 5, 2015 by Julie Onofrio

Click on images to enlarge.

shoulder muscles — An Atlas of Human Anatomy, Carl Toldt, MD 1904

shouldermuscles4 — An Atlas of Human Anatomy, Carl Toldt, MD 1904

An Atlas of Human Anatomy, Carl Toldt, MD 1904

shouldermuscles7 — An Atlas of Human Anatomy, Carl Toldt, MD 1904

shouldermuscles8 — An Atlas of Human Anatomy, Carl Toldt, MD 1904

Palpation Skills for Massage Therapists

November 30, 2015November 27, 2015 by Julie Onofrio

ELAP recommendations:

Subject: Palpation and Movement

Topic: Orientation to Palpation and Movement

Learning Outcomes

Conditions: Having completed 4 hours of instruction on an orientation to palpation and movement, the learner is expected to:

Demonstrate knowledge of the key terms and concepts related to the development of palpation skills and the basics of human movement on a written examination.

Why should you learn palpation skills?

What ‘tools’ can you use to palpate?

What are the goals of palpating?

Learn to discriminate levels of tissue, muscle, bone and joints. Sense differences in tissue quality.
Palpation skills for massage therapists is learning to use touch to identify the various soft tissue structures of the body and the condition of those tissues. What you learn from touching is used to assess the somatic responses of the body and for making treatment decisions. Through palpation, soft tissue such as ligaments, muscles, tendons, joint capsules and other body parts can be identified. Palpation of the physical aspects of the body is only the beginning. Once you can feel the physical aspects then you can use what you learn to assist clients in learning to feel their bodies more.

Touch is the only sense where you are also touched when you touch someone else. Learning to touch others with intention and care you will be also able to tune into what you are feeling when you touch. This is one of the keys to working in a therapeutic relationship with a client.

Learning Palpation Skills

Learning to palpate and feel a clients body is a matter of just practicing and figuring out what it is that you are touching. With supervised practice and guidance your skills can constantly improve as you begin to trust your senses. Only you know what you are feeling. The client only knows what they are feeling.

Palpation is done mainly with the hands but some of your other senses may also come into play when working with clients. Sight, smell and hearing may also be used. It is also necessary to have a good understanding of anatomy and physiology so you can begin to understand the structures and what you are feeling under your fingers/hands when you touch.

Begin by recognizing how you use your senses. Palpation is a collection of several abilities. The dominant eye is used to focus on the object while the non-dominant eye provides depth perception. You can find your dominant eye by holding your arm out in front of your eyes and holding up your thumb. Aim it at something in the distance and alternately close one eye at a time. The eye that sees the thumb as aiming at the object is your dominant eye.
Peripheral vision is important in sensing movement.

Different areas of the hand are sensitive to different types of stimuli.

Pads of the fingers are most sensitive for fine tactile discrimination. You can use them to sense texture, tension, surface resistance, small areas and pulses. The tips of the fingers are not as sensitive and are not large enough to sense the full shape of most structures.
The back of the hand and fingers are most sensitive to temperature
The palm of the hand is most sensitive to vibration and shapes. You can switch between the palmar surface of the fingers and the palm.

Use a light touch to keep your senses open and to prevent distorting the tissue being touched. Too much pressure will override the sensitivity of your touch as well as solicit various responses in the client such as guarding and increased tension.

You can adjust the depth, direction and duration of your touch to assess the tissue.

Knowing your underlying anatomy is important here. Find the prominent landmarks and muscles.

You are the only one who can determine how things feel to you.

Keep in touch with your client at all times. Get as much feedback as you can.

Use client feedback to educate the student about palpation
use information to educate clients about touch and their bodies
Ask questions that are open ended (not yes or no questions) Use where, what, why
The client is always right. Your role is to just provide feedback and mirror what you find.

Ask questions:
What do you feel when I am touching here?
What physical or non-physical sensations do you feel here?
What in your body needs attention?
Can you feel the tension here?
Can you feel the difference now?

Observation is the act of gathering objective signs. A sign is a measurable or observable indication of less than normal function. A sign is not a feeling. You can observe injuries and how the body compensates for those injuries. Look for signs of heat, swelling, cold areas, redness, paleness, contours and tension.

5 Objectives of Palpation

(Mentioned in the book Palpation Skills by Leon Chaitow, as summarized by Philip Greenman in Principles of Manual Medicine)

Detect abnormal tissue texture
Evaluate symmetry in the position of the structures, both tactically and visually.
Detect and assess variations in range and quality of movement during the range, as well as the quality of the end of the range of any movement.
Sense the position in space of yourself and the person being palpated.
Detect and evaluate change in the palpated findings, whether these are improving or worsening as time passes.

Also important to note the texture, resilience, warmth, humidity of the skin and tissues.

Resources:

Know your anatomy and physiology.

Know your kinesiology and insertions, origins of muscle attachements

The seven-step palpation method: A proposal to improve palpation skills Andree Aubin, Karine Gagnon, Chantal Morin. Journal of Osteopathic Medicine (PDF)

Self care for massage therapists

November 24, 2015November 24, 2015 by Julie Onofrio

When you learn about self care in massage school or read current articles on self care for massage professionals they teach proper body mechanics, proper posture, eat right, exercise, meditate or do some type of movement and of course getting regular massage to help stay grounded. While these things can help, they are really just the tip of the iceberg – the external components of self care. But knowing what things to do for self care and doing them are usually two different things. What leads you to take action or not take action is the underlying unconscious beliefs about whether you are worthy or need self care.

Self care is everything you do to take care of yourself in every way.

Physical strength, flexibility
Diet and Nutrition for energy and health
Mental clearness free from drama and critical mindsets
Emotional security and self confidence
Financial self care making more than you spend, saving and having enough money for self care and running your business
Spiritual or connections with others

Being financially responsible is one such method of self care which usually is not mentioned in self care classes/articles. Having the money that you need to live and run your business is the highest form of self care possible. The other way to take care of yourself is taking care of your personal needs for appreciation, love and nurturing. When you combine the two things you won’t have to worry about body mechanics or how hard you work on clients or working more than the agreed upon time.

Helping has a way of bringing up our unmet needs. It shows up in counter-transference. The reasons why massage therapists want to help others is usually filled with unconscious unmet needs and old feelings. Counter-transference influences the client interactions and the healing process sometimes hindering it. When you are in a state of counter-transference , projecting your old issues and feelings onto a client it can cause you to lose the objectivity you need to see the client clearly and hear the client clearly. See also: Why do you help?

The best thing you can do to take care of yourself is to become more conscious of your unmet needs and repressed/suppressed feelings so that you can be more present in your massage sessions for your clients. That is what they pay you for really. Your unmet needs and old emotions are what get projected onto others and onto clients in the form of counter-transference. I have written about counter-transference before here.

Your unmet needs and old emotions are projected into your practice, your money issues and your personal relationships. Self care that addresses these issues and helps you to become more aware of these issues can often reduce the physical stress of doing massage. The more you take care of yourself in that way, the more confident you become in asking for what you need and creating boundaries to take care of yourself in the client/massage therapist relationship.

In simple terms, projection happens when you are not aware of your feelings or needs so you ‘project’ them onto someone else. Projections can cause reactions such as always giving advice to a client. To become more present means to be able to feel the feeling that is causing the projection (are you following this? It is hard to understand since it is unconscious.)

Remember – this is an unconscious process. Everyone is unconscious most of the time. Since it is unconscious you are not aware of what you are really doing. Becoming more conscious is a very complex process. We live our lives with many blind spots. Some people won’t even believe they are doing something unconsciously because it seems so real. It is real.

The way to track your thoughts and beliefs is through your feelings and becoming more aware of them.

Supervision and peer supervision can help you to become more self aware. Supervision is not someone telling you what to do in the regular definition of supervision in the workplace. Supervision is the process of working with a more experienced massage therapist in order to understand your practice issues more and help you become more aware of yourself.

Working with a skilled psychologist can also take you deeper into your old patterns of behaving onto can do wonders for your massage practice and personal life. Since all relationships start in transference and the therapeutic relationship has a way of intensifying that transference it is important to find out more about your unmet needs. For the most part all we can do is grieve the loss of never having had them met as it is too late to get them met. Then it is a matter of taking personal responsibility for yourself and actions. The more you take care of yourself, your unmet needs and deal with the emotions, the more present you are able to be in your sessions and be there for clients. The more you take care of your internal self the easier it is to do those external self care things like setting boundaries around your time and financial needs.

Transference for Massage Therapists

January 4, 2019November 23, 2015 by Julie Onofrio

Transference is one of the most important concepts to understand for a massage therapist but the least understood and talked about. It is usually covered in a few hour workshop in massage school. Transference is a very complex phenomenon that comes from the psychology profession. The reason that it is so important to understand is the fact that the process of transference is actually what can lead a person to becoming more aware of their thoughts and issues. Transference is what heals.

Ben Benjamin author of the book The Ethics of Touch: The Hands-on Practitioner’s Guide to Creating a Professional, Safe and Enduring Practice
defines transference as this:

Clients defer to the practitioner’s judgment because they desire to be helped by an authority figure that possesses greater knowledge, healing ability and, therefore, power.

Since a power differential exists in any health care relationship, the client may be inclined to respond to the practitioner as he or she would other authority figures, and in doing so, may recreate elements of similar past relationships. This situation is known as transference, a normal, unconscious phenomenon that appears during a therapeutic process. Professional helping relationships usually have a strong transference element in which the parent-child relationship is unconsciously re-established. In transference, unresolved needs, feelings and issues from childhood are transferred onto the helper.

Elliott Greene author of the book “The Psychology of the Body” writes this:

Transference is the displacement or transfer of feeling, thoughts, and behaviors originally related to a significant person, such as a parent, onto someone else, such as the massage therapist. It is a common reaction of clients to their therapists. A bit of transference happens in most relationships in which there is feeling present. Usually, transference-related feelings were formed in the past, so it could be said that these feelings transfer from the past to the present. In transference then, the client relates to the therapist and present moment as if the therapist were the significant person. In this sense, transference is a projection of the internal drama of the client, and the therapist is assigned a particularly important role and script.”

Nina McIntosh in her book “The Educated Heart” says this about Transference.

“Transference may sound complex and unusual, but it’s actually part of our everyday life even outside of our offices. It’s normal for any of us to bring the past into our present relationship. In fact it happens all the time. They are magnified in a manual therapy session because of the intimacy of the setting, the clients altered state and the way that the practitioner/client roles mimic those of the parent/child.””Transference isn’t a rational process.

Terrie Yardly-Nohr in her book “Ethics for Massage Therapists” says this:

“The very nature of the therapeutic relationship allows transference to happen easily. Bodywork can trigger a variety of emotions from clients such as anger, frustration, sadness, fear, or joy. These feelings are generally the result of some emotion the client felt in the past towards another person.”

Cidalia Paiva in her book “Keeping the Professional Promise” says this:

“Transference refers to those situations where the patient projects onto the therapist old feelings or attitudes they had about significant people in their past, often parental figures. Transference is often referred to as ‘the unreal relationship in therapy’. The roots of transference are most often found in early childhood, and it constitutes a repetition of past conflicts with significant people in our lives.

So what is transference then?

Simply put, transference happens when there is difference in authority that resembles the parent-child relationship. The client who comes to a massage therapist receives the nurturing that they never received as a child and puts the massage therapist on a pedestal. The nurturing touch brings out the old feelings and emotions that were repressed or suppressed in early childhood. The client unconsciously begins to see the massage therapist as the nurturing parent and it can bring up feelings of attachment that were not resolved growing up. It is when the client unconsciously thinks that the massage therapist is their mother or father or other significant caretaker. Note the word – UNCONSCIOUS.

Attachment is what happens between a mother and child that allows the child to grow and build self esteem. The infant knows learns about themselves through touch. There are various stages of attachment that occur in child development where the infant feels like they are one with the mother. (And of course they once were in eutero.) As a child grows they learn that they are separate from the mother. This is where things often go astray. If a secure attachment is not formed in their early part of life, they will have life long challenges that result from that.

Massage and nurturing touch re-enacts the process of development. I actually think this is also why spa treatments are so popular with the use of healing waters and body wraps. Getting regular massage and developing a relationship with a massage therapist in which the client feels nurtured and cared for as if they were receiving it from their mothers can help heal the grief of not ever getting those early childhood needs met.

Transference is really important yet difficult to understand. The best way to understand it is to experience it. You may or may not have had some of these feelings arise when you were getting a massage from someone:

Feeling like you don’t want the massage to ever end
Not wanting to leave the office
Seeing the massage therapist outside of the office and wanting to follow them where ever they go.

Or from the other aspect seeing it in your clients:

bringing you flowers or special gifts
hearing about people’s personal problems
being asked to make exceptions in scheduling and payment options.
inviting you out socially as a friend
asking you out on a date or making other advances on you.

Or if you ever worked with a psychologist or mental health professional in therapy, you can come to learn more about transference from seeing your own. Becoming aware of your projections in a therapy setting can be a painful experience. It is a matter of getting a look at your unconscious thoughts through relationship. It can be a very eye-opening process and really lasts a lifetime.

While some of these things may just seem like normal things, it is difficult to know the difference. You probably won’t know the difference.

What you can do is create a code of ethics and a set of policies and procedures for your practice that will help you make proper decisions in any situation. It is having boundaries that teach people when they are in transference that you are separate from them is what will allow the person to heal and build self esteem.

The other thing about transference is that it not only occurs in these helping types of relationships but almost all relationships. Friendships, significant others, family members and the person who checks you out at the grocery store who seems to ‘look just like your mother”.

Reading and learning everything you can about transference can also help. These are some of my favorite books:

The The Psychology of the Body (Lww Massage Therapy & Bodywork Educational Series)

Ethics for Massage Therapists

The The Educated Heart: Professional Boundaries for Massage Therapists, Bodyworkers, and Movement Teachers (LWW In Touch Series)

Issues and Ethics in the Helping Professions
On Becoming a Person: A Therapist’s View of Psychotherapy

Erections During a Massage

January 10, 2020November 21, 2015 by Julie Onofrio

Erections during a professional massage happen there is no doubt about it. The way the massage therapist responds to it will depend on their level of professionalism and of course the situation. How the massage therapist responds can influence the therapeutic relationship which is the basis of interaction in a massage room. Getting an erection on the massage table can be as embarrassing to the client as is is to the massage therapist.

What should you do if you notice your client has an erection?

Run out of the room screaming for help?
Close your eyes and hope you are seeing things
Say something?
Work deeper on another area of the body that is less sensual
Throw a towel over it
Say something general like “Oh, That happens”

Erections are a natural occurrence that can not be controlled. Each situation will have to be evaluated. First if there is obvious threat to your safety and well being with the male client asking you to do something about it or he is sexually stimulating himself- get out of there right away without saying or doing anything else. Be ready to call the police if the person does not exit immediately.

That being said most cases are innocent and do not mean anything. If you respond with disapproval or further embarrass the person it can be damaging to their emotional well being. Some men will not seek out massage because they worry so much about getting an erection during massages.

For women massage therapists in particular, erections are often associated with thinking that the client is coming on to them and thinking of the massage as something sexual rather than therapeutic. They can also begin to think that they are giving the wrong message to the client.

Cherie Sohnen Moe in her book “Ethics of Touch” says:

Several realities shape female perceptions of erections. Many were raised with pervasive myths about erections: If you are with a man and he has an erection a) you have caused it and b) you are responsible for taking care of it. Additionally, erections are often associated with rape and sexual violence.

Nina McIntosh in her book “Educated Heart” says this:

Some people wrongly believe that if a man is having an erection the practitioner must immediately end the session. There is the misconception that for a man to have an erection, he must be deliberately sexualizing the situation and either mentally or physically stimulating himself. The truth is that having an erection can be an innocent accident and just as embarrassing to the client as it may be anxiety producing for the practitioner.”

Women often react in fear to a male erection on their massage table because of the many cases of men looking for something more than just a massage. They think that if they don’t stop the massage, it may escalate to something more like an unsafe situation for themselves. Since erections on the massage table are not talked about much dealing from a place of fear can add to the embarrassment and shaming of both parties. You don’t want to add to the situation, yet you want to protect yourself.

If a male is obviously doing things to bring on an erection or relieve an erection it has no place in the massage room.

Each case has to be looked at individually. If the client has a past relationship with you and hasn’t had this issue come up before, it is most likely ok to continue working or talk about it.

If it is a new client and they are making sexual comments or acting inappropriately, a massage therapist has the right to end the massage at any time.
Terrie Yardly-Nohr in her book “Ethics for Massage Therapists” says it this way:

A therapist has the right to refuse to treat a client if the therapist determines that the therapeutic relationship cannot be maintained in an ethical manner.

If a massage therapist finds themselves constantly getting clients who are seeking more than just a massage it is often a good idea to have the massage therapist take a deeper look at their intentions and professional image. ( I actually worked with a massage therapist who was having this problem and she couldn’t figure out why. When I looked at her website I saw pictures of her in sexy tank tops showing more than was needed. Another always worked without proper draping and wondered why erections were more common.)

The more we can talk seriously about issues like this, the stronger we can become as a profession setting boundaries that can protect the massage therapist and educate clients. Healing on both sides of the issue can happen.

How to deal with Erections on the massage table.

Assess the situation – are they asking for something more? Can you clear the situation up by explaining that you don’t do that or do you have to send them out the door? It is possible to have a regular client get caught up in the physical aspects of it all and ask for something more and still continue the relationship. You have to decide but also know that shaming men more for this can be damaging. Are they laying quietly ignoring the situation? Don’t do anything.
You can use thicker sheets or place a thick towel on top of the client’s erection to cover things up more.
Have a section on your website explaining the situation to tell people it is normal.
Talk about it if necessary.

So dealing with an erection on the massage table is a matter of evaluating the circumstances and using compassion.

And don’t forget that women also can be stimulated during a professional massage but of course it isn’t as obvious or as much of a threat although I have heard stories of male massage therapists getting special requests from women clients.

Since erections do happen we need to be able to deal with them in the manner that supports us both professionally and personally. Nina McIntosh in her book “Educated Heart” says this:

Some people wrongly believe that if a man is having an erection the practitioner must immediately end the session. There is the misconception that for a man to have an erection, he must be deliberately sexualizing the situation and either mentally or physically stimulating himself. The truth is that having an erection can be an innocent accident and just as embarrassing to the client as it may be anxiety producing for the practitioner.”

If a male is obviously doing things to bring on an erection or relieve an erection it has no place in the massage room.

Each case has to be looked at individually. If the client has a past relationship with you and hasn’t had this issue come up before, it is most likely ok to continue working or talk about it.
If it is a new client and they are making sexual comments or acting inappropriately, a massage therapist has the right to end the massage at any time.
Terrie Yardly-Nohr in her book “Ethics for Massage Therapists” says it this way:

A therapist has the right to refuse to treat a client if the therapist determines that the therapeutic relationship cannot be maintained in an ethical manner.

And NO – for those who are finding this page by searching for erections during massage and happy endings – NO! Happy endings are acts of prostitution and are illegal!

Learning to Touch for massage therapists

November 28, 2015November 18, 2015 by Julie Onofrio

Learning to touch for massage therapists is usually one of the most basic level classes in massage school. How you touch others and the quality of your touch along with your own history of touch will influence your success as a massage therapist. Being a massage therapist is much more than just doing a massage. Your role as a massage therapist requires that you be as present as you can for the client who is on your table. You will need to know what you intend to communicate through your touch and find out if you actually do communicate that through your touch.

Through massage school you may become aware of some of your past issues with touch. It is one of the most important parts of massage school. Touch is the only two way sense – when you touch someone you are touched back. What you feel when you touch others as a massage therapist will affect how your touch is perceived. People don’t really care what technique you are doing. All they know is how it feels to them. It may remind them (consciously and more often unconsciously) of how they were held and attended to as a child. It may remind them of what they were lacking as an infant. It may remind them of people in their past. If there was physical, sexual or even mental/emotional abuse it is most likely a part of their physical body.

Knowing your own past touch issues is important when working with all types of clients. It can help you to be more present with people no matter what their level of touch receptivity is. How touch was used or withheld in your family, what the rules were around touch all influence your image of yourself and your self esteem. Infants who are not touched enough will respond by becoming avoidant to touch and will often grow up with defense mechanisms to protect themselves from the pain of not having their early needs met.

Take the time to look into your history of touch – being touched and giving touch.

Touch can be used to punish or hurt. Touch can be used to nurture, reassure and support. It can be used to stimulate and excite as in shaking someone to wake them up or tickling. And of course there is sexual touching which is not a part of massage but is an important part of your touch history.

Your clear intention is really the most important thing you can bring to the massage profession. It can only come when you have personally worked through your own touch issues first before working with others. It actually will be a constant learning process as your massage practice develops and matures.

Learning to touch and use touch as a framework for communicating with clients in the healing process you will encounter various elements of touch.

Trust is necessary for clients to be able to get on your massage table and is the foundation for the therapeutic relationship that occurs with the massage therapist/client. Your awareness of yourself and your personal and professional boundaries are what create the framework of trust for clients.

You may also be using all of your senses to work with clients sensing your own feelings first and becoming aware of your own body as you work on others. You will be learning to touch various body parts and various levels of tissue of the body which requires you to be aware of your own body. The depth, quality of touch, type of pressure and applications of massage requires this.

Getting feedback from clients is often a challenge because many will not know what pressure or technique is best for them at first. They also will think that you will know best but encouraging them to find out for themselves can create an even more powerful massage session.

Presence is the ability to stay present and aware of your own feelings while you are working on someone else and not let those feelings affect your work or get in the way of what the client needs or letting those feelings take your attention off of your clients needs. It also requires that you trust more in the healing process and have a deep understanding that you are just a guide on the journey with the client.

Massage Peer Supervision

January 4, 2019November 14, 2015 by Julie Onofrio

Peer Supervision defined by Webster is to oversee, direct or manage. The term supervision makes me think of a supervisor in a business setting who just sits back and tells me what to do.
The type of supervision I am talking about comes from other medical professions such as psychology, social work and nursing. The goal of supervision is to increase awareness and on-going self awareness of the therapist. Supervision is all about the therapist and whatever they need to become what they want to be! The more support we can get as therapists, the more support we can give to clients.

Supervision could make your work life more satisfying by helping you understand stumbling blocks that get in your way and by giving you support where you need it, for instance, with setting limits, trusting your intuition or appreciating your assets. Good Supervision can give you confidence and free you up to do your best work ~ Nina McIntosh, Educated Heart

Supervisors are usually senior massage therapists who specialize in working with issues related to the therapeutic relationship that occurs in our practices. This is done through listening to how the therapist feels about whatever is going on in their practice. It does not mean that the supervisor is going to tell you what to do! The goal of supervision is to have the supervisor mirror what is going on in the therapist with the intent of having the therapist learn for themselves what it is they need to do in their practice. This is done through the process of active listening. During the process, the therapist may ask for the supervisors opinion knowing that is just that – their opinion.
Individual supervision is a one-on-one relationship where the therapist hires a supervisor. A commitment to meeting regularly is needed to build the relationship and work to find the core issues that the therapist is struggling with. Some common issues to work on are boundaries, transference and counter-transference, projections and specific details of practice. Working on an individual basis, the therapist gets the exclusive attention of the supervisor.

Some definitions of supervision:

‘A formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations. It is central to the process of learning and to the scope of the expansion of practice and should be seen as a means of encouraging self-assessment and analytical and reflective skills’ (Vision for the future 1993). ]
Butterworth & Faugier (1992) said supervision refers to a range of strategies, including: ‘preceptorship, mentorship, supervision of qualified practice, peer review and the maintenance of identified professional standards’ and was: ‘both a personal and professional experience’.
Swain (1995) differentiates supervision in contrast to more well-known procedures: ‘(supervision is)…not psychotherapy or counseling…nor is it directive management, individual performance review or staff appraisal. It is not a form of disciplinary procedure…it is not any of those things which some nurses seem to fear it might be or could be used for’.

When to use Supervision

Dealing with challenging clients such as those that are controlling, demanding or difficult to deal with.
Feeling like you are drained after working with clients.
Feeling sexually attracted to clients
Feeling bored or uninterested in your work. Falling asleep yourself while giving massage.
Feeling resentful of clients or your job or your massage practice.

Swedish Massage Strokes

November 27, 2015November 14, 2015 by Julie Onofrio

Stroke	Purpose/Uses	Mechanical effect	Reflexive effect	Contraindications
LIGHT EFFLEURAGE Gliding, Fanning, Tree branching, shingling etc.	Transitioning Spreading oil Evaluating tissue		Relaxes muscles (parasympathetic nervous system) Relieves pain (Gate control theory, endorphins) Increases arterial and capillary circulation Increases vasodilation (slowing heart rate and blood pressure)	Hyperesthesia Marked or pitted edema Gross swelling Open wounds distal to inflammation or infection
DEEP EFFLEURAGE Knuckling,		Increases venous and lymphatic flow removing wastes, reducing edema Improves nutritional status of tissues Increases arterial and capillary circulation, bringing nutrients Warms superficial tissue Desquamation of dead skin	Same as above Deeper muscle relaxation Capillary dilation longer lasting	Same as light effleurage Very hairy skin New scar tissue Venous stasis
PETRISSAGE Picking up, wringing, kneading, open C/closed C, alternating thumb, squeezing, lifting, skin rolling (lifting tissue away from underlying structures)	Used after effleurage Relieves congestion Reduces swelling Digestive disorders Muscle shortening Spastic paralysis Fatigue	Stretches muscle fibers and stimulates muscle tone, broadens fibers Breaks up adhesions Increased circulation and waste elimination Moves interstitial fluid	Slow-relaxes nervous system Fast-stimulates NS Increases glandular activity of skin Increases peristalsis when done over abdomen Affects proprioception	Atrophied muscles Flaccid paralysis Acute inflammation
DIRECT PRESSURE FRICTION Compression	Use after tissues have been warmed up Hypertonic muscles Treatment massage Deep tissue work	Compresses and spreads tissue Temporary ischemia Mobilizes muscle/tendon junction	Reduces pain and spasm Hyperemia Increases peristalsis when done over abdomen	For all frictions: Acute inflammations Neuritis Recent injuries Osteo and rheumatoid arthritis-especially acute stages Muscles lacking innervation(paralysis) Debilitating neuromuscular dysfunction such as MS, ALS, MD.
LINEAR OR CIRCULAR FRICTION	same as above	Myofascial releasing-separating adhered fascial planes Broadens and stretches muscle fibers Increases muscle	Decreases tension through stimulating Golgi tendon reflex Increases circulation Creates hyperemia
Cross fiber friction	Use only after a thorough warming of involved tissue Apply at right angles to scar/fibrotic tissue Superficial tissue must move over underlying structure Apply frequently enough to have an impact	Breaks up adhesions Assists in realigning scar tissue	Relaxes muscles by stimulating Golgi tendon reflex
Heat rub friction		Heats skin Warms tissue	Vasodilatation Relaxes muscles
TAPOTEMENT Tapping, Pincement, Slapping Hacking, Cupping, Beating, Pounding	Stimulation of tired muscles Relaxation of hypertonic muscles	Loosens mucus in thoracic cavity	Stimulates nervous system, muscles, vessels Enhances muscle tone via contract-relax response Increases circulation Stimulates organs through low back Increases gaseous exchange Stimulates skin and glandular activity	Muscles is spasm or cramping Spastic paralysis Atrophied muscles Flaccid paralysis Insomnia, neurasthenia or complete exhaustion Neuritis or painful conditions Over bony area No heavy tapotement over the kidneys No heavy tapotement over low back in pregnancy or menstruation
FINE VIBRATION Static or moving	Relaxation		sedates nervous system reduces pain(gate theory) relaxes muscle	same as tapotement
COARSE VIBRATION Static or moving		loosens ligaments	Penetrating stimulation
JOSTLING/SHAKING		Increases synovial activity Increases circulation	Stimulates organs Reduces muscle guarding Rejuvenating tired muscles	same as tapotement
SWEDISH GYMNASTICS Active free, active assisted, passive, resistive		Stretches muscles and ligaments Increases circulation and nutrition Increases waste elimination Loosens adhesions Increases ROM and flexibility	Stimulates NS Increases blood pressure and temperature	Torn ligament, tendon or muscle Unhealed fracture Post surgery Heart conditions ( active and resistive) Acute injuries

Setting Your Fees for Massage

January 4, 2019November 10, 2015 by Julie Onofrio

One of the common questions I get is ‘How much should I charge for a massage”? The question really should be ‘How much do I need to make each week/each session to run a profitable business.

I was talking to a friend of mine who asked me if I knew any cheap massage therapists. She had been going to someone who was charging about $40-$50 an hour. That person apparently went out of business and had to go back into the corporate world to make a living. So was charging less than the national average of $60 a wise thing to do?

Many think that charging less will get them more clients. They start out charging less for their services because they think that they are right out of massage school and not very good so they need to charge less and attract more clients. While they may not be as experienced the value of massage is really relative to each clients perspective and may not have anything to do with how good of a massage therapist you are.

Charging less in the beginning may be a good incentive for people to come in. I recommend that as soon as your schedule is full to start charging more. Yes you may loose clients but the bottom line is that you need to be making enough to support yourself and your family. As you get busier you can be choosier about who you work on taking clients who pay you more.

Some areas of the country where the cost of living is less may have lower fees for massage therapy services.

I have outlined some things to consider when setting your fees:

You will only be able to do a certain number of massages a day/week physically, mentally and emotionally. Most massage therapists do about 20 hours of massage a week. Some are able to do more. Since you are only able to do so many massages, you need to charge more to make a decent living.
What is the value of a massage? What does it mean to people to be able to come in and get relief for their pain or problem? What is the value of providing regular weekly massage to someone and helping them heal their attachment, security and self-esteem issues?
What amount do you need to charge so that you do not feel resentful of the massage client? I have heard many stories of massage therapists feeling resentful and yes even to the extent that the person wanted to apply more pressure to the massage client than they could stand. While this is not a usual thing for a massage therapist it may arise when you feel resentful.
Charge enough so that you are not expecting a tip. Some people will tip, some won’t. Depending on tips for income is not very helpful financially. If someone does tip think of it as a bonus not an essential part of your income.

Nina McIntosh in her book The The Educated Heart: Professional Boundaries for Massage Therapists, Bodyworkers, and Movement Teachers (LWW In Touch Series) says this about setting fees:

Your rates affect what both clients and colleges will think of you. If you charge more than the norm, some clients may be put off, while others may think you must be offering something special for the extra charge. If you charge less than the going rate, some clients will be attracted to the bargain but may not value the work as much….

The amount you charge also affects how you feel about your work. Make sure that your fees are fair to you and that they take into account all of your expenses. Charge enough so that you won’t resent your clients. Also, make sure you don’t feel as if you are overcharging. If you are not comfortable with your fees, clients will sense it and feel uncomfortable too.

Setting Your Massage Fees when Billing Insurance

Setting your fees for when you bill an insurance company is a whole other ballgame. Many massage therapists charge more when they bill an insurance company saying things like – they have to wait longer to get paid and they have to do more work to get paid. There is a big discrepancy over this issue that I have only just recently found a legal answer for. When I went to a workshop put on by two local Seattle area attorneys they made it really clear that those extra things that go into insurance billing are just a part of doing business and they can not be charged extra for. You can charge the extra amount that you pay or would pay a billing person to submit each bill and for the work you/they have to do to get paid. Otherwise charging more to an insurance company than you do your cash clients for the same service is considered insurance fraud and that can be punishable by a $5000 fine and 5 years in prison.

What about the fact that you are doing medical massage? I for one do not do anything different when someone comes in for a regular massage and pay cash for it compared to someone who I am able to bill their insurance company for the services. If you could prove in a court of law that you do treat the client differently and that you use different skills and knowledge than you may be OK.

There is also something called the Usual and customary fee schedule for insurance companies that set rates for insurance companies. I think the last time I checked for Seattle area it was about $132 a hour. The thing is that we don’t really know how they are getting that number. If you bill for auto accidents, those insurance companies will usually pay whatever you charge so if massage therapists (or others) are charging more than their regular cash clients to insurance companies and that is the number being used to determine the UCR – is that really factual, ethical and legal?

This actually is one of the things that I think our massage associations should be doing more work on for us -figuring out for each state what are the legal implications of setting different fees for massage therapy sessions.

The other thing to know is that professionally you can ask others what they make but if you ‘collude with others in setting your fees’ it could be seen as price fixing. ( I am not of course a lawyer but that is what I was told by the workshop I mentioned above.)

Setting fees that support you and your business is just good self care and it is just business. It does not mean you care less about others who can not afford your services. When you are making what you need to make, you are able to give more money or use your money to set up services for disadvantaged people to get affordable massage or even free massages.

So what do you need to charge so that you will be a successful massage therapist?