In the early 1900s, surgeons in Boston began gathering together to review cases in which patients died or were harmed unexpectedly. These conferences came to be called morbidity and mortality conferences, or M&Ms. Since 1983, M&Ms have also been a mandated part of general medical education: medical residents meet weekly to review all complications and deaths that occur under their care, whatever the cause.1
The fundamental truth underlying M&Ms is the recognition that medical practitioners can and do cause harm, despite good training and best intentions. The goal is not to blame or punish physicians who make mistakes, but to learn from them and drive the medical profession forward. Because physicians are willing to stand in front of their peers and present their errors in a nonjudgmental forum, we all benefit from reductions in preventable medical errors and improved treatments and protocols.
I believe we in the bodywork field would do well to recognize that we, too, can and do cause harm. We need our own form of M&Ms. And since we don’t hold people’s lives in our hands like physicians do, I propose we call our M&Ms “Missing the Mark.”
Despite our best intentions, bodyworkers miss the mark in ways large and small. In a field that is focused on wellness, recovery, and relaxation, it can seem like “bad branding” to turn a spotlight on the errors, unexpected outcomes, and injuries we can cause our clients. But it is exactly this kind of honest reckoning that will improve our outcomes over time, improve client satisfaction, and give us confidence that we are using the best possible practices in our profession.
In January 2018, I had the opportunity to discuss the “Missing the Mark” concept with Haley Winter on his How’s the Pressure podcast.2 We named the episode “Failure,” knowing it would be provocative, as a direct response to the relentlessly upbeat and positive ways our work tends to be presented.
Though neither of us thought of it at the time, Haley was the perfect person to have this conversation with. Before becoming a massage therapist, Haley was a professional athlete who pitched for the Seattle Mariners. As he reminded me in a recent conversation, “Baseball is a game of failure.” Even the best players fail a good percentage of the time. His decades in baseball primed him to expect to miss the mark and to deal with failure in ways that built his resilience, allowing him to learn quickly from mistakes and then show up fresh in the present moment, ready to fully engage.
“About the only problem with success is that it does not teach you how to deal with failure.”—Tommy Lasorda
On the podcast episode, Haley asked me if I had ever hurt anyone on my table. I took a deep breath and answered with an honest, “Of course I have.” There are instances I know about, where I was misattuned with my touch or spoke words that were damaging, despite my best intentions. I’m certain there are instances I don’t know about, where I never had the chance to learn or to make amends.
I am keenly aware that no matter how much I aim to partner with my clients, a power differential exists in my work. This is true for all of us. We are seen as the experts—the ones who know best. And because we are not in our clients’ lived experiences, we cannot always judge how a technique, a spoken phrase, or some well-intentioned “homework” will be received. We would all do well to assume that, at some point, we will do harm.
Our conversation led Haley to ask all his future guests about their “favorite failures.” He was pleased to observe that these leading lights in the industry were, to a person, delighted by the question. They valued the opportunity to speak frankly about missing the mark. Many of them revealed deeply personal stories and hard-won lessons.
Shedding light on the ways we bodyworkers miss the mark will help us personally in our own practices. It will also help us collectively as we develop an evidence base that is tailored to the bodywork field, rather than one strictly in the medical model. Just as M&Ms help drive the practice of medicine forward, reckoning with our failures can lead to research that truly reflects how we work: practitioners who have expertise using their hands to address the body’s varying densities of tissue and fluid, providing individualized treatments to clients.
Let’s take a look at some ways we miss the mark in manual therapy and bodywork.
Physical Injury or Harm
We miss the mark when we cause tissue injury from poorly executed technique, when we misuse equipment or our equipment fails us, and when we cause injury or a flare-up of a condition because we don’t recognize a contraindication or caution. We also miss the mark when we work outside our scope of practice, no matter the outcome. This could be when we recommend supplements or dietary changes without appropriate training and certification in nutrition, or prescribe exercise without specific training to teach and supervise it.
These ways of missing the mark are commonly seen in insurance claims. One of the most common claims is for exacerbating symptoms of a herniated disk, often from chair massage. Some therapists don’t adequately screen for cautions, and in their zeal to provide value in a short session, go too deep too fast, or take clients in unsafe ranges of motion. This could be largely avoided with a brief intake (yes, even for a 5-minute chair massage), so we can do our best to ensure our technique is appropriate for the client in front of us. Another common claim is for injuries sustained when a table or massage chair collapses.3 So I ask you: When is the last time you checked your table legs?
I’ve had colleagues recommend yoga asanas that are clearly inappropriate for clients we have in common. These colleagues don’t recognize that the poses are contraindicated because while they attend yoga classes themselves, they don’t appreciate that knowing how to perform a pose does not mean they understand how to teach it or when it would be useful. Our shared clients have experienced nausea, dizziness, and shortness of breath from these well-meaning but misguided attempts at instruction.
Breaches in the Therapeutic Container
We miss the mark when we breach our client’s trust. This could be by not respecting their physical and emotional boundaries; by projecting our ideas of who they are or what they should be doing; by exploiting the unearned intimacy that is part and parcel of our work; by not being clear with our business policies; by not making appropriate referrals when the client would benefit from work that is outside our scope of practice; and by exhibiting prejudice or bigotry. Sexual misconduct is an extreme example of a breach in the therapeutic container and may lead to an insurance claim or legal action.
Mostly, these breaches don’t cause much of a stir. They are the types of failures that quietly make us untrustworthy. Therapists who gossip about their clients or talk about the content of their sessions are breaching the therapeutic container. We also miss the mark when we are inconsiderate of clients’ time by running over or being prone to rescheduling at the last minute. Other examples are promoting our religious or political beliefs, minimizing client concerns, and giving advice.
These types of failure (that quietly make us untrustworthy) cause clients to stop seeing us even when our hands-on work is excellent. They keep clients from recommending us to their friends and loved ones. They cause skilled therapists to have trouble filling their schedules, and many of these breaches aren’t adequately addressed—or even mentioned—in our therapeutic trainings. This is why Kate Mackinnon and I spent a chapter exploring these types of issues in our book, Elements of a Successful Therapeutic Business (BookBaby, 2019).
So, What Is to Be Done?
We each have a personal responsibility to face our failures, to make amends where we can, and to make every effort not to make the same mistakes again. I have confidence that with humility and mindfulness we can all address the ways we miss the mark. The first step, of course, is to recognize and accept that every single one of us can and does cause a range of harms. We each will benefit from having an honest reckoning with ourselves, and also by asking those we trust where our blind spots are.
Once we have some clarity about where and when we tend to miss the mark, it’s time to take action to help ensure that we don’t continue. We can improve our manual therapy skills with added training. We can take steps to make our equipment and space safe and welcoming. We can take ethics trainings and get supervision to review our cases. We can train ourselves to understand and address our implicit biases, the ways we judge people without even being aware of it.4
I’d like to see us all strive to adopt a more humble and curious approach in our session work. For instance, if a client flinches, you can take the opportunity to check in right then and there: “I noticed you just tensed up. What happened?” Perhaps there’s a way you can improve what you’re doing, and you won’t know without partnering with your client. Perhaps this is an opportunity for your client to really feel into their body and understand their response.5
If we pretend not to notice a flinch, that’s a breach. We then are training our clients that discomfort is a part of the process, and they should just take it. This can lead to clients losing connection to their felt sense. It’s important we all learn to recognize the difference between someone being deeply relaxed on our tables and someone who has checked out and is no longer present in their body. Someone who isn’t present with what’s happening can’t give informed consent to treatment, which leaves us more likely to miss the mark.
At some point, we’re all going to say something unskillful. Perhaps a word you think is pretty darn neutral is triggering for your client. Or you let slip a comment or personal opinion that isn’t appropriate in the therapeutic space. This is an opportunity to be transparent and to make amends. Simply own what you said; don’t ignore it! For instance, “I just heard myself say ‘this must be so difficult for you,’ when I actually have no idea how you feel about this situation. Please forgive me. I really am interested in the impact, if any, this injury is having on your life.”
We can maintain curiosity about our work even after a session has ended by following up with our clients. Consider contacting new clients by phone after your initial session to see how they’re faring. On the off chance a client is uncomfortable or in pain, you will have an opportunity to remedy the situation. As clients come in over time, take a few moments to review how they felt after their last session, and how well you’re meeting their goals. If we’re not helping our clients, it’s important we know so we can adjust or refer to a more appropriate provider.
As a profession, we have a responsibility to shine productive light on the ways we collectively and individually miss the mark. This starts, I believe, with how we teach our work. I’m fortunate to know excellent manual therapy instructors, and one of the things I admire about their approach to teaching is their commitment to presenting their own missteps. This creates a learning environment that encourages exploration, experimentation, and skill building. It demonstrates that competence is built over time, with practice and curiosity. It shows that our field is dynamic and that our work can and should change as we gain new information.
Miranda Warburton, PhD,6 anthropologist and teacher of tui na and craniosacral therapy, offered some thoughts on teaching in a recent exchange: “I think it is critical for people to know that not only did I not always do it right, I don’t always do it right now, and I am always learning. It is important for both teachers and students not to always have to be right, not always think you know, and not pretend you know when in fact you don’t. And, as I learn new information, I want to show that what I perhaps thought was great then, I realize now was not the best. It’s an important life lesson about not being complacent, and not doing the same stuff you have always done just because you’ve always done it. I want to inspire people to do more, to be better.”
In a learning environment, both instructors and students should expect that we won’t be perfect—or even good—at new techniques. After all, these are physical skills we are learning, and physical skills take thousands of hours of repetition to perfect. But many of us come to this work having been told we have a natural talent or are a healer. When we carry that persona, it can be hard to admit we make mistakes.
Haley Winter recognizes that most of his massage students won’t have the comfort with failure that he carries from his baseball career. He notes that if we’re afraid of failing we can’t be present, and we’ll miss vital cues. This makes us more likely to misstep, and less able to respond and recover. As he puts it, “You can’t learn from a mistake that you won’t acknowledge.” So, in class, he talks openly about how he shows up around missing the mark, and he encourages each student to develop their own internal relationship with the inevitability of making mistakes. This helps them build resilience and trust that they can recover when things don’t go as planned.
One way to encourage a healthy relationship with missing the mark is teaching students how to give useful feedback to each other. It helps us become better therapists, and also helps us become better clients because we need to pay attention to what we’re experiencing as someone practices with us. A simple format used in many of my trainings is asking recipients to tell their trade partners what they enjoyed or appreciated about the trade, and then offer suggestions for what might work better for them. Notice that this does not ask students to tell each other what they did “wrong,” but instead to reflect on their own needs and how they might best be met.
When we gather as a profession, I hope our conferences incorporate more opportunities for us to present our own M&Ms—cases in which we missed the mark—in a nonjudgmental forum. I’d welcome seeing keynotes and prominent panel discussions about ethics issues. Just as we present outcomes to promote the benefits of a protocol or technique, we should want our colleagues to know what does not work, what causes harm, and what we have learned. This can spare others from making the mistakes we have made.
Let’s Assume We’re All Doing Our Best, and Accept that Our Best Won’t Always Be Good Enough
I hope this article starts a discussion that will continue beyond these pages. Let’s find ways to come together to learn from each other and take the stigma out of missing the mark. We all make mistakes in our work. We all fail. It’s how we respond to our failures that demonstrates our values and our true potential, and will move our profession forward.
While You Hope It Will Never Happen, Claims Do Occur, and Clients Do Suffer Injuries.
By Debbie Higdon, ABMP Risk Management
Minimize your general liability risk by performing important safety checks of your office space
Check to ensure all areas are clear of any fall risks, such as slippery rugs, electrical cords, or other hazards that may cause your client to trip and fall. If you have slippery floors, take precautions to minimize your risk. View your space and imagine what could potentially be hazardous: an exposed table warmer cord or a decorative vase sitting on the floor?
Inspect your equipment for any wear and tear or any signs of being faulty. Make sure all bolts and screws are tight. Claims have occurred from a massage table or chair breaking or tipping while a client was getting on or off. If a client has any disabilities, make sure they are assisted, if needed, when getting on or off the table or getting dressed. Make sure that a client knows how to get on and off the table properly. There have been claims where a client was getting on or off the massage table while leaning on the front or back of the table, causing it to tip and the client to fall.
Are intake forms and SOAP notes important?
Yes! In some cases, a client will not immediately inform you that they were injured by you while performing massage or bodywork. What if a client calls you out of the blue six months after you provided a massage and claims that you injured them by causing deep bruising and tissue damage, and that they have been seeing a doctor for their injuries and they are missing work. Immediately, you would want to check your client notes for the specifics of the massage provided. What techniques did you provide? How did the client present before their massage, and was there anything noted on their intake form that may have contraindicated the massage? In the event of a claim, those intake forms and notes will be needed during investigation of the claim and may even be subpoenaed.
When something goes wrong during or following a service
Assess the extent of injuries or damage. Obtain medical help or call the police if warranted or required by law. Do not be overly defensive or hostile to the claimant. Do what you can to soothe the situation. Many times, minor claims are dropped once the claimant’s emotional anger diminishes. It is not advisable to offer complimentary treatments or refund service fees in an attempt to correct the alleged problem, as this may be construed as an admission of guilt. Report the incident to ABMP.
Listen to your client, stay within your scope of practice, and obtain adequate training for any new modalities you want to add to your practice to protect your client and yourself.
Notes
1. Steven J. Kravet, Eric Howell, and Scott M. Wright, “Morbidity and Mortality Conference, Grand Rounds, and the ACGME’s Core Competencies,” Journal of General Internal Medicine 21, no. 11 (November 2006): 1192–94, accessed May 2020, https://doi.org/10.1111/j.1525-1497.2006.00523.x.
2. Haley Winter and Robyn Scherr, “Failure,” January 2, 2018, in How’s the Pressure?, produced by Haley Winter, podcast, MP3 audio, 39:20, www.howsthepressure.com/failure-w-robyn-scherr.
3. These two examples were provided by Debbie Higdon, ABMP’s Risk Management Manager, in a phone call on March 2, 2020.
4. Project Implicit offers several self-administered tests on implicit bias. The results can be deeply informative, especially for those of us who consider ourselves to be unprejudiced. Project Implicit, “Home Page,” 2011, accessed May 2020, https://implicit.harvard.edu/implicit/selectatest.html.
5. If a client has never flinched on your table . . . are you sure you’re being honest with yourself?
6. 6 Harmonies, “Practitioners,” accessed May 2020, www.6harmonies.org/practitioners.