Ep 171 – Don’t Let Your COVID Guard Down with Cal Cates

A pair of hands holding a paper surgical mask.

In this episode of The ABMP Podcast, Kristin and Darren are joined by Cal Cates to discuss what it means to stay resilient with masking practices, understanding “mask fatigue” and “COVID fatigue,” why the mask you are wearing is the right mask to wear, and how high-risk individuals are more common than you would think.

Read Cal Cates’s article in Massage & Bodywork magazine here.

Author Images: 
Cal Cates, founder of Healwell.
Author Bio: 

Cal Cates is an educator, writer, and speaker on topics ranging from massage therapy in the hospital setting to end-of-life care and massage therapy policy and regulation. A founding director of the Society for Oncology Massage from 2007–2014 and current executive director and founder of Healwell, Cates works within and beyond the massage therapy community to elevate the level of practice and integration of massage overall and in health care specifically. Cates also is the cocreator of the podcasts Massage Therapy Without Borders and Interdisciplinary.


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Full Transcript: 

0:00:00.2 Speaker 1: The Elements Massage brand believes massage therapists deserve a supportive team, business and marketing resources, linens, lotions, and the chance to learn as much as they want. So many Elements Massage studios offer continuing education too. What's better, they're hiring. To get your foot in the door, let them know we sent you by visiting elementsmassage.com/ABMP. That's elementsmassage.com/ABMP.


0:00:41.4 Darren Buford: I'm Darren Buford...

0:00:42.7 Kristin Coverly: And I'm Kristin Coverly.

0:00:43.7 DB: And welcome to The ABMP Podcast, the podcast where we speak with a massage and bodywork profession. Our guest today is Cal Cates. Cal is an educator, writer and speaker on topics ranging from massage therapy in a hospital setting to end of life care and massage therapy policy and regulation. Cal is the current executive director and founder of Healwell, a non-profit organization that works with children in hospitals and clinical facilities. Cal also trains massage therapists about sustainable caregiving, as well as partners with hospitals to conduct research about the effects of massage on people living with illness. For more information, visit Healwell.org Cal is also the host of the podcast, Interdisciplinary found everywhere podcasts are available. And Cal is the columnist for Massage and Bodywork magazine. Today we're talking about the newest column in the November December 2021 issue titled, Don't let your COVID guard down.

0:01:36.5 DB: Hello, Cal and hello Kristin.

0:01:38.2 Cal Cates: Hello.

0:01:39.0 KC: Hi, thank you so much for being back with us, repeat, ABMP podcast guest. Hey, we're so excited to talk to you today, but before we get to our hot topic, let's set the stage for listeners who may not be familiar with Healwell and everything you do. So give us a little bit of a recap on Healwell's mission and the work that you do in our profession.

0:02:01.8 CC: Yeah, well, Healwell's mission, we're actually presently retooling our mission because our mission used to be improving quality of life for people affected by acute chronic and serious illness through massage therapy, research and education, and we do that, but we do a lot more than that now. And we've kind of really come to terms with the intersectional possibilities and really imperatives of doing that work, so looking at what are the things that prevent massage therapy from being a more mainstream piece of medicine, and a lot of that is just straight up like run of the mill textbook ignorance meaning not knowing on the part of providers. But it's not just not knowing about massage, it's not even understanding that massage therapy is really an interpersonal experience more than a pair of hands, and much of the research that's been done about massage therapy in all populations, 'cause there really hasn't been a lot in people with serious illness really focuses on the intervention, but it doesn't look at the experience of the person who might be receiving the intervention and what happens in that interaction between the provider and the receiver.

0:03:09.1 CC: And then we also have found that just what we've learned as massage therapists at the bedside of really ill people and working with their families is not taught to most mainstream healthcare providers. So we offer a lot more training now in compassionate communication and sort of the juicy parts of ethics. Not the sort of like, "Do this, don't do that," but really like, "Why is ethics so rich and interesting and how is it that actually... How do we work in a world where there isn't a black or a white?" It's like, "This is sort of right," depending on the context and when you're working with people in serious illness and things like... What kind of questions come up? And I think really a big part of that, as well as just the Equity and Access work that we've been doing since we started in 2010, but really highlighting that now and bringing that more to the fore obviously, unfortunately, George Floyd's murder really sort of made people more willing to talk about that and certainly made funders more interested in supporting programs that bring things like massage therapy that are typically relegated to the luxury space to the people who really need them, who are living with serious illness, who would never even think about massage therapy.

0:04:20.4 CC: So we offer courses, we have about 20 therapists who are employees of Healwell, who work in hospitals and clinics around the Washington, DC area, and we partner with many of those facilities, as you said, to do research and then ideally to publish papers about what we find out when we do that research.

0:04:36.9 DB: So let me follow up on that, because when we first started the podcast, and you were our first guest, so when we first started the podcast, we were talking at that point, that was early in the pandemic, and you had ceased all work. So since then, you've gone back into work in the hospitals. What is that like right now?

0:04:55.9 CC: Yeah, well, it's interesting because for us, we have been working with contact precautions and personal protective equipment forever, they're just sort of the normal trappings of a hospital environment. We still... Our therapists at least typically don't go into work with folks who have COVID and really... It's an expense issue as much as it's a personal risk issue, because going into the room to work with a person who is affected by COVID, you're looking at a lot of money and personal protective equipment for each entrance into that room and for an intervention that certainly would improve their quality of life, but is unlikely to save their life, basically, hospitals are just kind of saying, "Let's limit risk, let's limit expense, let's really have you continue to focus with other patients that you typically work with."

0:05:42.6 DB: So what might you be wearing... You mentioned you were already wearing... You've already been wearing PPE forever. Has anything changed when you're working with non-COVID patients?

0:05:53.4 CC: I would say overall, the hospitals are just more vigilant about PPE and about... People just... Humans get lax. And when there's not a global pandemic happening... Well, a pandemic, 'cause pandemic means global, when that's not happening, people are like, "Well, you know, I mean, I can wear the same mask here and there etcetera," and certainly because shortage people were doing that even at the height of COVID. But I think generally just there's more awareness of cross-contamination and general infection prevention and control.

0:06:31.0 KC: Cal, I'm so fascinated because you are in a unique position, you've actually been in an ICU ward, even though you didn't go into the room of a COVID patient, but you were able to observe the nursing... Nursing staff and doctors going in and out, and the level of PPE, the level of care, the level of machines. I don't think any other massage therapists or very few have had the chance to really see that with their own eyes. Can you tell us a little bit more about that?

0:06:56.6 CC: Yeah, well, it was really interesting because now that the COVID numbers are down more than they were, and honestly, here in Washington, DC, and a few hospitals that we're in were probably... We were actually on inpatient units and seven different hospitals, and the numbers are down to the point where COVID patients are not being shunted to other units. They don't have a dedicated space. So at this time, the ICU, which our ICU has about 29 rooms. It was kind of a ghost town, there were maybe eight other patients on the unit, and then this one gentleman who had COVID and it was... There were machines all outside the room, there were three physicians and two nurses and a respiratory therapist who were actually rounding at the time that we were there, seeing patients. And it was incredible because in their very typical way, over the time that we've built relationships in this hospital, they're very open to our questions, and so they were clearly... The immediate care for this patient had been done for a little bit and they were just sort of discussing his case, and we were able to ask questions about the proning process and why it's beneficial, and just sort of, "What is it like to care for a person who is so incredibly frail and complicated?"

0:08:10.6 CC: And that many of the people... And in this particular person's case, he was a young otherwise healthy person, so they're caring for this person who now, any decision about his care could mean the difference between him surviving COVID or not, that there's a real sort of disconnect with this idea that this person was just out in the world, and then picked up this virus and is now fighting for his life, and the amount of the number of staff and the intensity of care and just how... I tried to imagine... There's just this one patient right now, but that even just six, eight months before that, this was all of the patients in this unit, and just the incredible strain on resources, human and mechanical and just... It does sort of... It's hard not to go to the place where you just wanna go and slap a mask on every person you see in the world and be like, "It's real. Please care about this."

0:09:06.7 CC: But yeah, that was the first patient that I had actually seen live being treated for COVID and the stories and the magazines, and even on the news, to be in that place right next to those people and next to those machines was really an eye-opening experience. And I was glad that we were there with students because the students were like, "Oh okay, I get it now." And you can't... Even the best writer or the best story teller, it just paled in comparison to being right there.

0:09:41.2 KC: Oh, of course, that impact... You must have been able to feel it emotionally and physically, just feel...

0:09:47.5 CC: And the loneliness, I think too, because typically, there are many... The ICU is more strict generally about visitors, especially for people who are particularly dealing with a complex condition, but there was no one there but staff. And to just to know the data about people surviving or not, who have been on ventilators or other sort of life sustaining equipment, having family members, hearing those voices, having people touch them, just the incredible human toll of what we had to do in treating people for COVID and preventing them from seeing their families, and just the ripple of suffering and loss from that and not being able to be present, saying, saying goodbye to your family member on a tablet that a nurse is holding. These are the things, and in our interdisciplinary community online, some of the nurses and social workers and chaplains talking about like, "It is hard to be present for the end of a person's life regardless, but to be holding up a piece of technology so that people can talk to their person who maybe is ventilated and can't speak is... "

0:10:54.3 CC: I don't even know how you begin to kind of integrate that as an experience that you've had in your life. And then to have it over and over over the course of 18 months or two years...

0:11:03.0 KC: Yeah, we have no idea, like you said, we can hear the stories, we can see it on the news, read it in a printed article, but it's not the same as seeing it, observing it or living it, for sure. Something that struck me too what you said is, this particular COVID patient was otherwise a young healthy male walking around the world, so he could have easily have been a client in anyone's private practice. Let's switch gears and talk about our private practices a little bit. Have you started yours again?

0:11:30.7 CC: Yeah, as the Executive Director of Healwell, I have very few clients in my private practice that I see anymore, but I have... During COVID, because of all the things that happened to so many of us, I actually moved to a much smaller place, so now my private practice is in my living room, so I have... I had started at that point, I guess it's been since vaccinations became available, so probably last January, I started to see just a few clients in my home office.

0:12:00.3 KC: And are you... What is your masking policy, vaccination policy? Walk us through all of it, how do you communicate that with clients, what are your rules and regs have you set?

0:12:09.4 CC: Yeah, well, I think I am certainly in the luxurious position because I have a very private practice, and most of the clients that I see are people that I've known for a long time, and so talking with them about their comfort level, are they vaccinated, are they not vaccinated, no one that I see isn't vaccinated. So I haven't had to make that call exactly. But what I do is just say, "I want you to feel as comfortable and safe as possible." I open the windows, still one of the main things, even before masking and physical distancing is air circulation, so having the windows open having a fan going, just making sure that that area is changing out on a regular basis. And I don't usually see people in a row, so I'll see one person and then I won't see another person for a couple of days, probably.

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0:13:37.0 KC: I'm in a very similar situation to you, because of my full-time job at ABMP, I have a part-time practice in my home, and so I've been seeing the same people for 15, 20 years, but same... I haven't had those conversations because most of my clients are vaccinated, they're mostly health care workers, one of them has a spouse who's in a compromised medical condition. But I do have everyone wear masks. I wear a mask, they wear a mask and no one has given me one piece of questioning about it. Concerned about it, everyone's like, Thank you. Absolutely. That's really the response. Thank you. Absolutely.

0:14:12.6 DB: So this is a good segue to the article that you wrote for Massage and Bodywork magazine about not letting your guard down with regards to COVID. What prompted you to write that?

0:14:21.9 CC: Well, it's been really... I've struggled from the beginning with the way that the massage therapy profession seems to have divided itself much like the country, in terms of how seriously to take COVID or if even to take it seriously. And I know that so much of that is also led by and guided by where people practice and the politics of where they practice. And it's deeply heartbreaking to me that this has become a political issue. It's not politics. It's science, it's a virus, it exists whether or not you believe in it. And I think I really struggle, especially as we... I started to see people become vaccinated and also not become vaccinated, and this idea that if you're vaccinated, it's all good. And I really wanted to be clear that it is great, get vaccinated, we need to be vaccinated if we have any hope of slowing the possibility of additional variants and really getting back to something that is vaguely normal, which I mean, I'll be the first to say what we were doing before, wasn't normal. I have no interest in going back there, but I know that a lot of people are really interested in going back to something that was like our pre-COVID lives, and the best way to do that is to get vaccinated and also to continue to mask and to continue to take this seriously.

0:15:43.5 CC: And I think it really set us off on the wrong foot that the leaders at the time that COVID came to our country, just said, "I don't know, is it real is it not real?" And kind of made it about China and made it about things that weren't about what we were talking about. And I kept hearing people saying, "Well, you know the vaccine, it was created really hastily." And this is the beauty and the curse of a column is you have 800 words to make your point. And when I first write my column, almost every time, it's like 2000 words, and then thankfully I live with another person who's a really good editor, and she's like, "Wow, this is too long." And I'm like, "I know, but how am I gonna rid of those 1200 other words?" And so I thought, "What is digestible in a column?" And all of those other issues are big and important, and I want everyone to know that actually this vaccine has been in the works for 20 years, because this is not a brand new novel virus, even though we called it the novel virus, like the COVID strain is a thing that has been around the SARS, and so we were luckily ahead of the curve in creating that vaccination.

0:16:47.1 CC: But even if you are vaccinated and even if your clients are vaccinated, they are going out into the world with people who are not vaccinated and that we don't know, particularly if we are vaccinated, if we're carrying the virus because we're likely to be asymptomatic. So you see your client, you don't know who they live with, who lives with them, who they might encounter after you have seen them. You don't know where they've been. What they're bringing to you, if you're gonna see... I think Kristin, you and I acknowledge that the way we practice is somewhat unique. Many of the people who are probably listening to this podcast and who are ABMP members, see two, three, eight people kind of in a row. So the idea that we can sanitize and freshen the air and do the things that we need to do to keep all eight of those people and all the... Let's say they each only interact with eight other people, that's still a lot of people. And when you look at what's called the R-naught, which is sort of the contagious rate of the virus, the Delta variant in particular is really contagious, so it's an R-naught of six or seven which means that you are likely, if you're carrying the virus to infect up to six or seven more people just by walking around in the world.

0:18:02.7 CC: So we need to wear masks. I get it, I'm over it too. But you know what, I'm not over dying from COVID or giving COVID to someone who has trusted me to care for them, and I think this is... We have to come back to what's happening here, this is not political, it's physiological, it's... Our immune systems have demonstrated that without the help of a vaccine, we are not able to fight this, and we've also seen that with the Delta variant, it really spreads quickly, and the longer we go allowing it to spread, the more variants, the smarter the virus gets, the less able we are to manage it. And that as massage therapists, we're a hub, we see so many people, we're just sending out rays of people out into the world, and we can just put a mask on. And it's really funny because I... In my original version, I suggested that if you don't wanna wear a mask, you should have everyone who comes into your practice sign a form that says, "I understand that my healthcare provider is unwilling or unable to do the bare minimum it takes to protect me and my health." And I guess Darren thought that was a little too in your face, which I get.

0:19:14.3 KC: Did I get the red pen?

0:19:17.6 CC: But you know part of why we're in so many of the pickles we are in our world today is 'cause people don't wanna say what's true, and what's true is that it's not that hard to wear a mask, and in the article, all the experts say, which mask should you wear, the one that you're gonna wear and that's gonna cover your nose hole and your mouth hole, that's it. Don't get paralyzed about, "Should I wear an N95, should I wear this... " Put a thing over your your mouth hole and your nose hole and where it consistently. That is the thing that's gonna work. So my hope was to just offer that simple piece of advice, knowing that we can get into analysis paralysis with what kind of air filter should I have, what kind of this should I have? At the bare minimum, you should be masking and your clients should be masking.

0:20:03.4 DB: I think it's interesting right now because we're fighting a different battle than maybe a conversation we'd be having a year earlier, we'd be having a very different discussion about whether to mask up or not. And really, what your column about is about, is about the complacency that we're now all of us experiencing right now. You're in a pretty public position, so are you hearing pushback from any other practitioners or anybody on your staff with regards to that?

0:20:33.1 CC: We're pretty no-nonsense with our staff and our staff are employees, so they basically have to do what we tell them or they don't work for us. Which is part of why we made our folks employees a couple of years ago, because working in the environments we work in, there's not room for you to decide that you don't want a flu shot or that you don't wanna wear a mask or the other things that technically would take us out of the realm of reasonably having them be contractors. But I think it really comes down to people being uncomfortable telling other people what to do. And I really struggle with that because as a healthcare provider, if what I am asking you to do, hopefully, I don't have to tell you. What I'm asking you to do is to keep you and me safe and healthy, and I'm not infringing on your rights, I'm not... And I have a complicated relationship with the idea of whether or not you have to demonstrate to me that you've been vaccinated. I get that people wanna keep that private and... But I do think that it's not an infringement for me to ask you to wear a mask.

0:21:34.4 CC: A because it's... You can breathe, people have been working in masks for a real long time in other environments. And B, because if you're coming to my office, you can go somewhere else and get a massage where maybe they won't ask you to wear a mask, I mean, it's a free country as they say. So here, if you're gonna receive treatment from me, this is what I require, you can meet me in this place or you can go somewhere else. But I think people use the huge body of information about types of masks and ways to prevent spread as an excuse to just say, "Forget it, I just can't be bothered." And unfortunately, what we're finding is just a lot of individual converts who unfortunately lose a family member or lose a client or lose someone in their life that makes them go, "Oh, I guess it is really serious and really contagious, but it doesn't spread." We still have that thing of like, "Well, those are the outliers," and I'm not really sure what the cognitive dissonance is or how it continues to persist. But it does and America is really holding that line of like, " Well I don't know how serious it is." And like, "Well, we're kind of leading the world in deaths, so I guess it's pretty serious."

0:22:43.1 KC: And then Cal, I have some colleagues and friends who are absolutely trying to do their best by their private practice, by their clients, by themselves, all of it, so they're really paying attention to city and county rules regarding masking. And so when a city and county rule changes, they change their practice in accordance, but then the county rule and city rule changes again and they change back, so they're finding themselves in this sort of yoyo position. What kind of advice or a response do you have for someone who's in that response position? Respond and change, respond and change.

0:23:17.7 CC: Yeah, I think, don't. I mean the thing is that the changing of the county codes and the state codes is politics, it's showing that you can be more free now because the numbers say you're less likely, but the numbers don't account for Aunt Tilly who drives across town to see her grandkids or for whoever flies in for somebody's birthday or the numbers can't... They're just a number, they don't actually track the individual movements and behaviors of humans. So until COVID goes away, there's really no need to stop masking. I think we're far from when... I personally, I wear a mask every time I leave the house, when I go to the grocery store, when I go anywhere, and I think that we really need to just settle in and get used to that, and I think there's a real small number of people who can't find a mask that will work for them? That people say, "Well, I can't breathe in a mask." I get that it's annoying. I just flew this weekend and they canceled my flight on the way to the airport, so I sat at the airport for six hours in my mask, and then I got on the plane and I flew two hours and then I laid over for another hour. I wore my mask for I don't know, 18 hours. Did I love it? No, I could breathe. I'm gonna make it.

0:24:35.4 DB: Yeah, that's a really interesting Cal, because the physical therapist office that I go to, and there must be 20 to 30 practitioners in there. I speak to the owner occasionally, and he said... I've asked him with regards to masking or just any new cleaning policies, it was like, "You know, are you gonna go back?" and he's like, "No, I should have been doing all of this before." So as far as cleaning all the equipment after each user or wearing masks, he's like, "Yep, that's just gonna be standard from here on out." And he goes, "And this gave me permission to do something I should have already been doing, to be honest."

0:25:11.9 KC: Same at my practice. That's how I feel too. Yeah.

0:25:14.1 CC: That's what all the hospital-based practitioners that I know when this first started, were like, "Yeah, welcome to our world." Really, we should have all been doing this for a very long time. And I understand and have real compassion for the massage therapists who were like, "I'm out, that's not what I signed up for. I wanna walk downstairs in my bare feet and throw a blanket on the table and not think about it." That's cool, and that's over. So I get it if that doesn't fit for you, but this is really a place where we can't deny that we're healthcare providers anymore and that it really... Yeah, we could and should have been masking and cleaning and doing all the things that we're now doing a long time ago, and should just keep doing it even hopefully when COVID is under control and gone the way of polio.

0:25:58.9 DB: Cal, I don't know if you remember from the column or not, but you list this insane stat about how few people have had the flu, do you remember what that is off hand?

0:26:07.3 CC: I don't, it's less than a 1000. In the last two years, each year, it was under a thousand people who got the flu.

0:26:16.1 DB: And why is that?

0:26:19.3 CC: Well, I'm so glad you asked Darren. We can't know for sure, but the people who know these things draw a pretty straight line to masking and lack of flu transmission. 'Cause the same number of people got the flu vaccine, people behave the same way they were behaving but the masking seems to have made a pretty big deal. And I've talked to a bunch of people who said like, "Forever now, during flu season, I will just wear a mask even if we reach a place where COVID is under control and that's not a thing that we do like... " Nobody wants the flu. And while, "Most people don't die from the flu," do you wanna risk it? Like, I don't.

0:27:00.8 DB: Something's workin' there, man.

0:27:01.4 CC: Something is working.

0:27:03.2 DB: You know what, I'm gonna say something. So we've gone back to a hybrid policy where we work in the office three days a week, and I get a cold, and you know what's not fun, having a cold after you've had not had one for two years. It's absolutely miserable. I totally had forgotten how awful that experience is for fourteen days.

0:27:20.7 CC: Right. Oh that's rough.

0:27:22.4 DB: I just kept shaking, it's terrible.

0:27:25.3 CC: Yeah.

0:27:25.4 DB: Thank you so much, Cal, for joining. This was really important again, to revisit, because the complacency is out there, we all feel it, it's just... But we need to wear masks, that's what we're getting down to people. That's what we're getting to. I wanna thank our guest today, Cal Cates. For more information, visit Healwell.org. ABMP podcast listeners, ABMP members have access to more than 50 discounts through their membership. Services include discounts on continuing education, home utilities and cell phone service, legal fees, office equipment, and more. Go to ABMP.com/discounts to learn more. Thanks, Cal. Thanks, Kristin.

0:28:02.8 CC: Thank you guys. It was great to be here. Always fun to hang out with you guys.

0:28:04.5 KC: Same, and thanks so much for addressing what really is a hot topic and one that can be controversial, and one that all those of us who are in practice think about every day with every client. So I really appreciate you tackling what can be the tough topics. We appreciate it.

0:28:21.3 CC: Well, and I do wanna say that if you wanna talk about this and other hot topics, you should come to the Healwell community, community.healwell.org and we'll chat it up.

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A recent study found that touch interventions were effective in helping regulate cortisol levels, reducing feelings of depression in adults, and having other significant benefits.

Louisiana Bill Proposes Massage Program Hour Increase

Effective October 1, 2024, Louisiana massage students will no longer be eligible for federal financial aid because massage programs are limited by Louisiana law. But there is a solution: Senate Bill 353 will increase the required education hours for massage licensure from 500 to 625. ABMP fully supports this bill, and we explain why you should too.


ABMP CE Summit: Headaches


Join us online Tuesday, April 30, 2024, for the ABMP CE Summit: Headaches, which take learners on a journey from understanding headaches to working with clients with headache pain using multiple modalities and techniques.


Podcast: Cancer, Clots, and COVID—A Complicated Client

A client was recently treated for colon cancer—and it didn’t go well. She had surgical complications, a bout of sepsis, and more. Is massage therapy safe? We discuss on this episode of “I Have a Client Who . . .” Pathology Conversations with Ruth Werner.

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