Harm reduction in client/therapist engagements can be organized into four simple, but hard-to-implement tenets: minimize judgement, avoid offering advice or opinions, respect autonomy, and understand the complicated nature of behavior. In this episode of The ABMP Podcast, Kristin and Darren speak with Cal Cates about the lack of self-regulation training, examples of judgment with a client, and how offering opinions can have a “silencing effect” on clients.
“Harm Reduction,” Massage & Bodywork magazine, January/February 2023, page 62, http://www.massageandbodyworkdigital.com/i/1488451-january-february-2023/64
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0:00:00.2 Kristin Coverly: Thanks to the support of generous sponsors and all the folks who paid it forward, Healwell is excited to announce it's offering its online symposium Within Reach: The Quest for Information and Research for 50% off. That's $160 for two incredible days of education and engagement that will transform the way you relate to not only research but all information. Join us, February 25th and 26th for this highly interactive virtual symposium. Learn more at healwell.org. Are you passionate about massage and love learning about the human body? Take your palpation skills to the next level with AnatomySCAPES dissection lab workshops, designed especially for touch therapists. This March 8th and 9th or May 3rd and 4th, you can journey into the matrix with AnatomySCAPES co-directors, Rachelle Clauson and Nicole Trombley, as they take you on a profound journey through the human fascial system. Rooted in current scientific research, AnatomySCAPES dynamic trainings help you see, feel and understand what lies beneath the surface. Visit anatomyscapes.com/abmp to learn more.
0:01:32.0 Darren Buford: I'm Darren Buford.
0:01:33.0 KC: And I'm Kristin Coverly.
0:01:34.0 DB: And welcome to The ABMP Podcast, a podcast where we speak with the 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 where podcasts are available. And Cal is a columnist for Massage and Bodywork magazine. And today we're talking about the recent feature in the January, February 2023 issue titled Harm Reduction. Found in your mailbox, if you're an ABMP member and open online to the profession at massageandbodyworkdigital.com. Hello, Cal and hello, Kristin?
0:02:35.8 Cal Cates: Hello, that is a lot of Bs and Ps that you have to jam in there in that last little bit. It's impressive.
0:02:42.8 DB: It's a little, it's a little mouth dancing. Yeah.
0:02:45.5 CC: And indeed. Yeah.
0:02:46.8 DB: But it's worth it.
0:02:46.9 CC: And I wanna toss in that Healwell, we hang out also with adult people who are very sick, not just the kids. We certainly hang out with kids too, but yeah, we're all over the place. Wherever illness is, you will find Healwellians.
0:03:00.6 KC: Healwellians, I love that, yeah.
0:03:02.0 DB: I love that. Yes, I do like that.
0:03:04.6 CC: Indeed. It's less scary than Orwellians. It's different. Oh yeah.
0:03:08.7 KC: I hope so. Let's hope so.
0:03:10.8 DB: And a very, very different thing.
0:03:14.6 CC: Indeed.
0:03:15.5 DB: Listeners, last podcast, Kris and I talked about communicating well to positively affect the massage experience and outcome. This time we're shifting that communication topic a bit to talk about not causing harm during the session.
0:03:30.4 KC: Alright, Cal, in your article titled Harm Reduction, you mentioned that as a profession, we're hyper-focused on education on techniques and hands-on work, but we receive little to no training on communication and self-regulation skills. So let's start our conversation by defining self-regulation skills for our listeners.
0:03:49.5 CC: Oh man, that's a crazy Dutch doll of layers of definitions that are necessary. I think the first thing I wanna say is, and I know that we'll get to this throughout our conversation, but when we think about harm reduction, one of the things that I would really love for us all to do as human beings is to understand harm much more broadly. And that harm can happen and mostly happens in these really insidious and hard-to-spot ways, and that we tend to sort of, I guess, prioritize and sort of create fear around visible harm, physical harm, your hot stones are too hot and you burn someone's skin or you push too hard and maybe cause a strain in a muscle, but the harm that we do regularly is mostly by accident and is, and even somewhat imperceptible to the person who has been harmed, which makes it even more complicated. So self-regulation is this idea of noticing what's happening inside you and noticing how what's happening outside of you affects what's happening inside you and that it's this constant conversation that you're having or you have the potential to have with yourself and to say, "Okay, so this thing is... " And I don't even wanna use the word triggering, 'cause I feel like we could go down another rabbit hole about how that's become a thing that says like, "I don't wanna feel, so don't say or do anything that will make me experience emotions."
0:05:17.8 CC: Certainly, there is trauma and trauma-informed care kind of rolls into this conversation we're having about harm reduction and triggers are real, and also I think we tend to, we've sort of slipped into a place where, "If you're making me have feelings, you're triggering me." And we have to pull away from that and notice like, "Huh, someone used this word." Or in the article, I use the example, someone comes in smelling like cigarette smoke, I have a visceral response to that, I personally, like I... For other people, it might be some other smell or even just a cartoon character on a client's t-shirt when they come in, that when these things happen, we respond to them. We may not think we're sort of betraying ourselves to the client by saying like, "Oh, I hate Sponge Bob or cigarettes are gross." But inside us, we are telling stories about what kind of a person smells like smoke, what kind of a person wears a shirt that has this picture on it, and without even realizing it, we are shifting the way we're caring for them in ways that are leaving out parts of ourselves and that are sort of preventing us from fully seeing the person in front of us.
0:06:26.7 DB: So Cal, you're talking about, I just wanna be clear here for our listeners, we're talking about not necessarily the intake process here, but all interaction, right, during the session?
0:06:39.8 CC: Certainly. I mean, I think you start to establish trust or undermine trust during the intake process, but it is an ongoing conversation that again, even the word conversation, right, we think, "Oh, the things we say." And it's like, no, it could be the way we drape, it could be the way we respond when a client says something, whether we actually respond with our words or just the way that we're touching them, like it is, we have the potential to be regulating ourselves all day long in and out of the treatment room, and mostly we just don't. It's, we just tend to bounce off the world and the people that we interact with in the world, and it's a different skill to notice, "Oh, is this about me or is this about this person? What part of this do I have to manage inside me so that it's not affecting detrimentally my relationship and my ability to build trust?"
0:07:29.0 CC: When we're talking about in the treatment room, you're really trying to engender a space of trust and so that that person will share with you and does feel seen and over time is able to share with you the things that... Why do they keep coming back? There's something that they want to be different. So when I want help with something that I'm not happy with, I'm not gonna go to someone I don't trust to help me work through that. I'm gonna really want somebody who's like, "I totally get why that's happening, and I'm here, let's see what's possible. And let's see where you want to go. It's not about me and my story, it's about how much better you'll feel when this thing I have imagined for you is realized. It's about me really hearing what is it that's brought you in and how do I show up to that in a way that is aware of all my little stories about what I think brought you in and all that kinda stuff."
0:08:20.9 KC: Okay, let's start diving into things a little bit more deeply. Cal, in your article, you share four tenets for harm reduction, minimize judgment, avoid offering advice, respect autonomy and understand the complicated nature of behavior change. So let's start with the first one. Minimize judgment. What does it mean to minimize judgment?
0:08:42.5 CC: So what it means is to, as much as is humanly possible, and we are wired to make this hard to access, to really perceive as fully as possible the person and situation that is in front of us on this day, that even if this is a client that I see weekly or somewhat regularly, that when they come in today, I'm gonna do my best to let them be and see who they are on this day, in this moment. And that I think that it gets sticky because of course, people go, "Well, I do that, I don't, I don't judge. I love every person who's listening. That's me, I don't judge." Because that's how people are, but it's about the difference between the person you mean to be and the person you are. And I think this is, this whole issue of harm reduction is rolled into, we tend to assume that we're interacting with the world from our aspirational selves as opposed to who we actually are. And we know it's not okay to judge the smoker. So there's this weird default trip-up that happens in our mind where we say, "Well, it's irrelevant that they're smoking." Or, "It's irrelevant that they, I don't know, keep injuring themselves in this way." Okay, but it's not actually because it is changing how you think and how you feel about them.
0:10:00.6 CC: So the first step in minimizing judgment is just accepting that you're judging, and it's about softening the judgment, it's about being aware that, "Yeah, gosh, this behavior, this thing that this person does, brings into my space, pushes some of my buttons, and I have to do what I can do to find a balance in that and say, Okay, this behavior, I feel myself judging this person. How do I step back in this moment?" I mean, this is all very real time, which I think is the real skill of it, is that you don't... You can't be like, "Hang on, I have to step out. Your smell is grossing me out." You have to do this as you're talking with them. So I think that the more we understand about neuroscience and the way that our brains are wired to make sense of the world, part of moving through judgment is just normalizing that it happens, and that judgment is not a crime committed by terrible people, it is the way that our brains manage the incredible influx of input that's happening all the time. So we wanna put things in categories, and that's what we do, so how do we go, "Oh yeah, this is... Here's the assumptions that I make about this "type of client." Okay. Time to check myself."
0:11:13.5 DB: Cal, how do you win this? This is a tough one for me. So judgement. I know you mentioned softening it, how do you... What's a victory there? That's tough.
0:11:23.6 CC: Oh, I think just noticing. I mean, you're not gonna stop judging. You are going to... And I think this is why we won't do role plays in our classes at Healwell because I could say something to a client that you totally couldn't say and vice versa. And depending on the relationship that you build with a person, you can ask questions in a way that sort of opens that. So I feel like I could say to a client, "I have so much baggage about CrossFit. I just feel like it seems dangerous, it seems like you need a lot more supervision, so I just, I need you to know that that's a story that I'm telling." So when you tell me that you strained your hamstring doing CrossFit, if you feel like I'm glazing over, I invite you to say to me, "No, no, no. So this is what I did, I feel like I was using proper form or whatever."
0:12:16.4 CC: And we can be in a conversation that recognizes that I'm not infallible, I'm well aware that I might miss something because my story is, "Quit going to CrossFit." So I think part of it too is that it's this idea of not like, we have this thing as humans, and certainly as healthcare providers, you don't wanna let the other person in on what's not perfect about you, and I feel like over time, you develop relationships with your clients where you can say like, "So, gosh, you know, when you left last time I realized that I latched on to this thing when you came in. You told me about X, Y and Z, and I just went there and as you were leaving, I thought, Oh, I forgot to ask about this or that, or I could have come at this completely... Like I didn't invite you into that process at all, and I wanna do that differently this time." I think that that's... People actually really respond well to being asked to collaborate in their care.
0:13:13.8 DB: If you did that and I'm the client, I'm all in. Are you kidding me? I'm all in. If you like, if we're able to kinda break that barrier there, that's a big, big deal, whether regardless of... You mentioned before, which could have been right when I told you I was super into CrossFit, that's okay too. But definitely when you circle back around to it.
0:13:35.5 KC: Because then you're approaching the practice and your relationship as a human and not as an "expert."
0:13:41.6 DB: Yeah, totally.
0:13:42.0 KC: That always is right all the time.
0:13:42.7 CC: Well, think about what happened if you saw your doctor and the next time you went in to see your doctor, she said or they said like, "Gosh, last time I was in such a hurry, and I even have a note here that I wanted to go back and ask you about something, and I forgot." Like, oh my gosh, I'm never finding another provider, you are my person forever. So we think that vulnerability is a liability, but I think it's actually a possible bridge to a connection.
0:14:08.0 KC: Okay, Cal, let's jump into the second tenet, which is to avoid offering advice or opinions. First question, is that possible? Second question, tell us more about that.
0:14:20.0 CC: Oh man, my son is 12 and they have so many opinions and so much advice to give, and I'm constantly giving them feedback about like, so like... And they're like, "Well, I'm just telling you what's true." And I'm like, "Oh, so you're not actually. You're telling me what you learned "big air bunnies" from a meme, and that's not true, and it's shaped your opinion." And so it's funny to laugh about my 12-year-old lecturing me about zombies and all those things, but I feel like just like it's a judgment to say in my mind, "I bet this is carpal tunnel." It's offering advice and opinions when, I feel like there are a bunch of examples in the article where we think we're helping. It's not, again, it's not malicious. I'm not here to say that you are just spilling all over people and causing harm because you're just a harmful person. It's like someone says, "I wanna get up more at work, I feel like I sit too much." And you just jump right in and say, "I just heard about this app that whatever, whatever, you could set an alarm, or what if you put thumb tacks on your chair?" You're just trying to help, but what this person is saying is, "Talk with me about this thing." Maybe they're wondering, "Do I have to get up more often? It sounds like everybody's saying I should get up more often." "But are you actually suffering by sitting as much as you think you're sitting and are you even sitting as much as you think you're sitting?"
0:15:44.5 CC: And it may not be a thing that we can unravel in a single visit, but that you just start to listen for how much should-ing is your client doing and what's under that. Like, "Who's telling you you should be getting up more? Who's telling you that you should be eating more carrots? Like I am here just to ask you where this is coming from, not to tell you how to fix it." And I think that that's really... And again, people will say, I'm sure there are folks listening, will say, "Well, I give my clients that kind of advice all time, and they love it." Of course, they love it. They don't know that they could have something different. And that's what they think they're supposed to get. You come to a massage therapist and you get answers. And it's like, but what if you get exploration, what if you get some ideas about how to develop your own answers that will feel more sustainable and congruent with the way you wanna live your life? And that, massage therapists say, "Well, like informational interviewing, that's totally outside our scope." Yeah, to a certain degree. Like it depends how far you take it, but asking neutral questions that invite your client to consider if this thing they've stated as a problem is actually a problem for them, that's totally within our scope. We don't have to solve it, which is great, 'cause we can't.
0:17:00.7 KC: Let's take a short break to hear a word from our sponsors.
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0:18:17.8 KC: Let's get back to our conversation.
0:18:20.6 DB: Cal, can you tell me a little bit... 'Cause one of the things in this section of the article, you talk about offering opinions can have a silencing effect. And I thought that was really profound. Can you talk a little bit about that?
0:18:33.0 CC: Yeah, well, I mean, I think part of it comes down to our assumption that when someone states something that they are struggling with, that what they're asking us to do is to tell them what to do about it. And we can do that. And they might say, "Great, thanks," and try it. But I think really what most people are doing is saying, "This is hard for me. And I just want you to like hear me and like, are these questions you would ask?" And you know, it's like in the hospital, when we're training massage therapists how to talk with people who are either nonverbal or can't like say whole sentences. And we notice how often we ask compound questions, like we say, "Do you need another pillow or you're okay?" That's real hard to answer if you're nonverbal, right? So do you need another pillow? And then I just wait for you to tell me if you need another pillow. And I feel like this is a similar situation where waiting is so important. Someone says like, you know, "Yeah, like my hip hurts when I... " I don't know, insert thing that you've decided you know how to help them stop doing that. And instead, I could say so like, "Does your hip hurt other times? Or is it bothering you or," you know, sometimes people feel like they have to do like an organ recital when they come to the massage therapist, right? You can't just come to feel good, you have to have a thing that's wrong with you.
0:19:51.6 CC: So can we just like, make a little space and we don't even have to like make it, it's there, we have a half hour, an hour, however long we're working with this person, and we feel like it's disturbing them to sort of talk during the session. Chatting is disturbing, but asking just questions that allow them to just wonder. And that, you know, like in the article, I talk about, sometimes you'll ask a question, and that's it. And it just you ask a single question, and the person goes, "Huh, I haven't thought about that." And or sometimes you ask a question, they go, "Huh, you know, I don't actually, like I get up to go to the bathroom and maybe get some water. So maybe like two, three times max a day, I get up." And so they're saying, okay, I'm interested in talking about this and then maybe you work a little more and you say, "So do you do you feel like that's enough? Getting up? Like, what... How does it feel to you to like... When you think about, I get up three times a day, like, how does that feel?" And then they get to decide, like, "Actually, I'm focused, and I'm getting my work done. And then when I go home, I work out or I walk my dog. And that's like, when I have my movement time."
0:20:55.4 CC: Or maybe they go, "God, it feels terrible. Like I hadn't noticed that I don't get up that much." But they got there. You didn't say like, "God, doesn't that just feel terrible when you sit at your desk all day?" It's like, no, don't tell them how it feels. It's like when you say, "Oh, this is really tight here." It's like, okay, like, why don't we just get a vice and just make it tight, because I've just told you it's tight. And so now your brain is having that conversation. And you know, we just we want to know instead of discover. So how can we do that?
0:21:25.7 KC: Let's transition to the third tenet, which is respect autonomy. Tell us more about that.
0:21:30.4 CC: What I love and hate about this whole sort of concept is that you can see how it all relates, right? Like, so the self regulation comes in to the respecting autonomy to the offering advice, like noticing the thing that's inspiring you to speak or to wait or whatever. And so when we talk about autonomy, it seems like this really big word of like, you know, "Well, of course, I would never restrain my client, right?" Okay, well, good. That's an excellently low bar to start with. But autonomy is also challenged when we say, "So I want you to go home and do 30 minutes of insert rehabilitatory activity every day until I see you next time." Okay, but if that person doesn't have the room for that, doesn't actually have the time for that isn't gonna make the time for that, like, when we apply a treatment plan to a person without inviting them in, we're challenging their autonomy. I remember years ago, I was at a health care conference about how people eat. And they were talking about moving away from the word compliance. Because it's kind of this whole paternalistic idea of like, I told you what to do, and you didn't do it. So of course, you don't feel better. And they were talking about working with Black and Brown communities. And this was in New Mexico.
0:22:43.2 CC: And that the patient was telling the physician that, you know, I eat this number of tortillas a day. And the doctor said, "Well, okay, eat half of that, half that many." And there was a language barrier, there were a variety of things, but the person went home a month later, came back, and, you know, doctor's like, "How did it go eating less tortillas?" And she's like, "I didn't, like, this is a staple of our diet. It's really easy. I make them at home." Like, you know, but didn't have the the wherewithal to say like, "So can we try something else?" Because the doctor tells you and if you don't do what the doctor says, then of course, you're going to be sick and well, you deserve to be sick, right? And so, how can we notice that in our desire to help, in our desire to, I read a study that said, if you blah, blah-ed, this would happen? Well, great, but this person wasn't in the study, right? So what's necessary when I make a recommendation to you about anything? I really have to think about where do you live? How much time do you have? Does this even sound like a thing you want to do?
0:23:41.2 CC: Like, if I suggest this, does that feel like it's gonna fit in your life? Like, here's what I'm hoping you can do between now and the next time I see you like, I'd like to see more flexibility in your hips. Like there are a couple of simple things I can show you. Does that sound useful? And then you get like, if it does, well, yeah, but okay, so let's work around your reservations. Like it's a conversation about, it doesn't do any good if I give you a list of exercises that you're not going to do, or I tell you to go home and fill a rice bag and put it on your neck every night if you're not going to do that. So autonomy is really about inviting, again, inviting your client into the process of what will help you feel empowered in the process of feeling better.
0:24:26.9 DB: Do you feel like the client's honest at that point? Or they're still feeling the power differential in the conversation?
0:24:33.0 CC: That I mean, this is right, this is part of where self regulation comes in, too, because we get a sense of like, is this person withholding? Am I aware that this person is just sort of nodding? Because they A, want me to shut up, B, no they're not going to do it, C, have internalized that story of if I'm unwilling to follow my health care provider's advice and I feel bad, then I deserve to feel bad. I mean, that's a very compelling cultural story. So it's not as easy as like, that's it, just do what Cal just said, and it'll be amazing. Like you're going to do it wrong. Some clients will totally evade you and elude you. And some clients do not want any of this like will shut you out. And over time, you keep doing your thing being you and maybe people will soften maybe they don't but I think this is the thing is we go, "Oh, they don't seem receptive. I think next time I'm going to be a little more you know, I'm going to pull back a little bit." And it's like they can choose to stop coming to see you if if this isn't what they're into. I mean, that's you know, we talk all the time about you know, when when should you fire a client. Clients can fire us to like everybody has a choice in this engagement.
0:25:37.2 DB: Okay, Cal, the final tenet is understanding the complicated nature of behavior change. Tell us more about MTs being agents of behavior change.
0:25:46.9 CC: Yeah, well, I feel like this is another place that we we don't... We don't think of ourselves this way. And we quickly hide behind the scope barrier. And we say, "Oh, you know, I'm not here to help people behave differently." Yes, you are. And they aren't always... Your clients won't always ask you. They won't say like, "I have this behavior that feels harmful, and I want you to help me change it." Right. They come in and they say like, "My thumb hurts, and it's hurt for like three years." And you know, over time, you discover some things that they've been doing that might sort of point toward some pain. I mean, it could also be arthritis. But what they're inviting you to do potentially, is to support them in exploring why some things in their lives are dissatisfying. And whether it's in their body or other places, I mean, I talked in the article a little bit about how, you know, people will come in and they'll say, "Oh, my boyfriend says I should bloody blah."
0:26:42.0 CC: And listen, I'm not suggesting you be a relationship therapist but you know how it is when someone says like, "Well, my boyfriend says I should drink more water." And like just the way they say it, you're like, and you think your boyfriend is not helping you. And you don't believe that that's the issue, right? So like, it's not about choosing sides between the boyfriend and the client or anything like that. It's about inviting the client to say like, "So well, what do you think?" And then they say, "Well, I think my boyfriend needs to keep his big mouth shut." Or, "I think that, you know, when I drink water, I have to pee. And so that's a pain in the butt." And, you know, whatever you just learn about, okay, so like, is water on the table as a possible part of the solution? Or do we need to go in another direction? But you know, it's just so easy. And it's another myth of connection, that we feel like we're bonding when we say, "Oh, you know, my husband's always telling me what to do, too. And it's like, urgh it's not about you, like, you know, and you'll have a little bond in that moment. And you laugh about, you know, how these people who are supposed to love you are always telling you what to do.
0:27:40.4 CC: But it's not... That's not actually building therapeutic trust. And that's the connection that you want to create is sort of to allow them to have whatever opinion they have about their spouse or advice offering person, but really to invite them back to themselves about so you have a perfectly wise and wonderful mind, and you are the person in your body. When you hear that advice, how does it land? What do you think? And then you're just there to hear what they think. So you can ask more questions about what they think and what might be useful for them.
0:28:12.8 KC: Okay, Cal, I have loved so many things that you've mentioned in this conversation, and I'm guessing that our listeners have to and have had several aha moments along the way. And so what we don't want to do is leave them with lingering aha moments, we want to give them some tips and tools to actually start being agents of change for themselves and their own practice. So what advice do you have for our practitioners who are listening in their next session? What can they do to start making changes in each of these areas?
0:28:42.4 CC: Well, I would say the first thing to do is to not go in planning to make change. You know, the first step of change is noticing. It's saying, you know, it's like, let's just, I'm going to make a mental videotape of all my sessions for the next three weeks. And I'm just gonna see like, "Am I doing these things? Huh? Wow. I am doing some of these things. Some of them I do all the time. Some of them I have no idea what Cal's talking about. But like, there's some stuff in here that like, I could shift. And I could shift it." It's not an I should, it's not I need to call every client I've ever touched and apologize for harming them. It's like, "Oh, now that I'm noticing this, I mean, this is behavior change, right?" Like, "Oh." Okay, you have to get to that ambivalent place where you go, "Huh, yeah, like, I can see that I'm missing the opportunity to be of the level of service that I want to be and that it's not about doing it right."
0:29:36.2 KC: It's really about just showing up to these moments. So I think that the first step is really to decide to start noticing how you interact. And then you get to decide which of these things feels doable right now as something that I could shift. Where do I want to start, you know, maybe you have a client that you've been seeing for a really long time. You say like, Hey, you know, I listen to this crazy podcast, and this person was talking about bloody blah, and like, will you do this like experiment with me like, you know, are these things you've noticed? I mean, there are a lot of ways to go about it. But I think the... My number one recommendation would be please don't turn yourself into a project. You're doing great work. Your clients are feeling your love. I guarantee that people are feeling better when they leave your practice. And there's more available. So it's really just all about sort of expanding what you're already doing and really just centering yourself in that work.
0:30:31.1 DB: I want to thank our guest today, Cal Cates. To find out more information about the work that Cal is doing, visit healwell.org. Thanks Cal. Thanks, Kristen.
0:30:40.1 CC: Thank you guys. It's always a pleasure to be with you.
0:30:43.2 KC: Same. And thank you so much for all that you shared today. It's going to help all of us just create a different awareness of how we communicate and interact with clients.
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