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Muscles of the Shoulder Pictures
Julie Onofrio
Palpation Skills for Massage Therapists
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
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
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)
Issues and Ethics in the Helping Professions
On Becoming a Person: A Therapist’s View of Psychotherapy
Erections During a Massage
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.”
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.
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
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.
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Massage Peer Supervision
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
| Mechanical effect | Reflexive effect | Contraindications | ||
| LIGHT EFFLEURAGE
Gliding, Fanning, Tree branching, |
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| DEEP EFFLEURAGE
Knuckling, |
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Same as above
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| PETRISSAGE
Picking up, wringing, kneading, |
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| DIRECT PRESSURE FRICTION
Compression |
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For all frictions:
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| LINEAR OR CIRCULAR FRICTION | same as above |
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| Cross fiber friction |
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| Heat rub friction |
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| TAPOTEMENT
Tapping, Pincement, Slapping |
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Loosens mucus in thoracic cavity |
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| FINE VIBRATION
Static or moving |
Relaxation |
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same as tapotement | |
| COARSE VIBRATION
Static or moving |
loosens ligaments | Penetrating stimulation | ||
| JOSTLING/SHAKING |
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same as tapotement | |
| SWEDISH GYMNASTICS
Active free, active assisted, |
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( active and resistive)
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Setting Your Fees for Massage
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)
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?
The therapeutic relationship for massage therapists
One of the least talked about concepts in massage school is the therapeutic relationship that occurs between the massage therapist and the client. Cidalia Paivia in her book “Keeping the Professional Promise” says:
When a massage therapist and a patient come together, the therapist and patient enter into a therapeutic relationship. What distinguishes the therapeutic relationship from other relationships is its very special purpose and goal, which is to serve the needs and interests of our patients.
The Therapeutic relationship’s primary function is to facilitate the health and well-being of our patients, ensuring that we bring our full presence and commitment to this experience.”
When people come to us seeking help with their condition or distress, what happens is that a power differential is created. People come to us thinking we can ‘fix’ or help them. They think that we hold the answers to relief from their symptoms. They are vulnerable because they are in pain or under stress. The act of seeking help recreates an old pattern of relating to someone in power which is based on our early relationship with our parents or major caregiver. Since no caregiver is perfect and able to provide for all of our needs we are left with holes in our essence and we seek to fill these in most relationships especially one where a person is actually seeking help. (Transference)
On the other hand the “helpers” have their own issues and reasons why they feel compelled to be the helper. (Countertransference) While on the surface many help because it brings more meaning to the helpers lives, helping is also a great way to really learn more about oneself. Rachel Remen in her article “in the Service of Life” talks about helping in this way:
Serving is different from helping. Helping is based on inequality; it is not a relationship between equals. When you help you use your own strength to help those of lesser strength. If I’m attentive to what’s going on inside of me when I’m helping, I find that I’m always helping someone who’s not as strong as I am, who is needier than I am. People feel this inequality. When we help we may inadvertently take away from people more than we could ever give them; we may diminish their self-esteem, their sense of worth, integrity and wholeness.
Because the nature of touch can bring up so many deep and unconscious feelings and emotions in clients and the massage therapist, it is important that a massage therapist have an understanding of what happens in a therapeutic relationship and understand how what they do and say can influence the relationship.
The thing with counter-transference is that the roots of it are often so deeply embedded in who we are, we are unaware that the source of our feelings and reactions may be based on our own unmet needs from early childhood so we unknowingly jeopardize the therapeutic relationship. It often shows up in the way we always want to help others, how we always want to give advice to clients, and in many other ways.
Maintaining the Therapeutic Relationship
The therapeutic relationship is based on the massage therapists ability to stay present with a client and not judge, fix or otherwise hinder the client’s process of healing. It requires that the massage therapist have a clear idea of what their own needs are and learn to get their own personal needs for appreciation, validation and to be needed met in other areas of their lives so that they can become and stay more present with the client for the clients healing process. Working within the therapeutic relationship requires that you be able to give empathy for the client. To be able to give empathy, one needs to have met their own needs for empathy first by doing the grief work that is related to not getting your needs met and working with a skilled peer supervisor or mental health counselor to rewire the brain and body for empathy.
Since so many of our needs are really unconscious, it is important to begin to become aware of our own needs and learn to take care of them outside of the therapeutic relationship so that we can become more present to witness the healing process in clients.
So often massage therapists find themselves crossing the boundaries between friendship and clients, wanting to fix a client, wanting to give more, getting paid less, giving advice and acting in other ways that will actually foster a client’s dependence on the massage therapist. The massage therapist will often start sacrificing their time and energy in order to help a client or so they think. There is such a fine line between helping and when helping is actually hurting that it is near impossible to distinguish until it is too late. The massage therapist will end up feeling resentful, burned out, facing physical injuries/illness which may lead to career ending events.
The presence of a massage therapist depends on their own awareness of themselves and the reasons why they feel compelled to help. Our early childhood is where it all starts. Our self esteem is developed at an early age. We begin projecting our unrecognized feelings on others shortly after birth. When our early needs for nurturing, appreciation and acceptance were not met, we see ourselves as less than worthy and it is reflected in all of our actions and reactions. When our own needs for empathy and mirroring are left unmet from early childhood, they often get in the way when we try to help others. We can learn to be of service more when we take the time to receive the empathy that we need for ourselves.
As a massage therapist, we owe it to our clients to do our own personal growth work and fill in the holes left by the wounds of our past. Learning about ourselves and setting clear boundaries in a massage practice can take you much farther in building your practice than any marketing plan. The clearer you get about who you are, what you are doing and why, the clearer your relationships with your clients and potential clients.