When a client walks into your treatment room, they are asking for your hands to help them. But oftentimes, they are also asking—whether explicitly or implicitly—for us to tell them what’s happening with their bodies.
In this episode of The ABMP Podcast, Kristin and Darren sit down with David Lobenstine to discuss his latest article in Massage & Bodywork magazine, “Leave Diagnosing to the Doctors,” what the differences between assessing and diagnosing are, consequences to talking to clients in ways that aren’t helpful, and how to create possibility in a session.
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0:01:33.9 DB: I'm Darren Buford.
0:01:34.6 KC: And I'm Kristin Coverly.
0:01:35.6 DB: And welcome to The ABMP podcast, a podcast where we speak with a massage and bodywork profession. Our guest today is David Lobenstein. David has been massaging, teaching, writing and editing for over 15 years. He's an authorized instructor of pre and perinatal massage therapy workshops, and co-author of the book, Pre and Perinatal Massage Therapy. He also designs and teaches his own continuing education workshops, both across the US and online. For more information about David, visit bodybrainbreath.com. David is also an author for massage and bodywork magazine, and today we're gonna discuss his most recent article, leave diagnosing to the doctor, in the March April 2022 issue. Hello, David. Hello, Kristin.
0:02:18.2 David Lobenstein: Hey guys.
0:02:18.7 KC: Hi, David, welcome back to The ABMP podcast. We're excited to have you with us again.
0:02:24.2 DL: Likewise, likewise, always a delight to be here.
0:02:27.8 KC: And we've got something really interesting to talk with you about, so as Darren mentioned in the bio, your most recent article for massage and bodywork magazine is titled Leave diagnosing to the doctor, how our friendly advice can backfire. That's a big title. So let's talk about it a little bit more. What was your impetus for writing the article? Was it something you've been thinking about for a while? Was there one occurrence that sparked that idea? Tell us more about that.
0:02:55.6 DL: Not a single occurrence, I'd say more endless occurrences. I think the longer I'm in this business and the longer that I'm working with other massage therapists, I think the more fascinated I have become with how our good intentions can go awry, and so the very obvious manifestation of that that a lot of us are unfortunately all too aware of is physically... We really wanna be good therapists, which often means that we put every possible fiber of our muscles into our work and we over-exert ourselves, we get repetitive stress injuries, etcetera, we have all kinds of physical issues as a result, but then there is this whole other realm as I see it, of emotional and intellectual good intentions, where we really want to help our clients understand their bodies and understand what they're going through, and so the way that we talk with them, as well as the way that we actually work on them, I think can pose these problems and again, our best intentions to be good therapists and to help our clients have these unintended consequences.
0:04:15.0 DB: So David, I have a question, what's the difference between assessing and diagnosing and how do MTs walk that slippery slope?
0:04:23.3 DL: It's a great question, and I think it's one that we often don't spend enough time on in massage school, and then the longer we work kind of the murkier that boundary gets, that slope gets more and more slippery, so we all know the basic rule massage therapists are allowed to assess, but they're not...
0:04:46.5 DL: We are not allowed to diagnose, and so I think the easiest way to remember this is in terms of our skill sets. The people who do the diagnosing are doctors, they are the ones who can look at a patient's set of signs and symptoms, and then they can come to a diagnosis about what's happening, whether they have sprained an ankle or whether they have any number of medical conditions. We can have a whole separate discussion about how accurate those diagnoses are and the problems with those diagnoses but that is one box. The doctors have that skill set of being able to say, You have high blood pressure or you have type 2 diabetes. Then us massage therapists, we have a very different skill set. So what assessment means is that we can use the skills that we learn as a part of our training, whether that's stretching, whether that's doing rudimentary Physical Therapy tests, whether that's just our own palpatory skills as well as integrating our understanding of anatomy and physiology and neurology, and so we can come up with an assessment of the conditions of the muscles and joints that we are working on, but the key to remember is that our assessments are always tentative, are always about the state that we see or that we feel the muscles are in and they are not a clinical medical diagnosis.
0:06:28.9 DL: We cannot tell someone, You have carpal tunnel syndrome, what we can do is we can do an assessment and we can say, It feels to me like you have some tightness in your flexors or your extensors of your forearm, and you might wanna go see a doctor for further information. So those are the boundaries, but as we can all, I think probably know from our own experience, those boundaries are easily blurred.
0:07:04.6 KC: Okay, David, you write that there are consequences to talking with clients in ways that aren't helpful, really curious about that Can you give us some examples of how we might be talking to clients in ways that aren't helpful and what those consequences are of doing that?
0:07:21.1 DL: I think here, it's important to come back to our good intentions, and I think that's where this discussion needs to start, is that I don't believe any massage therapist intentionally goes out to say, I'm going to tell you what's wrong with you, and I know how to fix you out of any kind of malice or desire for profit or anything like that, so everything that I'm saying here is said with love to my fellow massage therapists and without judgment. This is the situation that we're in because we wanna help people. So the issues that I see both in my own practice, and I will be the first to admit that I can blur this line to, and as I see in the folks who come to workshops with me, who I teach, as well as the folks who I worked at with spas and chiropractors offices for endless, endless years is that what happens is clients are eager for answers. It's hard to get an appointment with your doctor for more than 15 minutes once a year, it's hard to know what is happening with our bodies, so our clients are eager for answers. As massage therapists, we know we're eager to help, so what happens is, even if we don't intend to often seem like we are supplying the answer, and so when we talk with someone who, for example, has those symptoms of carpal tunnel, to use that earlier example, it is all too easy for us, because we do have a fair amount of training and because we can do some assessment tests and because we do feel a lot of muscles.
0:09:09.6 DL: It's all too easy for us when the client says, I think this is carpal tunnel, for us to say, Yep. It's definitely carpal tunnel. Here's what we're gonna do, I'm gonna work with you. This is how we're going to fix it. None of that is... It is technically wrong, that's the whole point, but none of it is bad, none of it is malicious, it's all done with our open hearts, but the problem is, and these are the consequences that you were mentioning, Kristin, is that A... We are technically overstepping our best practices for our industry, and B, we are confirming something in our client that then limits how the client might see themselves. The client... I hate to say it, but chances are, the client thinks they have carpal tunnel because of something they read online, chances are they haven't gone to the doctor and actually got an X-ray or gotten a more detailed assessment that a doctor would give, chances are they can't get an appointment with their doctor either. They went online, they saw the signs and symptoms, and so they assess themselves, and so if we are confirming that "diagnosis," that self-diagnosis, that's already simplistic, what we're doing is we're already narrowing the possibilities for what the client does next. We're already locking the client into that idea that, yes, I have this problem, and then what are the results of that?
0:10:52.0 DL: The results of that are that they think they have this big problem with their body, and we don't know that's true, so we might be able to help them even after saying that, we might have the manual skills to give them some relief, but it would be far more effective and more ethical, if we left the conversation open from the get-go, say, I hear what you're saying, let's explore the possibilities for what it might be, and then proceeded with our therapy and further conversations with them, as we can talk about in a few minutes. And continue to keep their options open, to keep their possibilities open.
0:11:35.5 DB: David, do you have to sometimes face the coercion or persuasion of the client in that situation, because they're probably seeing you in a power differential. You know more than I know, surely you can tell me this.
0:11:52.1 DL: Absolutely, absolutely, and I think that speaks to that eagerness of our clients for answers, they want answers, however they can get them, even though they all search the internet, they know that the Internet isn't the best possibility, so they see us, we are available, and yes, we do have... Chances are, we have more experience than most of our clients with a given set of issues that they might be experiencing, so yes, there is this eagerness, there is this hunger to understand, and so as soon as a client puts us in that position of authority, as soon as they look to us for answers, we are participating in an unequal power dynamic, like you mentioned, Darren. The problem is that this unequal power dynamic feels really good for our egos. Us massage therapists, we don't make a ton of money, right? We don't get... We don't get a claim from the wider culture. Our IRAs are probably not too large and our health insurance is probably pretty crappy, but what we do get is we get positive feedback from our clients and man, that is like a balm for the soul.
0:13:12.7 DL: And unfortunately, it's a balm for the ego, so I think a lot of the issues that we get into here, the ways that our good intentions go awry is when we see this client who is really looking to us for answers and that feels really good. Again, no bad intentions, it just that it feeds our egos, and so our natural inclination when someone says, You can tell me the answer, is to say, Yes, I can tell you the answer. So that's where we have to step back, acknowledge our egos and go from a place of empathy and from a place of knowledge where we are acknowledging what we don't know, and that is as important as what we do know.
0:14:00.2 DB: Let's take a short break to hear a word from our sponsors.
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0:15:16.3 DB: Now, let's get back to the podcast.
0:15:18.4 DB: Okay, David, let's dive a little deeper into the client mindset there, how does diagnosing possibly confirm the client's narrative of themselves and why might that be potentially harmful?
0:15:28.5 DL: That's a fantastic question, and I think it's an area, this idea of the client's narrative that I think we don't... We often don't spend enough time thinking about. We're muscle people, we're body people, we're really eager to sink into the tissues as it were, where we wanna resolve those issues in the tissues, as they say, but I think what that means is that we're not often acknowledging that the way a client feels is just as much about the narrative, the story they tell about themselves, as it is about the physical reality of their body, the physical reality of what their tissues feel like is actually just a really small part of the equation of what a client says, when they walk into your office and they grab their neck and they say, Oh man, I've been having headaches or I can't get rid of this knot or I just feel this tension every morning when I wake up. When a client does that, they are... Yes, of course, they are telling us that there may be some "tightness" or some trigger points or whatever the physical manifestation is in their scalenes or in their upper chaps or...
0:17:03.5 DL: You guys can all make the list. So yes, of course, there are absolutely physical symptoms, there are things going on in the tissues, but the way that the client is telling that story, the way that the client presents themselves is I think even more important than what... What we're actually going to feel in their tissues, and so we need to work with the client's narrative, just as much as we need to work with their body.
0:17:34.9 KC: David, when you write about narrowing how we see our clients, you say that as a profession, we often do too much defining and declaring and not enough exploring and allowing, tell us more about that and how is that potentially impacting our clients?
0:17:52.2 DL: This is a doozy, I think. My sense from a decade and a half of massaging and a lot of teaching is that we all have a pretty clear sense of our bodies and how we feel in our bodies, so again, this is the narrative that we've been talking about. Some clients will come in every single session, no matter how much wonderful work you've done the week before, the two weeks before, and they'll say, Oh God, I'm exhausted, I'm in so much pain, X, Y, Z. Other clients will come in, even with pretty severe medical conditions, and they'll say, Hey, I'm so glad I'm here, I'm so eager to get on the table. I've been having some issues.
0:18:44.9 DL: And that presentation, I think that narrative that each of those clients are telling about themselves makes a huge difference in terms of how much benefit or not our work is going to have. So it feels to me like we all have a relatively set idea about who we are, like the old cliche goes, some of us are glass half full people, some of us are glass half-empty people, some of us are always going to focus on that tension that we have in the base of our skull. Some of us may have that tension, but they've just decided, I'm not gonna pay attention to that, I'm not gonna let that take over.
0:19:31.0 DL: We all have this pretty established sense of who we are and how our bodies feel, so it seems to me like the real gift we can give as massage therapists is to encourage clients to continue to explore how they feel and maybe even to shift how they feel, maybe even to alter the narrative that they're telling about themselves, so I think that one of the big problems with our faux diagnosing or our... Our sort of diagnosing right, of that the problems of being on that slippery slope is that we further narrow that narrative of the client is telling us... We're convincing the client, oh, yes, you do feel bad. Yes, you're right. You will always feel bad.
0:20:30.0 KC: Even though, of course, no therapist is ever gonna say that by confirming and by deciding, Yes, I am an expert and I am telling you that your muscles are incredibly tight, you are confirming that diagnosis, you are declaring that what they think about themselves, that very narrow, already narrow vision that that client has about him or herself is the truth, and that's just the way it is. So again, it's our good intentions, but we're just reinforcing that narrative that a client has about themselves, whereas I think in an ideal world, why not try to do the opposite, why not both in our hands-on techniques and in the words that we say to our clients, why not figure out ways to say, "Yep, you're feeling pretty tight this week, but I think we loosened some things up in the session, and then let me show you a little stretch or Let me show you a slightly different way of sitting at your computer, and maybe that will make an impact and then we'll talk further about it next week," that is really different than ending a session and saying, "Wow, you have the tightest shoulders I've ever felt." And some of my favorite colleagues, some of my favorite therapists that I've worked with do this all the time, and they're wonderful people.
0:21:56.6 DL: But it's this idea that we have to give all of the "knowledge" we have. And I think sometimes that can backfire. I think there are much better ways that we can use our expertise.
0:22:12.0 KC: Absolutely, David, I'm fully agreeing with you, and I'm gonna challenge myself and all of my colleagues listening out there to really pay attention to the words we're using with our clients in every session that we do over this next upcoming month. Really pay attention and identify small ways or even big ways, if needed, shifts that we can make in our wording to allow for that exploring and expanding with our clients rather than the defining and limiting. I love that.
0:22:41.3 DB: Alright, David. Let's bring this to a close. I know everybody's curious about how to create possibility in a session, how do we do that? And take us through the before, during and after the session.
0:22:52.8 DL: So the first point that I wanna make is that I think that the before and the after are just as important as the during, and I think massage therapists don't wanna hear this because obviously we take great pride in our hands, but I think the way we present ourselves and the attitude that we offer to our clients, the words that we say to our clients is just as important as actually the techniques that we do, so... My feeling is that when we are, for example, talking with our clients, before the session, doing a three-minute intake, we of course, absolutely need to and ask all of the specific questions that you're already asking. You need to ask about medication use, you need to ask about previous injuries or surgeries, we need to have all of that information just so we know we're not hurting the client, and we know that we're going to tailor our work to their needs, but in addition to that, what I think is particularly important is that we also just ask them a general question or several, how are you feeling today? What brought you to this session today? What would you like to explore today? Some clients will be totally confused because they won't know what exploring their own body actually means, but the key is that we need to open up that possibility, give them the chance to see themselves as more than just a set of conditions, as more than just a list of sign and symptoms, we need to see themselves as a living, breathing body that can...
0:24:35.8 DL: They can explore themselves just as we are massaging them. So that is... That's setting up the foundation for them to feel like they are inhabiting this body and they have a say in it, and how it can change and grow. Then during the session, I think that there are two keys, the first, which I haven't been doing a good job here, is talk less. The second is slow down. So the first one, talk less, I think that especially as we get bored and burnt out, we have a tendency to make small talk with our clients to make the session go by faster. I can't strongly enough encourage you to not do that, the client again, because of that power differential, the client is feeling obligated to answer you even if they don't really wanna make small talk with you, so they're not paying attention to their own body and you're not paying attention to their body, if you're making small talk.
0:25:37.5 DL: The second is slow down. Because we want our clients to be more in touch with themselves, to be more able to create their own new narratives about their body, we have to allow them to feel what their body feels like. There's this growing body of research on interoception, which is that inward perception of our own selves, our heartbeat, the feeling in our gut, how our muscles feel to us, we need to cultivate a client's interoception.
0:26:16.3 DL: And the way that we can do that is not by doing 10 quick effleurage strokes up and down the erectors and then a bunch across fiber friction and then quickly moving on to the next part of the body. The way to do that is to slow down our strokes and really sink in and let the client feel what is happening when we're contacting them, so my guideline and to echo, Kristin, how about this? A challenge for everyone listening is, in your next session, pick one part of the body, the back, a leg, whatever you want, and see what happens if you do half as many strokes as you usually do and just make them last... Each stroke last twice as long. My guess is that you will feel better as a therapist and your client will actually get better results and will feel better because they are literally feeling more.
0:27:17.8 DL: So that's during the session, talk less and slow down, and then after the session, this is a tricky one, 'cause especially those of us who are working in a spar or at a chiropractor's office, we're often in a rush, there's often not much time to talk, but I find that what we... The place we can really continue that sense of exploration and encourage the client to move back out into their own lives with that sense of exploration, with that sense that change is possible is in the little bit of time that we have after a session. So in my own private practice, what I do to maximize my time with a client is the client leaves the room after they've gotten dressed, I give them a glass of water, I say, "Do you have a minute? Do you wanna talk for a minute?" And then I invite them to come back into the treatment room with me while I change the sheets to get ready for my next client. So it's a simple thing, it's not taking time away from me, and it means that I can dramatically expand the therapeutic possibilities because then when they're sitting sipping their water, they are naturally in that kind of post-massage daze, they can reflect, they're not as consumed by all the crap that was on their minds when they walked into the session an hour or two hours ago, so there's a lot more chance for us to push the conversation forward and to open up the narrative.
0:28:45.7 DL: So I think to me, what's most important here is to acknowledge whatever they're saying. Always, always acknowledge a client's pain, acknowledge their worries, never dismiss. So if the client says, I just... It still feels so tight in my neck, or what did you feel? I just can't get rid of this sense of tension, always start by saying, Yes, I totally get it. There is some tension there, I understand. I felt that too, but then I always follow that up by talking about the shifts that I felt in my hands as we were working. So even if someone is still quite tight afterwards, what I say is, Yep, it felt like those muscles were really resistant to changing but after we worked on them for a few minutes, they did feel like they were a little bit less congested or a little bit less stuck, and so then once I think... Once I introduce that idea of change of shifts, then I encourage something that will continue as they move into the rest of their lives. And oftentimes, that's just a really simple quick tip, sitting on tennis balls when they're at their desk for a long time, so they're getting some relief in their hamstrings and their glutes.
0:30:08.7 DL: A stretch or two that they can do before they go to bed, a simple breathing exercise that they can do first thing in the morning, all things that are within our scope of practice, 'cause obviously we have to pay attention to that, we're never prescribing anything for them to do, but just suggestions, because again, I'm here acknowledging in every session that I give, that all we can do is just tinker with our bodies, the best chance we have for being happy in our bodies is to continue to be willing to try new things, to tinker, to experiment and that's how we continue to change and continue to grow.
0:30:46.7 DB: I wanna thank our guest today, David Lobenstein. For more information about David, visit bodybrainbreath.com. Thanks, David. Thanks, Kristin.
0:30:55.6 DL: Thank you so much, you guys.
0:30:57.4 KC: Thanks, David, for another great podcast.
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