Warmth, competence, rituals, and good listening skills in the massage room will help you harness placebo pathways. In this episode of The ABMP Podcast, Kristin and Darren speak with Mark Liskey about how the placebo effect can be a positive approach to massage therapy, the differences between expectancy and learned association, and examples of what can produce a placebo effect.
Read Mark’s article in the March/April issue of Massage & Bodywork magazine: http://www.massageandbodyworkdigital.com/i/1492048-march-april-2023/46?
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0:00:36.5 Darren Buford: I'm Darren Buford.
0:00:45.0 KC: And I'm Kristin Coverly.
0:00:46.4 DB: And welcome to the ABMP Podcast, a podcast where we speak with the massage and body work profession. Our guest today is Mark Liskey. Mark is a massage therapist of 30 years, CE teacher, provider, blogger, writer, and co-producer and co-host of the International Take Care of Your School Event, a self-care conference for massage therapists. Recently, he has written the Pain-Free Massage Therapist, a do-it-yourself Body Mechanic Strategies and Techniques book for eliminating pain in the massage room and extending massage careers. You can access free instructional body mechanics videos at his website, painfreemassagetherapist.com. Mark is also the creator of makethemostofmassage.com, a business resource for massage therapists. Access the Free Massage Business Crash course on his course's page. And Mark is the author of the recent Massage and Body Work magazine article, A Placebo Approach to Massage featured in the March-April, 2023 issue, which is the topic of our discussion today. Hello Mark and hello Kristin.
0:01:48.6 Mark Liskey: Hello, glad to be here. Thank you for inviting me.
0:01:52.0 KC: Oh Mark, we're so thrilled to have you back and especially about this topic. Very interesting. We're really curious to learn more and share this info with our listeners.
0:02:01.5 ML: Cool. I'm excited to talk.
0:02:03.4 DB: So Mark, today we're excited to talk to you about the things that are outside of the hands-on touch perspective of massage therapy and body work that tap into the client's placebo pathways to improve therapeutic outcomes and expectations. Super curious. So I'm gonna turn it over to Kristin here to ask that first question.
0:02:22.3 KC: Yeah. And I think we all wanna make sure we're on the same page when we're using our terms, right? That's the first step of any good conversation. Let's set the stage. Tell us what you mean when you use the terms placebo and the placebo effect.
0:02:37.0 ML: So typically with placebo, it's an inert substance like everyone thinks of the doctor, right? The doctor and the research project, they have the little sugar pill, they give it to the research patient and they feel better. In massage, we're not doing that. So we'd have no pills to give or anything like that. So what we're trying to do is we're try to tap into placebo related pathways. So in the article, I talk about like we're more like a vitamin pill. We have an active ingredient, but we wanna enhance that active ingredient and by doing certain things, we can access that placebo pathway to enhance our active ingredient.
0:03:10.6 KC: Yeah, and I think you gave a great example at the beginning of your article, just in general about placebo and your niece and her cup of coffee. So tell us a little bit more about that.
0:03:19.9 ML: Yeah, so this was completely accidental and I don't think it came through in the... I think some people thought I was mean, like I was trying to trick her and I really was not trying to trick her. [laughter] So we're just like... She want a coffee and we just had Decaf in the house, so I made a really strong cup of Decaf. She comes back like half an hour later and she's like, "Oh my God, that was such a strong cup of coffee. I'm bouncing off the walls." And so I'm like, I say "Hey, you know that wasn't regular coffee, it was Decaf." And her face just like got white. Do you know what I mean? She was like really upset. She'd been tricked, she felt stupid, she felt duped. I didn't mean for her to feel that way, but that's how a lot of... That's how we generally react to placebos.
0:03:55.5 ML: It's like it's a bad thing that you had a reaction to a placebo that you're weak or that you're mentally something is not right. Where the research that I talk to now, the idea is that, the placebo, if we can change that idea, we can actually use that placebo, the definition of the placebo and the placebo itself as a positive thing. But right now most people think a placebo is a negative and even research it's a negative thing. It didn't pass the placebo test. So that's why she had that reaction, which both of us would've that reaction.
0:04:26.4 DB: Let me ask you another question that I'm thinking our listeners may be wondering too. Is there anything deceitful about a placebo?
0:04:34.4 ML: It could be in the sense that you're not telling the person it's a placebo. Yes, definitely. But the difference with what we're doing in massage is that we're not applying a placebo. We're not administering a placebo. We're trying to tap into pathways. The way I look at it, we're not being deceitful. The researcher that I talked to, Darwin Guvera, he does placebo research on what he calls non-deceptive placebos. And he literally took that concept of the placebo, told people that this is a placebo we're giving to you. It's has this positive benefit. It's supposed to do this, it's supposed to do this. And he explained why the placebo is good for you. So he used that as expectancy and he got positive results with that. So he actually used the placebo, the definition of the placebo as an expectancy and got positive results. But it gets very tricky where you... There might be some ethical parts to this as you do massage where you have to make some decisions. But ultimately, I fall on the side that we're not really, we're not deceiving people if we're using it as a way to enhance placebo pathways as opposed to saying, "Hey, this is gonna work for you and we know it's an inert substance."
0:05:45.8 KC: I'm so excited for what's coming in. Our conversation is to talk about those placebo pathways and how as practitioners we can help use that placebo effect to enhance our client's outcomes. So that's coming. Before we get into that, I'm kind of thinking too, the way I'm viewing it is I think of it almost like visualization, right? Like if someone can think about the placebo effect, and you said even with that, you were just talking about a study where there was an expectancy. They explained that this was a placebo and people were using it just as a mind body connection tool to have a different perceived outcome. So to me that's like visualization. Maybe this is something we can all start using as a tool just beyond massage and beyond... We were talking about it has such a negative connotation, but does it need to, I don't know that it needs to, it could just be another tool that we can use even for ourselves to enhance and increase our chance of a positive outcome or to shift a pain experience or to shift a negative experience or the way that we're perceiving something or experiencing something. What do you think?
0:06:49.2 KC: I agree, Kristin. So my wife and I are plant-based, so we're big into, we buy into all of that there. There's a big component of feeling good when you eat and I'm hoping that has a placebo bump too. That's like one example of my life. But I'm sure we all have those things where we really believe in something, you know what I mean? You have that expectancy and we might be getting a bump from it. So, and it's not a bad thing.
0:07:13.4 DB: Mark, tell us about the 2019 landmark study that illuminated the importance of competency and warmth.
0:07:21.0 ML: So, to me, this study was sort of common sense. It's the kinds of things that we think of in terms of what our doctors or our health practitioners do for us, and what we would probably consider the good ones. The ones that when we walk away, we feel better. They may not solve the problem right there but we know that we're going in the right direction. And in this study that Lauren Hall did with her colleagues they were trying to find out what are the things that doctors can do to enhance the placebo effect? And what they found were things like, be warm, be competent. And another thing was that they found was having rituals. And by rituals we're talking about things like the intake. So when a person comes in, if you have an intake for that person and you're going through that whole process of like, "This is information we need from you." They're filling it out, they're telling their story, they're telling their narrative, they're giving you all that information.
0:08:21.3 ML: It's very similar to going to a doctor or going to physical therapist. This is a ritual in our society of the health process. So we're part of that ritual. And the assumption is that that's a positive thing. That when they come to a place that's doing the same thing that every other place is doing in the health field, that it's the right thing to do. Another thing is being competent. So being competent would be demonstrating mastery over your discipline. You want the person to feel that you know what you're doing. And you can do that in a lot of different ways. The basic ways are like having a great place for the person to come into, like a warm, inviting place, a clean place, professional looking place. You look professional, you look like what a massage therapist they would perceive to look like. You talk in a way that knows that the person understands that you have command over what you do.
0:09:21.2 ML: The other part of that sort of ties in with the competency is being warm and kind and compassionate. And that's all part of the therapeutic rapport that you build with the client as they come in and you're assessing their situation. You're having them tell you what's going on but you're also demonstrating that you care for the person. And you can do this like with simple things like by using their name, by active listening, so that you tell them what they said to you, but not in a verbatim way, but in your own way. So they know that you're listening to them. I also, I'm gonna flip back to the competency 'cause things are just coming back and forth. I think another part of competency is to give them a map of what you're going to do. So if they're coming in for pain relief, you tell them how you're going to approach pain relief. You can tell them what the expected outcomes might be. You give them an idea that you have a plan and that this plan has objectives and this plan has goals. So those are some ways I think that applying the study's findings to massage can be helpful. And it's what I do in my practice for the most part.
0:10:32.9 KC: And speaking of your practice, Mark, in the article, you shared a great story about Sherry, a client who came to you with chronic hip pain. And I'm wondering if you can tell us a little bit about that. And you were saying you kind of started using the techniques for placebo, placebo effect with her kind of not even knowing, but that they were having an impact on her perception of the work and her reduced pain.
0:10:55.6 ML: Yeah, so she came in and she was really not receptive when she first walked in the door. So it's experience of like, "Okay, this is gonna be a tough one." But as we dug down, the reason that she wasn't so happy and glowy was one, she was in pain. But two, she's also been through the gamut of going through places where she was trying to get her problems addressed and they just weren't being addressed. So she was frustrated. So right away there was that to deal with. And as we talked some more I started to explain what massage could possibly do. And this is sort of where we get into, to me we're in the ethical part because now I'm not promising or anything 'cause I don't know if I can help her to be honest. I have no idea. But what I wanted to do was not to extinguish hope also but not give her a false hope. So I explained what I was gonna do and the research that I felt supported what I was gonna do. So in some ways the research could have acted as an expectancy 'cause there's something in the way we were interacting that changed when I started to explain things to her, like how I was gonna do things.
0:12:04.4 ML: So why that's not an ethical problem with me is 'cause I believe in the research. Do you know what mean? Like if I didn't believe in the research and I was just throwing out there like anything, Then I'm sort of like, '"Okay, I'm sort of treading on that ethical issue." So we proceeded and she felt better like the next couple days she sent me an email and she was like much happier and she was, "This is the first time she wasn't in pain for months." And that was great. And then when she came back in, she was in the same amount of pain. So if it was a placebo enhanced visit, it was short-lived. So then I tried some other things. I explained to her again what I was doing and we again had a small bump but then it returned back. So to me it was helpful potentially but it didn't solve her problem or didn't... T helped her very short-term. The problem is you don't know what placebo and what's your active ingredient, which is massage. And you're sort of, you're a generalist at this point. We can't apply placebo specific research and to a certain situation in massage because it's not there. So what we're doing is we're just trying to use really general ideas to have an effect. And in that case, I would say with her it had some effect but it was very short-term. That said, it lead her to the next thing, which hopefully may have given her more relief.
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0:14:53.9 KC: So Mark, it sounds like when you were describing the different components that might go into a placebo effect in your work with Sherry, that really what you're doing is saying, "Massage therapists present yourself as competent, professional practitioners, set realistic expectations and communicate with your client about those expectations and what may or may not happen." So really it sounds like, to enhance this or to activate this placebo effect for the client and to allow them to trust you and to trust the work, it's really showing up, being professional and communicating clearly. Is that right?
0:15:30.0 ML: I think it's a big chunk of it, yeah. There might be more stuff with that, but I think that's a big part of it. And it's coming up, showing up for game day and showing up for game day is not physical like you're just saying, it's mental, it's there for that person. You show up, you're there, you're listening, you know what your job is. Your job is to try to facilitate this person, whether it's pain relief or relaxation, you're the facilitator. So yeah, I 100% agree with that.
0:15:58.8 DB: Yeah, the aspect in the study was gets it, which is the competency aspect. Which was like, "Yeah, I need... " guys, this is Darren super client joining the podcast now. So I need to know that you know what you're doing. That's a big deal. And that extends to anything, any kind of professional and certainly therapeutic relationship. And then gets you is that warm component which is like, "Yeah, you're connecting with me like a human being." And that's a big deal because we've been to many... Many of us have had sterile therapeutic encounters with extremely white walls and stethoscopes and robes. It's just very, very... It's not warm, it's not inviting and it feels like, "I just would like to get out of this room." Or some people might also say that with going to the dentist. How many people have negative effects or thinking even pre-going to the dentist that they're already ramped up, anxiety is ramped up.
0:16:54.7 KC: Right, and we all know how powerful our mind is in the mind-body connection in that relationship. So picture the last session you had that wasn't great, whether it was the environment like Darren alluded to or the techniques weren't resonating with you or the level of pressure. You may have mentally overridden whatever physical effects actually you received from that session because emotionally, mentally you didn't have a good experience. So it is really fascinating and there's really no way for us to know, like separate your physical reaction and response from the connection you have with your mind body. So it's really interesting to start thinking about it that way. How powerful the mental and emotional aspect of a client's experience in the session is in how they perceive the physical response to the session.
0:17:44.7 ML: So Darren, if I can circle back to you, I have a question for you. As a super client, what would be the perfect therapeutic situation or the therapist itself? How would you want a therapist to do the massage for you?
0:17:58.7 DB: I'm so glad you asked 'cause I made a list [laughter] That's dialing into my hyper editor right there. Yeah, greeting, greeting is really important, warm inviting, the space like you mentioned. But establishing that ritual is critical and that goes back to the intake process which now associates me, the experience, with a therapeutic healthcare experience and massage is part of that, and massage therapy is part of that. And so, associating those two things in my brain now has leveled up the experience. The next thing is probably, and you mentioned it in your article, but allowing enough time. When you feel rushed, you better believe, I know that you're rushed and then you're moving the process along really quickly, and so I'm like, "Okay, well, I guess I got to get on the table. Now we're doing our thing and now no more warm. Now we're into the session. And the communication's over." But allowing for that time allows for a feedback, back and forth and something that I've noticed, receiving lots of massage and bodywork over the years is, as a client we always aren't the most forthcoming on the intake.
0:19:17.3 DB: So I'm just gonna say that again 'cause I really, practitioners should hear that. Yeah, we're gonna fill out the intake, we might have filled that out at home. If you have an app or something where there's like your doctor, now you're doing those forms at home and then you show up and you have to do those in person. Sometimes Kristin and I have talked about on this podcast how important, even if you're doing that, it is still very important to revisit that in person, 'cause it now reframes the situation and again it levels up the healthcare experience. But I may have filled it out, I may have done it quickly, I may have left a few things out of there because I may be like, "I don't feel comfortable, I don't wanna tell them about that. That's not really pertinent to the massage I'm getting today." But believe it or not, one of those things, if you're asking me questions, I might be like, "Well, yeah, I do have this knee thing I didn't put on them. It's not really a thing. I was never operated on. I mean, I've never had an injury there. I don't know. It's kind of been lingering for like a long time.
0:20:13.2 DB: And now, extend that to the session when you start to, Oh my God, you just... You were touching, you're working on my hip there. I didn't even mention this 'cause I didn't even think about it before. So the intake leads into that and it provides security and safety for the client to open up even more during the session. And if you've allowed that space, you better believe that I'm probably going to dive into it. And this is, I'm actually explaining this as if this was our first session together. Now add multiple sessions together and I'm probably just gonna be an open book.
0:20:44.4 DB: The more that we've established a really warm relationship together, I'll be like, well, you know what? There's this toe, this toe, I might've broken this toe. I don't know. I mean, is there anything you can work on and see what you think about that? Those types of things I found in a lengthy relationship, really, that's where the bonding starts to happen in the... And trust starts to happen too.
0:21:06.1 ML: Right. No, I think to me, especially when you said the timing part really hit home because pre-COVID we were like 15 minutes, like in between clients and then we did half an hour because of the cleaning and everything. And I kept it at half an hour because it really does allow for someone to tell you what they're feeling and it gives them that time where they don't feel rushed and also gives you more time to explore and to be a better therapist and to get more information. So how about you, Kristin, do you have, in your practice, do you have like long periods in between your clients or what do you do?
0:21:40.1 KC: I have a part-time practice because I am at ABMP full-time plus. So I have a small group of clients that I see every month. I've seen most of them for 20 plus years. And so it's a wonderful little massage community. But when I do have clients back to back and I see clients on Sunday afternoons and Monday evening. So sometimes on a Sunday, I'll have several clients scheduled. I leave now an hour in between because I used to leave a half hour when I was in my regular practice, full-time practice.
0:22:08.7 KC: Now it's an hour because I take, not only turn the room over, but I also will take my puppy out for a walk in between clients so that she's happy for each one. So I've kind of built in a little bit of extra time there, but that's because I personally can, it's my very relaxed part-time schedule. But when I was seeing clients full-time, it was always a half hour in between so that I could have time to have my intake conversation. And then we get what my other colleague would call it a fat 60 minutes, which means 60 minutes of hands-on time. She would call it a fat 60 minute session, meaning you have your conversation and then it's actually 60 minutes of hands-on time in addition to that. So that allows time for that as well, if that's your choice.
0:22:52.8 ML: Wow. That was really good. I mean, you're really pushing the placebo-related mechanisms there.
0:22:58.1 DB: I am never going to forget the term of fat 60. That is...
0:23:06.5 DB: That's so cool. I love that. And you know, when you were saying that, Kristin, it actually made me feel sad or sorry for practitioners who may need to flip an experience in like 10 minutes. I don't have that experience. I'm not trained like you guys are at all. So I've always wondered that what's that like to dial that up so quickly, that seems like a challenging thing to do.
0:23:28.8 ML: I can tell you from personal experience, when I had to do it, it was simply, I got behind. Because I wasn't going to like sacrifice the integrity of that relationship, the therapeutic relationship, to move faster. Like I can only move so fast. And at some point, if you're rushing someone, like you said, Darren, you're sort of counteracting everything you want to promote. And so it depends. And I know my wife was like that too. You just get behind. So, and then you're calling the next person, yeah, I'm behind and letting them know you're behind.
0:24:00.3 DB: Just as a client, I actually appreciate that. If you tell me that you're running behind and you're honest, that's huge. If you just send me a quick text message, that's really big. But if I walk in and see you panic and then I start to feel like a number a little bit.
0:24:12.4 ML: Right.
0:24:15.4 DB: It's not the greatest experience. And I know we've all experienced that in numerous healthcare operations before where you're like in a doctor's office and you can be a lot of time waiting. And when you go in, you know that they're rushed. And so.
0:24:26.9 ML: Well, right. So part of our job, Kristin, is to sort of pretend too when you are actually a little bit frazzled, there's part of your job is to look like you're not. It's a habit. Like everything's a habit. So as soon as the person walks in, the flip switches. And you're that person, you're that professional. And as soon as you put your hands, you can't do a relaxation massage when you're uptight. So I mean, I think there's that feedback. As soon as you put your hands on the person you sort of become relaxed too.
0:24:56.3 KC: Yeah. And the absolute value of that 30-second practice before you open the door to the client, of taking the breaths, recentering yourself, saying outside life, we're closing the door on you. And now I am in full massage mode. Like you can really shift a lot in 30 seconds. And so, yeah, there's always the practice you do right before you greet the client. So you're in the right space to create a session for them and to create their space so they can get what they need from the session. Not about you. It's about them.
0:25:28.4 DB: Well, this has been an awesome experience today. I want to thank our guest, Mark Liskey. For more information about Mark and the work he's doing, visit painfreemassagetherapist.com and makethemostofmassage.com. Thanks Mark. And thanks Kristin.
0:25:42.6 ML: Thank you. It's great being here.
0:25:44.8 KC: Mark, thanks so much for a really fun and insightful conversation. Thanks for joining us.
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