Ethical scope of practice

[kathryn]

Let me start by writing that I really enjoy MFR (Barnes) and have had some wonderful results along with the other types of work I do use in session. I am signed up to take a SES course and apprentice with Barnes himself in Sedona this summer and I am currently training with an advanced Barnes therapist who is really good at what she does. Also, I regularly receive work from advanced therapists.

My post is about the prompting that goes on in the sessions. Do most advanced therapists do this, or just some of them? What I mean by prompting is during a release or feeling a restriction, the therapist asks something along the lines of "what emotion is under this restriction?" and other similar questions. This prompts the client to start revealing very personal issues in their lives and how the pain may relate. The therapist then goes on into a dialogue and the client goes further into their emotional state and how it got there.

The concern I have is that this therapist (and most other Barnes practitioners) does not have any sort of psychiatric or counseling training at all. I have personal experience with therapy in group settings and know firsthand that people will make up experiences or feelings in order to comply with the therapist and they (the client) wil even begin to believe those things about themselves which just screws them up further. No, it doesn't make sense, but it does happen. Only a trained therapist can tell the difference and how to prompt clients into this kind of self-work.

In my work, I am aware of the emotional aspect of massage and the Barnes MFR in particular is quite powerful stuff. However, my job is to create a space in which the client may do their own healing in their own way. Meaning that I do not encourage clients to talk about their issues or associate them with things going on in the body. If the client wants to share, I just listen but offer no advice or prompting. Sometimes an injured shoulder is just an injured shoulder, not necessarily because you feel like you have been a burden to your mother.

Really, this post is just an expression of the problem I have with encouraging emotional releases and it is definitely not within our bounds as a massage therapist. I am hoping that most Barnes trained therapists don't do this type of thing and will be sorely disappointed to find out that it is a common occurrance. But, it will not prevent me from continuing my education in this (otherwise) amazing work. I am not trying to set up a debate with those who feel it is helpful for their clients or that it has helped them to have a therapist (with no training in mental health) use this type of dialogue in their sessions. Just putting it out there that it is not within our scope of practice as massage therapists.

[shivashiva]

I think that there is a way to be very allowing for our clients to have emotional release (2 major ways to do this are to do our own internal healing and being completely 100% okay with ANY emotion that they can have on the table) without using "leading" language like the kind you describe. I think there is even languaging that is neutral and non-leading that can be used to let clients know it's okay to share, or that it's okay to have an emotional experience, without expecting or wanting anything. Again, to get this really right you have to be okay internally, not just reading a script.

I trained using some Hakomi and Gestalt techniques immersed in bodywork, using allowing, non-leading language. I believe you can create an optimal space for emtional healing to take place without stepping out of our professional boundaries. I think the specific phrase you used "What emotion is under this restriction?" is way off base (the person who uses it, that is). It definitely is putting something in the client's mind. A better way to approach something like that would be, if (and only if) you can see there is some emotion happening (reddness in the face, quivering lips, tears, some other similar sign) "Some feelings there, huh?" If this is said in the appropriate way the client will not feel pressured to answer, and they will feel that it's okay to feel what they are feeling, and things can proceed from there. If you cannot see any emotion from the outside, there is no reason to bring it up.

Anyway, just rambling a bit. Not much to do with Barnes, et al. I imagine in the advanced training they might do some training with the emotional aspect, which would put a practitioner in a better position to deal with it when it happens, and do it skillfully. Anyone know?

[maestra]

My JFB MFR trained therapist is a dear friend, and she does use the dialoguing techniques with me. I did have a MFR treatment Monday and I do recall her asking if there was an emotion attached to a certain area of pain or restriction.
Sometimes I do know and if I do, I will say so. I find it comforting that I am not on this journey of self-discovery totally alone.
It is important for me to remember though, I am the guide... my body leads us where I choose to go. If I don't want to go there... it's ok to say so.
So, she will sometimes ask if there is an emotion or how an area feels... but most of the time I am not aware of something "underneath."
I appreciate that she does not push the issue... or judge me. I can share or not. It is what it is... and she's ok with that and so am I.
I am about to take MFR I... and don't really know how I would feel about dialoging this way with my own clients. I think I would need to feel very comfortable with my client before I'd bring up this sort of "work."
(The dialoging, not MFR! LOL)

[cstbrian]

I do quite a bit of dialogue work with my CranioSacral Therapy clients. Not all of them, but definitely the majority of them. I have trained in SomatoEmotional Release (SER) I&II and am a teaching assistant for both classes. I have also taken a class called The Brain Speaks; which is an advanced class about neuroanatomy and physiology. During this class we actually dialogue with different parts of the brain and nervous system. I have also worked closely with a couple instructors and Diplomate-level certified CranioSacral Therapists. I have absolutely no training in any kind of talk therapy.

Why am I talking about all this? To show, before I make the following statements, that I have quite a bit of experience in this 'grey' area of dialogue during a body work session.

Through all of these classes we stress the importance of the client leading the session; including the dialogue. I believe that asking "what emotion is under this restriction?" is much too leading of a question to be asked. I feel that even shivashiva's question of "Some feelings there, huh?" is leading to a client, even if you visibly see signs of emotion, I personally would never ask those questions. (keep in mind this is all my opinion of how I approach 'talk-bodywork' based on my training and experiences.)

I almost always enter into dialogue with very general, non-leading questions such as, "What are you noticing right now?" or "What's happening right now?" I believe that questions like these leave open the possibilities for discussion based on where the client wants to go. He/she doesn't have to talk about the emotional state underlying a restriction for that restriction to go away. And there's not always an emotional issues attached. So, by asking "what emotion is under this restriction?" the client's attention then goes into trying to figure out what that emotion is, which may take him/her away from the actual experience.

Also by asking such a specific question, you may immediately shut down the client who does not wish to talk about emotions. However by asking, "What are you noticing right now" the client can take the dialogue in whatever direction he/she chooses: emotions, physical sensations, even spiritual information.

I have personal experience with therapy in group settings and know firsthand that people will make up experiences or feelings in order to comply with the therapist and they (the client) wil even begin to believe those things about themselves which just screws them up further. No, it doesn't make sense, but it does happen.

I believe if the questions are truly non-leading and the therapist is following the client, the client will not have to 'make things up'; he/she will be comfortable talking about whatever comes up - or nothing at all, which is absolutely fine! Many 'SER' sessions happen without any dialogue at all!! If the client's body is ready to process something and it is the right time and place, and you are the right therapist to support him/her through that process, it will happen - dialogue or not.

Also, in SER I&II we are trained in techniques that listen to the body in such a specific way, that we can tell when a client is truly in his/her process or when he/she is just talking. We use these techniques to help gently guide the dialogue so the client can stay in process if that's what the body needs that day. Again, it's all about listening to the client's body.
This is the key to all of this!!!

It's about bodywork - not talk therapy.

We encourage the use of the minimal amount of dialogue (if requested by the body) to help the client move through a restriction. This minimal amount of dialogue is lead by the body. We are constantly monitoring the tissue and how the tissue changes as the client dialogues.

So, to bring all this together ... I do believe if done correctly and lead by the client it is absolutely within our scope to dialogue with a client. When done correctly, we are not practicing talk therapy. We are using active listening skills and reflecting statements and mirroring questions. We should never diagnose or even make a judgment or suggestion about their dialogue. I am in no way acting as a mental health therapist, and the therapists I do work with say that I am in no way crossing boundaries with the way I work. Most are impressed how I stay so neutral and don't feel like I am ever leading the dialogue.

We all work every day with tissue memory. We talk about mind-body connection. We see clients who don't get better because of the trauma that is trapped in their cellular memory. If we as BODYworkers do not help to directly address the tissue memory while we are working with the body, I believe we are doing our clients a dis-service. I believe that no one else out there works with the tissues of the body the way that we do. So if the client needs to dialogue about his/her car accident to fully release the neck pain that has been bothering him/her for over 20 years, I think it's within my scope to follow his/her tissues through release and guide him/her along the way.

If we don't work directly with cellular/tissue memory, who will?

Brian

[maestra]

If the client's body is ready to process something and it is the right time and place, and you are the right therapist to support him/her through that process, it will happen - dialogue or not.

Excellent point cstbrian! I agree, if it's going to happen... at least we can be 'prepared' to support the client in the process.

We all work every day with tissue memory. We talk about mind-body connection. We see clients who don't get better because of the trauma that is trapped in their cellular memory. If we as BODYworkers do not help to directly address the tissue memory while we are working with the body, I believe we are doing our clients a dis-service. I believe that no one else out there works with the tissues of the body the way that we do. So if the client needs to dialogue about his/her car accident to fully release the neck pain that has been bothering him/her for over 20 years, I think it's within my scope to follow his/her tissues through release and guide him/her along the way.

If we don't work directly with cellular/tissue memory, who will?

Brian

Yeah, excellent comment Brian.

And I've had a client like that who showed up on my table 16 years after the car accident... never realizing that their neck issues were tied into guarding an injury that had taken place so many years before! I mean imagine what that knowledge could do for a person. Even if the myofascial restriction was not released in that particular session... the knowledge of where the 'issue in the tissue' came from is helpful to them.
And by listening should they wish to discuss it... we may find that they include more information that may help us in treating them... such as specifics of how the injury occurred. ("I was T-boned", "I was looking to the left", etc.)

And if there is a bigger issue that the client needs to discuss with a mental health professional... that's where our referral network would definitely come in handy!

I see kathryn's point... but I believe that so much of what we do all comes down to the core issue, of intent. If the intent is to support the client in their healing process... I think the client's body/mind will recognize that. If the client feels safe and supported my guess is things will probably naturally unfold.

It's definitely a fine line... and I personally wouldn't engage in dialoging with every client... but I do realize that it may be an aid to healing in the right circumstances. (A healing partnership.)

[kathryn]

Yes Brian, the way you suggest working with the client is how (as massage therapists) I do think it is within our scope of practice. You have been able to explain in a clear manner how we as massage therapists can help our clients. Dialogue with the client about memories of past injuries or if the client wants to discuss what is going on with their body is well within the bounds of our work.

My issue is with the therapists who attribute a repressed emotion with every injury and try to work this belief into the session by creating a dialogue to get the client to admit that is true. Or who are fishing for an emotional response while working a restricted area of tissue.

As Maestra wrote, there is a fine line between the two and hopefully as therapists we are aware of that line and diligent not to cross it.

[shivashiva]

Thank you Brian! Yes, I would have to agree that even, "Some feelings there, huh?" is a somewhat leading question...The most non-leading open ended phrase I use is similar to what you mentioned "What are you experiencing now?" or even "Did something just shift?" if you notice a change, and that can apply to any realm, physical, emotional, mental, etc.

Brian, every single time you talk about SER, or emotional support in your bodywork I feel intensely drawn to it, like "you're speaking my language" so I'm going to have to go look up SER now to see if there's any classes nearby I can take! I got all of my emotional training from one teacher and I'm interested in getting some other perspectives that are in the same vein. So thank you.

[cstbrian]

My issue is with the therapists who attribute a repressed emotion with every injury and try to work this belief into the session by creating a dialogue to get the client to admit that is true. Or who are fishing for an emotional response while working a restricted area of tissue.

As Maestra wrote, there is a fine line between the two and hopefully as therapists we are aware of that line and diligent not to cross it.

Exactly!! And in my opinion those are the therapists who are going into sessions with their own agenda in mind and not letting the client's body lead them.

As a bodyworker getting a session how many of us can tell when the client is following our body and when he/she is 'doing something to us'? Dialogue should feel the same way. Very natural - like you're having a conversation.

And if there is a bigger issue that the client needs to discuss with a mental health professional... that's where our referral network would definitely come in handy!

Yes! And thank you for saying that. Sometimes I forget to talk about that because for me it's implied. But yes, I often refer or at least make sure the client has some sort of support system in place! It's so important. It's another way to help make sure we don't become the client's talk therapist and stay the client's bodyworker.


Brian

[WaltFritz]

The concept of emotional pasts and scars revealing themselves during session is not a new one. In MFR training we are exposed to these issues and are taught to deal with them. The operative concept should eb that no counseling or leading is done. If a memory or emotion surfaces, simply encouraging the client to look at that issue is what is taught. Despite the fact that many believe that mental health professionals are ill equipped to deal with the tissue memory componant of trauma (an oft repeated phrase in many trainings), we are not the ones to legally or ethically best deal with these traumas. As facilitators, we can encourage exploration, but only within a narrow area of scope of practice.

In my training, assisting at seminars, as well as reading of other therapists treatment experiences, I believe that this line is too often crossed. A positive outcome as a result of this boundary crossing is often used as justification for the infraction, but that person exposes themselves to a huge risk of liability, not to mention the potential damage to a client if things go wrong. I may not be popular among my peers for these statements, though I've already given up on a quest for popularity among many in my field.

[cstbrian]

A positive outcome as a result of this boundary crossing is often used as justification for the infraction, but that person exposes themselves to a huge risk of liability, not to mention the potential damage to a client if things go wrong.

I appreciate your input on this topic. I am hoping you can elaborate on what the liability is as well as the potential damage to a client if things go wrong. What can go wrong? When the therapist is absolutely working with the client's body how is this damaging?


Brian

[WaltFritz]

Brian,
Thanks for the reply and questions. You asked "When the therapist is absolutely working with the client's body how is this damaging?". I feel that little can go wrong. The big "if" is whether the therapist is working from a place of ego or thier own sense of knowing vs. what is truly shown and led by the client. I've been doing this work for 16 years and have a wide exposure to both Upledger and Barnes trained therapists. Most do not lead and do not work from a sense of what they feel. Not all follow this priniciple, though. What both teachers teach leaves a huge space for the individual "intuition" of the therapist to conduct the session and lead it along a path. I have seen therapists who think that they are following the clients body, but patterns tend to repeat during sessions with different questions that make one wonder whether it is the clients stuff or the therapists stuff that is being processed or uncovered. No finger pointing here, just observations. If we are using the still point as a reference point for when a significant place is encountered, one must look at the research that was done a number of years ago regarding the inter-rater reliability of palpation of the Craniosacral rhythm.

http://www.ncbi.nlm.nih.gov/pubmed/8090842

If no valid inter-rater reliability exists for the CSR, how can one trust that a still point has any greater validity beyond what the therapists themself feels? Not a knock on CST, I use it daily. But all methods should be looked at from both sides.

There is a segment of the therapy community that feels that all therapists working with emotional issues such as us should be brought up on charges for inducing false memories. Google this yourself, you'll find a website that loves trashing Barnes and Upleger, as well as the therapists who do thoses works ( I do not need to give them more publicity here). I amy not agree with how they view my work, but many very vocal opponants exists.

What liability do we face? Practicing outside of one's professional practice act would be one huge liabilty. I don't think any of us want to go there. What damage can be done? I am assuming that you meant to the client, right? If one leads, etc, I think that great damage can be done. It is difficult to tell whether the memories or emotions that come up on the table are real, factual events or simply metaphoric representations of other problems. I am not in a position to judge this. The process needs to be one of allowance, not leading. Any more than this puts one at risk for a lawsuit and puts the client at risk for further damage. If you are practicing CST or MFR within the confines of this, you have nothing to worry about. But, please be assured that many push the envelope much further than this. And when teachers are implying that the mental health profession has it all wrong and that we can help the client through this more effectively, we have things to worry about.

[cstbrian]

Brian,
Thanks for the reply and questions. You asked "When the therapist is absolutely working with the client's body how is this damaging?". I feel that little can go wrong. The big "if" is whether the therapist is working from a place of ego or thier own sense of knowing vs. what is truly shown and led by the client. I've been doing this work for 16 years and have a wide exposure to both Upledger and Barnes trained therapists. Most do not lead and do not work from a sense of what they feel. Not all follow this priniciple, though. What both teachers teach leaves a huge space for the individual "intuition" of the therapist to conduct the session and lead it along a path. I have seen therapists who think that they are following the clients body, but patterns tend to repeat during sessions with different questions that make one wonder whether it is the clients stuff or the therapists stuff that is being processed or uncovered. No finger pointing here, just observations.

I do agree with you on many points here. I'm not trying to 'knock' my colleagues but I believe that there are few who practice CranioSacral Therapy who are truly working within the paradigm. Intuition does play a big part in the work, as I believe plays a big part in all effective bodywork. It's often the therapist's diagnostic intuition that leads him/her to the primary restriction (no matter what modality we are talking about). CranioSacral Therapy is no different.

You bring up a good point with regards to patterns being the client's stuff or the therapist's stuff. Once a therapist decides to add SER work to his/her tool belt, I believe it is his/her responsibility as a therapist to get worked on regularly to help clear out his/her own emotional issues. From SERI and beyond there is a large component of the class that is about processing your own 'stuff' as a therapist. The more one works on and realizes what his/her issues are, the more effective, grounded, and neutral the therapist can be in a session.

If we are using the still point as a reference point for when a significant place is encountered, one must look at the research that was done a number of years ago regarding the inter-rater reliability of palpation of the Craniosacral rhythm.

http://www.ncbi.nlm.nih.gov/pubmed/8090842

If no valid inter-rater reliability exists for the CSR, how can one trust that a still point has any greater validity beyond what the therapists themself feels? Not a knock on CST, I use it daily. But all methods should be looked at from both sides.

I agree: we should look at both sides. So I need to say a few things about this study.
First of all, about studies in general. I believe that what one sets out to prove in a study he/she will prove. What one sets out to dis-prove, he/she will dis-prove. How do you explain so may contradictory studies about Echinacea, Kava, acupuncture, acupressure, massage, etc.

Secondly, the study only involved three people trained in CST, does not discuss what level or type of training they have, and how long they have been practicing. All of this makes a huge difference in one's ability to assess the craniosacral rhythm (CSR) effectively. We have done exercises in class and in study groups (with advanced trained, well practiced therapists) where one person evaluates and writes down what he/she finds. A second person evaluates and writes it down as well. Notes are then compared. The amount of times therapists get the same findings are very high. Try this 'experiment' in a CSTI class and I'm sure your findings would agree with the study's results.

Third, the study was done with the belief that the CSR doesn't even exist (as most studies about CST are done). Check out this article at Massage Today which explores the controversy of cranial bone movement. Most people in the medical field still believe that cranial bones fuse in early adulthood. So, how would any of them possibly believe that there is a CSR?

There is a segment of the therapy community that feels that all therapists working with emotional issues such as us should be brought up on charges for inducing false memories. Google this yourself, you'll find a website that loves trashing Barnes and Upleger, as well as the therapists who do thoses works ( I do not need to give them more publicity here). I amy not agree with how they view my work, but many very vocal opponants exists.

Unfortunately, I do know that these people exist. I say 'unfortunately' because I don't think these people care about the positive outcomes of our clients and will never look open-mindedly at these types of therapy. I know in your last post you mention "positive outcomes being justification for the infraction"; but what's wrong with positive outcomes? If the outcome is positive what's the problem?

What liability do we face? Practicing outside of one's professional practice act would be one huge liabilty. I don't think any of us want to go there. What damage can be done? I am assuming that you meant to the client, right? If one leads, etc, I think that great damage can be done. It is difficult to tell whether the memories or emotions that come up on the table are real, factual events or simply metaphoric representations of other problems. I am not in a position to judge this. The process needs to be one of allowance, not leading. Any more than this puts one at risk for a lawsuit and puts the client at risk for further damage. If you are practicing CST or MFR within the confines of this, you have nothing to worry about. But, please be assured that many push the envelope much further than this. And when teachers are implying that the mental health profession has it all wrong and that we can help the client through this more effectively, we have things to worry about.

I guess I need to make this statement ...
By no means do I believe that I am 'perfect' in regards to my work as a bodyworker practicing CranioSacral Therapy. (And no, I don't believe anyone has made any claims or questioned my work.) But I do believe that I very closely follow the true paradigm of CranioSacral Therapy in that the session always comes from the client. I have done a lot of practicing, training, working with highly skilled therapists and most importantly, I continue to get on the table and do my own work.

The reason I make this statement is that when I make any posts related to CST/SER it is from this place that I speak (well, type). I know that there are bodyworkers out there who practice CST/SER that are not truly in 'the zone' and are just 'doing' CST to a client. My goal with my posts (and CST education in general) is to get people to understand what the core of CST work truly is and how it can support our client's health.

I understand there are those out there who push the limits and bring in their own stuff and their own agenda. I believe the same to be happening in the massage field. Or any bodywork field for that matter. After taking classes, one will interpret the information he/she receives based on his/her past experiences and how he/she wishes to interpret and integrate the material. There are no 'Cranio-police' out there monitoring everyone's work.

It is those who practice in this way that bring about the question of practicing outside our scope. It is those who I encourage to re-take classes, join study groups, find mentors, and absolutely get worked on themselves. And yes, it is out of our scope to be talk therapists and some therapists go there. Perhaps it is too much of their desire to 'fix' or to be the perfect therapist so the client comes back, or the therapist's own need to be important in his/her client's life. Whatever the reason, some do take it too far.

I am glad to be having such an open, honest discussion about this topic. I think there are lots of things that need to be said about this work that people have been afraid to say. I hope to continue to provide some clarity and insight into the process. Yes, I am a bit biased because of my extreme passion for this work, and I do try to stay open to both sides of the debate. But it's hard for me to not stand up for the work when the results are so positive and so many people are helped.


Brian

[WaltFritz]

Brian,

I agree with everything that you've said. There is a research article from a number of years ago that supposedly found that an MFR leg pull is less effective than a more traditional contract-relax type of procedure, when looking at hamstring length. On the comments section of my website,

http://www.myofascialpainrelief.com/Res ... ments.html

I have voiced my concerns over the design of this study as well as other studies, and it mirrors some of your concerns over the CST article. Research often proves what the testor wants it to prove, despite claims to the contrary.

There are police out there for both MFR and CST, though their voices are seldom paid attention to. Internal regulation by either group seems slim. From an MFR perspective, it is only when one voices dissent on a sanctioned forum that one receives a slap or banning. Though this seems seldom related to mis-deeds in the clinic rather, it is publicly dissenting from the party line. External policing only happens when a patient percieves that malpractice has occurred.

You asked "but what's wrong with positive outcomes? If the outcome is positive what's the problem?" If the method of treatment is outside of our accepted practice act, it becomes a problem no matter the positive outcome or not. Purposefully placing a client into a position of past injury or trauma, knowing that the person is holding onto memories from this event, and simulating or triggering a response I believe is out of bounds. But this is a condoned and often taught technique. Does a positive outcome justify this?

As a licensed health professional, I believe that one must look beyond what might be taught to us and ask whether it is right, ethical, and legal. Most practitioners do so. The overly enthusiastic or biased ones are the therapists I have concerns about.