Last week, Governor Inslee announced a 4-phase approach to re-opening our state in the face of COVID-19 risks. These phases represent a graduated way of balancing relative risk of exposure/transmission with genuine benefits of being back at work (financial, services provided, mental well being, etc.). I like this graduated approach; that seems realistic given the likelihood that opening up will increase cases. As folks have mentioned, I expect that we’ll be moving back and forth, hopefully only between phases 2-3, for a while. This is a plan we have to live into and alter as we see the consequences.
And this got me thinking: how could I articulate 4 levels of safety parameters with regard to my clientele? When is it appropriate to work with people who have a range of needs? Here’s my current best thinking about it.
What follows is a guideline based upon my own skill set with considerations. I am NOT saying that this is what the Governor’s phases indicate, nor that this is what the Board of Health/Massage Board is advocating. This is not an interpretation of public health policy. It is a guideline I’m creating for myself using the principles of the public health guidelines. If it helps you think about your own practice, I’m grateful.
I’m assuming that IF I’m practicing, I’m doing so with the appropriate level of PPE, sanitization, health screening, etc. (My following posts will consider these in light of new guidelines.) As I learn more, it’ll likely change, as any good map does.
Phase 0-1: Most restricted — Emergent services only
This is the most conservative approach to seeing people. (To keep the numbering in sync with the governor’s plan, I’m using a zero to indicate the level of shut down we’ve already been exercising.) Because most of what we do is NOT emergent care, most of us are not seeing people at this time.
The exceptions I can imagine or have made include:
• alleviating impairment of basic functions: chewing/swallowing, digestion, and elimination/toileting; breathing for base line (not optimal levels)
• alleviating severe CNS/neural impingement and/or severe pain
• alleviating specific positional/movement problems that, if left untreated, would have long term, significant detriment for the patient
Examples in my practice:
• a baby with feeding difficulties significant enough to be diagnosed with failure to thrive
• a patient with severe vertigo who was unable to get to the bathroom without hurting herself
• a patient, post-concussion, whose symptoms worsened to include double-vision and severe vertigo
• Mostly I’ve made these exceptions per request from a referring MD/ND (their condition has been screened at that level as well)
• The work takes only as long as it takes. When I feel improvements to the specific problem have been made, I call the session. (So far, this has been between 20-30 minutes.) This minimizes our mutual exposure and leaves their body enough energy to recuperate.
Phase 2: Near-most restricted — Moderate to Severe, and A Good Fit
Opening up as on a particular date could mean that we’re flooded with a lot of requests for appointments right away. So we’ll have to prioritize, at least enough to take care of our own bodies going back to work after such a long stasis (wow — my hands/arms/attention have lost their stamina!). I’m interested in working with people who need my specific skills.
• opening up to people with moderate as well as severe symptoms: CNS/ANS dysfunction, acute/subacute musculoskeletal injuries, digestive/eliminative problems, post-op rehab, etc.
• these are people for whom home care/self care is not an option; they may have resumed other care as well (PT, DC, etc.)
• therapeutic interventions (“clinical massage”)
• sessions are shorter (limiting exposure as well as practitioner self-care)
• people whose needs are a good fit for my particular skills (cranial, visceral, structural — what are your best skills, who are your best clients?)
Example from my practice
• client who has severe scoliosis and chiari malformation; working from home has aggravated her symptoms significantly. Her DC hasn’t reopened; she managed with home care for about 5 weeks, then starting getting neural signs from the CNS impingement
• established client with chronic sciatica who ‘over gardened’ during SAH and now can’t walk, sleep, etc.
• These people may need longer sessions and/or have multiple goals. Prioritizing their needs is important as you begin a new phase of treatment.
• Remind clients that these sessions won’t be like their usual sessions; at least, they will have lost the momentum they had before the shut down.
• These folks may be coming in with a lot of residual tension! Take care of your hands/body!
• Working mostly with established clients and/or known referrals; we want a high level of trust with regard to client self-reporting.
• When we get to this phase, I’m considering getting tested for antibodies. In particular, I’m considering focusing on reaching out to front line workers to offer discounted sessions.
Phase 3: Modest restriction — Mild to Moderate Symptoms and/or General ANS Relief
Unless your work or work place is specialized, here are the folks that, IMO, make up a large portion of our clientele. They are relatively healthy people who seek out massage therapy to improve their daily lives. Massage as an intervention here is on a par with yoga, stretching, meditation and general fitness. (This is when gyms will be allowed to open at 1/2 capacity.)
Our work makes a tangible difference with: movement and range, posture, modest aches/pains, better sleep, decreased stress or general anxiety, etc. While not “essential” or perhaps even “critical,” touch at this level is still a health care activity. It is both therapeutic and preventative. Our clients will have missed us greatly! And, there will be a whole new layer of people significantly in need of touch and stress relief.
One concern I have for this time is that we might over-relax our hygiene/PPE habits. This time, in my imagination, will feel the most like normal, while not being fully open. Hopefully by this time, we will have access to any diagnostic testing and many of us will have had antibody testing. (I am undecided about requiring antibody testing of my clients.)
It’s also likely that there will be heaps of emotional/psychological processing going on. As a society and as individuals, we’ll be at the beginning of seeing the long term effects of this pandemic. By all estimates, this will be a difficult process. This phase will include looking back at where we’ve been with COVID, while at the same time still living with it as an active public health concern. We will start to ask ourselves ‘where are we now?’
As providers who spend a lot of time with clients, who share the intimacy of touch with our clients, it’s likely that we will be having those conversations with people as they ‘return’ to their bodies through touch. Clarifying our scope of practice–we’re not counselors– will be important. As will our own self care during this time. How can you hold your own heart? How do you want to be present with others?
Phase 4: Open practice — ‘Not so new’ normal; Post-traumatic growth
There will be a time when all the new measures of hygiene and safety feel integrated into our practices–we will become accustomed to it. That’s the way humans are as a species: we’re adaptable. Many of us have integrated wearing gloves into our work while doing intraoral work. Some of us have been in the profession long enough to remember when draping was optional. While we won’t always need to be on high alert, we will become more familiar with what high alert means on a practical level. If we can learn from this process, adapt and gain skills that support our health and the health of our clients, we will be stronger for it.
This is called post-traumatic growth. It’s different than resilience. Resilience is when we are able to undergo a challenge and respond to it without overwhelm. On the other side, we move forward much the same as we were before. Post-traumatic growth is when we are changed by what happens to us, sometimes significantly. Adaptations become habitual; new skills are learned; our sense of self is changed. There is no going back. While we do grieve what we lost, we can also honor what we have learned and how we have continued on. Both resilience and post-traumatic growth are capacities we can develop.
COVID-19 is too huge a phenomenon, too widespread, too devastating, to not call for growth. My deep prayer is that inside such a global re-orientation of human attention and activity, we’ll be able to have a different conversation together on the other side. A conversation that is more inclusive, more sustainable and more healthy in all respects.
The current 4-phase plan to reopen from COVID-19 sheltering in place makes a lot of sense to me. It sounds familiar. Since February, I’ve been struck by COVID’s onset socially echoes my experience with earlier health challenges. On an individual level specifically, it reminds me how I navigate dietary restrictions on inflammatory foods.
The moment things change
My introduction to changing my diet as a health strategy came with breast cancer. Because I sought care from conventional and alternative providers and because my cancer was caught early enough not to be life threatening, the conversation about diet routinely figured in my care visits. Both sides of the medical aisle, as it were, agreed. How you eat has a profound–if not fully understood–effect on the incidence of cancer. It also underpins the health the body needs to withstand cancer and whatever treatments one chooses.
Diet was something I hadn’t paid much attention to beyond a ‘well rounded diet’ or ‘what do I want to cook’ kind of way. Not ever from ‘this will harm you’ or ‘this will heal you.’ That was a big change. I remember looking over books and websites, reading through materials from the oncologist. I remember:
• feeling swamped: there’s a disease-fog that arises, taking attention and energy. Every day activities suddenly take longer, easily losing focus in the midst of simple tasks. (Right, there’s definitely a COVID fog happening.)
• feeling confusion: hearing often conflicting messages about what was most important to eat/not eat; hearing these messages from a shockingly wide range of people: my doctors, experts, non-experts, relatives, clients, friends…all fundamentally well-meaning, but geez. (Yep.)
• feeling optimistic: At least this was something that I could DO, some small way of taking action against this disease. (PPE, shelter, exercise, wipe down, wash hands, wash hands, wash hands…)
Everything I put into my mouth (or didn’t put into my mouth) suddenly became part of the cancer-conversation. It was exhausting and suddenly, something that gave me so much pleasure ‘before’ was lost, blanketed by the cloud of my illness. So much grief. (Yes.)
This process extended itself as my post-cancer time turned into my auto-immune time. There were 3-4 years of recovering from cancer while continuing to feel lousy. Like so many with autoimmune conditions, it took a long time to get a diagnosis. In my case it was because we didn’t realize we were looking at a systemic problem until it got bad enough, specific enough. Even so, once things got bad, it was still over a year to have the clarity of a diagnosis. (It stuns me to appreciate just how much we’ve learned since mid-January–4 months–about COVID, and how much more we need to know.)
With my AI diagnosis 10 years ago came a new round of screening for dietary factors. This brought new rounds of altering what I ate to learn more about my particular profile. Testing and retesting; ‘running the experiment’ as I came to think of it. Change one parameter at a time; give it 2-3 weeks; and reassess. Otherwise, you can’t track what might be happening. It’s too complicated. (I learned that testing gives us a view at a particular point in time. Some tests are more conclusive than others. At best they help guide treatment and behaviors. Still the body keeps changing; life keeps unfolding.)
I remember once, early on, walking into the food store with my 18+ list of foods I couldn’t eat without hurting myself. Standing just inside the door, facing a row of aisles, feeling the pull of habit that would have taken me down a usual path. My hands dropped to my side, eyes searching vaguely. I was awash in the realization that all the foods I was accustomed to eating were on that list. “What am I going to eat?” I said out loud. In the few breaths that followed, a voice inside me said, “Everything else.” Yes, everything else.
Learning about 4 Stages
My favorite resource on this journey is The Autoimmune Paelo Cookbook, by Mickey Trescott, NTP. It’s not just that a paleo diet is a good fit for my constitution, or that most recipes are at my interest and skill level. The thing I LOVE about her book is how she conceives of dietary restrictions as something to navigate. Her system isn’t binary. She honors that what we need to eat during a flare up is not the same thing as what we might eat when our system is calm. Rather than all or nothing, she has a 4-stage approach.
Like concentric circles, the center-most phase is what to do when things are bad. Risks are high and the system is highly challenged. It’s conservative and most restrictive. As the system heals and symptoms decrease, you can expand your range to include the next layer out, and then again a third layer. These intermediate layers are strategic about bringing in both nutritional variety and pleasurable variety–feeding both the body and the soul. Her outermost layer involves all foods. Nothing is off the table. Those ‘riskiest’ foods are simply identified as known inflammatories, to be eaten with caution, probably in small doses. Her system orients to the on-going changes in the body–in and out of flare ups–as well as the decision making process we live in every day.
A New Normal?
“Everything else.” What a gift that voice was and continues to be. I’m 12+ years into altering my diet — balancing my intestinal health, my nutritional needs and my emotional needs for pleasure and good company. What has become normal for me is to take these factors into consideration. Navigating risk and benefit, critical and non-critical needs, dancing with nutritional need and the pleasure of eating — this is normal, not new anymore.
Most days, thanks to meds and my behavior, my system is quiet enough that I can cheat a little here or there. When I cheat, I try to really enjoy it: choose well, accept it – rather than regret it. If I go too far, my body will let me know. Inflammation is the way that my body reminds me of what nourishes and what poisons. I also remember that most medicine can be poisonous at the wrong dosage. It’s the dance that I’m in every day, listening to that voice inside for guidance: what’s right for me today?
As we live further into a world with COVID-19, we will move from the emergency of the outbreak/diagnosis phase into the phases of living alongside the virus. Clearly having accessible diagnostics and treatments will open the horizon considerably. In any case, we’ll walk into a future where we need to assess risks and benefits and take appropriate cautions, just as we do with better-known diseases. In further posts, I’ll focus on how how I’m making sense of the 4-phase public health approach as it applies to my practice.
I’m so grateful to all those who are working on the front lines now — in hospitals, elder homes, individual homes, social services, companies who supply critical materials. And those in labs, processing, testing, retesting, using the best of your knowledge to find answers to the questions that underpin treatment and prevention. Thank you!
Last fall, we visited Taliesin, Frank Lloyd Wright’s home in Wisconsin. It was a thing to do during a family visit, something I hadn’t expected or known much about. I had heard of Wright, of course, but didn’t know much about his way of working. The ways humans shape their spaces is something that I’ve appreciated in my life, but not in a studied way.
And yet, there’s such an obvious connection to our work of ‘holding space,’ of ‘creating a container.’ In bodywork, craniosacral work in particular, we acknowledge the importance of the body’s dynamic, living field. We appreciate its organization. We engage it with our own living field, our intention and our actions–no matter how subtle or gross they may be.
Not sure what I’m talking about? Walk among the trees, even just one tree. This time of year, deciduous trees are starting to leaf out, but there’s still enough of their architecture showing to get a wonderful felt sense of ‘creating a container.’
The limbs reach upward and outward. There’s a dome etched against the sky by the edges of the last twigs. That creates a periphery, while the truck holds a central axis. Both are needed for a strong container: center and periphery. With trees, those are fixed, excepting extreme winds. I believe it is part of what gives us the experience of shelter, of being held.
What was so compelling to me in moving through Wright’s home was that each room had movable, breathable centers and peripheries. Each room has its natural purpose: sleeping, socializing, music, reading — giving the space a functional center. He didn’t think much time should be spent about the body: bedrooms, bathrooms, closets are all quite small and spare.
The larger rooms also had several structural focal points (windows, fireplaces, changes in ceiling pitch, crevices or alcoves). Commonly these focal points either drew nature into the space or nested a sculpture or other piece of art within the home. This often gives the interior space a layered feeling, a sense of potential. Everything felt placed with functional purpose as well as a sense of beauty. Details matter.
Focal points to organize movement
This also reminds me of our work with people, as the healing process is so layered. They come to us with a particular focus, an ache or a pain. (Such a place in the system is called an ‘inert fulcrum’: a place of stillness or lack of integrated movement.) After our assessments, we might identify one or two additional places that relate to their focus. We hold all of those in our awareness of their system (the periphery) while, at the same time, we work with the body in a focused way — either following what arises from the system, or inviting the system as we initiate changes.
In our work, what we would call ‘natural fulcra.’ A natural fulcrum, in our work, is an place in the body around which movement organizes, that is itself moving or dynamic. Our center of gravity is one example. The central tendon of the diaphragm is another: the respiratory breath organizes around this relatively fixed structure, and the tendon itself moves slightly with each inhale and exhale.
Compression — Decompression
One remarkable dimension of Wright’s home was the way he designed the overall layout. These crafted rooms were joined by passageways that are intentionally snug. Low ceilings, close walls, and dimly lit, these hallways provide a very intentional “compression” experience as he called it. And compressive it was.
The intention is to be compressed between the rooms, so that when you enter into the next space, there is the “release” of being in a more open and light-filled space. This is such a consistent, physical experience, that you can listen to the quick intake of breath (expansion!) as each person on the tour crosses the threshold!
It was such a blessing to be in a place of such layered intention; where the body’s experience was taken into account; where details matter and the whole field is held and interwoven with nature. I am reminded of Mary Oliver’s often quoted line: You only have to let the soft animal of your body love what it loves.
Wash Your Hands
We are humans relearning to wash our hands.
Washing our hands is an act of love
Washing our hands is an act of care
Washing our hands is an act that puts the hyper-vigilant body at ease
Washing our hands helps us return to ourselves by washing away what does not serve.
Wash your hands
like you are washing the only teacup left that your great grandmother carried across the ocean, like you are washing the hair of a beloved who is dying, like you are washing the feet of Grace Lee Boggs, Beyonce, Jesus, your auntie, Audre Lorde, Mary Oliver- you get the picture.
Like this water is poured from a jug your best friend just carried for three miles from the spring they had to climb a mountain to reach.
Like water is a precious resource
made from time and miracle
Wash your hands and cough into your elbow, they say.
Rest more, stay home, drink water, have some soup, they say.
To which I would add: burn some plants your ancestors burned when there was fear in the air,
Boil some aromatic leaves in a pot on your stove until your windows steam up.
Open your windows
Eat a piece of garlic every day. Tie a clove around your neck.
My friends, it is always true, these things.
It has already been time.
It is always true that we should move with care and intention, asking
Do you want to bump elbows instead? with everyone we meet.
It is always true that people are living with one lung, with immune systems that don’t work so well, or perhaps work too hard, fighting against themselves. It is already true that people are hoarding the things that the most vulnerable need.
It is already time that we might want to fly on airplanes less and not go to work when we are sick.
It is already time that we might want to know who in our neighborhood has cancer, who has a new baby, who is old, with children in another state, who has extra water, who has a root cellar, who is a nurse, who has a garden full of elecampane and nettles.
It is already time that temporarily non-disabled people think about people living with chronic illness and disabled folks, that young people think about old people.
It is already time to stop using synthetic fragrances to not smell like bodies, to pretend like we’re all not dying. It is already time to remember that those scents make so many of us sick.
It is already time to not take it personally when someone doesn’t want to hug you.
It is already time to slow down and feel how scared we are.
We are already afraid, we are already living in the time of fires.
When fear arises,
and it will,
let it wash over your whole body instead of staying curled up tight in your shoulders.
If your heart tightens,
science says: compassion strengthens the immune system
We already know that, but capitalism gives us amnesia
and tricks us into thinking it’s the thing that protect us
but it’s the way we hold the thing.
The way we do the thing.
Those of us who have forgotten amuletic traditions,
we turn to hoarding hand sanitizer and masks.
we find someone to blame.
we think that will help.
want to blame something?
Blame capitalism. Blame patriarchy. Blame white supremacy.
It is already time to remember to hang garlic on our doors
to dip our handkerchiefs in thyme tea
to rub salt on our feet
to pray the rosary, kiss the mezuzah, cleanse with an egg.
In the middle of the night,
when you wake up with terror in your belly,
it is time to think about stardust and geological time
redwoods and dance parties and mushrooms remediating toxic soil.
it is time
to care for one another
to pray over water
to wash away fear
every time we wash our hands.
Earlier this month, I described my fingers as lonely. It’s been so strange to not touch people — in greeting or departing, just passing by casually, and of course, with our work. I know I’m not alone in this. We massage practitioners like touching people so much, believe in the power of touching people. We’ve dedicated our lives and livelihoods to it. So deeply strange, now, to withhold these gestures.
Yet, this hiatus has also given me, us, an opportunity to reassess and re-orient our work. Before the shut down, I would often gripe about the time I didn’t have. Now I have the chance to explore things on my to-do list. I also can reassess my current interest or resistance to doing them. We know from trauma recovery that this kind of slowing down is a key part of the healing process: a chance to respond rather than react.
• Move within, but don’t move the way fear makes you move. — Jalaludin al Rumi
Slowing down has allowed me to hear the stories I’ve told myself to reinforce my past choices. Some stories have positive drivers: “I want to help people”. Some have practical underpinnings: “I need an income”. While others have a mixture of impulses: “If people get used to staying away, will they come back?” “Is my work non-essential?” These drivers get set early on, and if they are viable, they persist. The dilemma is going along for too long without reexamining them — like any habit we have. Having our habitual routines upset is very uncomfortable, but also gives us a deep opportunity to reorganized and realign. Another thing we learn in bodywork.
• I realized I had the attitude of compassion, but not the practice. — Brené Brown
Years ago, I read these words in Brené Brown’s The Gift of Imperfection. They really struck me. I realized that I had for years the attitude of self-care but not the practice. Significant illness over the last 10 years has taught me many kinds of self-care. For that I am very grateful, though it was not an easy road.
So much of this COVID enforced isolation has reminded me of the early phases of my illness(es). One significant difference now: so many of us, all around the world, have been submerged into this isolation. Together, alone. The process of simplifying, quieting, resting and witnessing ourselves is reverberating across continents. So much change could come of this time, if we are mindful about how we move forward.
• Your hand opens and closes, and opens and closes./If it were only one or the other, you would be paralyzed. — Jalaludin al Rumi
Moving back into practice after this long break, I want to be mindful to take care of myself. Here are some ways I’m shaping my practice in the near future:
I expect my hands and body will have lost some of its strength and coordination. Even though I’m doing some exercises now to keep my hands from being too restless, I’m betting that I might be stiff or sore when I start up. I’m scheduling myself for a massage monthly (something that I was just getting to before the shut down). I’m also going to work on fewer people in the first weeks, ramping up gradually, rather than going from 0-60mph.
I miss the quiet and the grounding that bodywork practice brings me. From taking time off in the past, I know my awareness will need to regain its stamina. To give the kind of attention we give our clients, an hour or more at a time, is not a simple thing. Though I am taking walks and have lots of ‘down’ time, it’s not the same as the focused presence we bring to our work. (The cats are getting some of that, which seems, to them, to be long overdue!)
Another reason for working on fewer people at the beginning, is that I remember how stressful it was to see people right before the shut down. Though we’re not counselors, our clients talk with us and we’re with them for extended time. We take in a lot of their emotional tone–physically and psychologically–especially as our work helps them shift autonomic state.
How can I take care of myself as I interface with people during this time? How many ‘how’s your COVID-19 time going’ conversations can I have in a day? Do I need to make boundaries about the ways we talk during sessions?
How can I involve my clients in that boundary-making practice? In the past, I have used a ‘thumbs up, down, middle’ hand signal when I didn’t want to open up topics for conversations. Giving myself and them permission to say, “I don’t want to talk about that right now.” Remembering the power in shared silence and simple witnessing.
The gift of not knowing:
Years ago during a peak time of my illness, my body would simply give out with fatigue. So I wouldn’t know from morning to night what I could do. At the time I was struggling with how to navigate other’s expectations about my involvement in social activities. As someone who prided herself on keeping her word in conscientious way, this was very humbling for me. Good humbling, but hard emotionally. I struggled with who I was used to being and who I newly was.
At the time, I was receiving care from Dan Lewis, a local chiropractor. As I lay in his common treatment room, I heard another client ask him, with great enthusiasm, if he was going to the Oregon Country Fair that year. Dan simply paused and said, “I haven’t decided yet.”
That was a big gift for me. I try to remember that I have permission to take care of myself, to learn as I go and to try things and see if that works. Our clients know us and care about us. I believe that the clients who are willing to affirm our well being as we reemerge into practice are the clients worth keeping. The paths forward for all of us, on a small and large scale, will need to be sustainable. How can you make your next practice more sustainable than your last?
Letting it unfold:
Whatever my practices and boundaries are as I reenter working with clients, I trust that they will evolve over time, even in just a few short weeks/months. Perhaps by mid-summer, we will be in a relatively ‘new normal.’ But between now and then, we get to figure it out as we go.
That permission–to learn as we go–is really important for us as professionals. It can run counter to the societal (and/or personal) expectations that we’ve got it all handled. None of us have this handled; we’re all learning together.
On April 6th, the WA State Board of Health gave us guidance about how to work with clients while the COVID-19 public health isolation protocols are in effect. Some of us have shut down our practices completely, some of us are seeing a few clients. One thing is for sure: when we begin practicing again at more usual levels, we’ll be using precautions that are new.
Here are my current thoughts about how we’ll be navigating those new parameters. (The bulleted sentences in bold come directly from the health alert. My thoughts are added in the following sentences.)
• Only provide massage to patients with urgent medical issues. In my previous post, I discussed how we can think about what qualifies as urgent. On a practical level, I’ve also been relying on clients to decide this for themselves. For some, their need is great enough that it surpasses the risk of coming in. With regular clients, I honor that they know what my work does for them and that they need it; that’s good enough for me. The only new clients I’m accepting at this time are babies in distress. (I could also see accepting new whiplash clients — shouldn’t there be no accidents right now?! Sheesh.) Needless to say, anyone not willing to use precautions doesn’t get an appointment.
• Cancel non-urgent massage appointments. So far, most clients are self-isolating — canceling their appointments when they know they can wait. When we start to open up again, we’ll likely need to have a way of screening clients’ level of need. At first, I’m considering offering shorter appointments and/or working on fewer people. To give myself and others a chance to get used to things during this unusual time.
What I don’t want to do is go back to work behaving as if we haven’t been through this extreme time. I won’t know ahead of time what my needs are, so I want to give myself permission to take it slowly. (My next post will be about how to take care of ourselves when we re-open our practices.)
• Remind sick employees to stay home. Being self-employed, you’d think this is a no-brainer. But I am grateful to COVID-19 for teaching me a deeper lesson of taking care of myself and not pushing through my own mild symptoms. I hope I can retain this lesson as life returns to ‘normal.’ I’m hoping we’ll all be more willing, in months to come, to wear masks when we get the sniffles, to stay home and rest, and to not judge others for doing so themselves.
Consider your practice set-up:
• Make sure patients practice social distancing of six feet in waiting rooms and other areas. This is pretty self-explanatory. A few weeks ago, it felt strange to have that extra space between us. Now, we’re getting used to it at the grocery store, the post office, bank, etc. So it doesn’t feel so odd, though I still need reminding sometimes.
• Closely follow CDC Guidelines for hand hygiene and clean equipment and facilities between patients. Here, I’m leaving 15 minutes between clients in order to wipe things down, clean and then dry with a second towel. When wiping down, I’m not just focusing on door handles and the like. Lots of people now are not touching the handle itself, to avoid germs, instead touching all over the door.
I’m considering posting a sign that says, “Please only touch the door handle–so I know where to wipe!” In the meantime, I’m asking them to let me open and close the door for them.
I’m also asking that people consistently leave their shoes outside the office. Because I often get down on the floor for assessment or working with kids, I don’t want shoes tracking in…whatever.
Screening clients and mutual protection:
• Screen patients for symptoms of respiratory illness (e.g., fever, cough, difficulty breathing). “Cough and difficulty breathing” are symptoms we can ask about. Checking for fever requires measurement; the guideline relative to COVID-19 is a temp of 100.4 degrees or more.
We’re using thermometers on ourselves, and soon will use them on clients as we all start to move around more. (There will be a phase when case rates are expected to go up, but hopefully only a little. Herd immunity requires that we do move as a herd, after all. So we’ll be taking that moderate risk together soon.) We have 2 kinds: an ear thermometer and an infrared thermometer.
The infrared thermometer allows us to take someone’s temperature while maintaining social distance. Aim the light beam at their forehead to get a reading. The Kinsa ear thermometer tracks our readings over time, and sends that data to their company’s mega-database. Usually I resist participating in meta-data, but this time, it’s a great idea. Information they’ve gathered has been successful in predicting overall disease trajectory and therefore public health modeling. Check it out! (Currently sold out of the ear model; have an oral model for all ages.) Clearly, if they have symptoms, refer them to their PCP or a nearby clinic.
• Consider wearing a face mask or cloth face covering when providing massage and when within six feet of another person. There are so many options here. Youtube is your friend. One thing worth noting: this virus is relatively fragile. Washing your cloth mask (and sheets) in the washing machine at a regular setting, regular detergent, even cold water is enough to kill it.
You don’t need to use bleach to clean your linens/cloth masks — in fact, Clorox is discouraging it. My sister in law happens to work for Clorox, so got the low down recently. BTW: if you’re wondering why Costco still doesn’t have palettes of Clorox products, it’s because they are prioritizing hospitals and elder care facilities. Just saying.
• Provide face covers and request use by clients when close proximity is necessary. Most of our clients are bringing their own, however we made an extra dozen or so cloth masks to be used by clients and washed each time. Again, easy to do now that we’re all becoming more accustomed to this simple measure.
Using on-line platforms or phone for sessions:
• Consider instructing patients to implement self-care measures such as rest, hydration, light stretching, light or moderate activity and self-massage. We have been partners with our clients in these recommendations already. I keep my expectations simple for these sessions.
Sometimes it’s just reminding them of the exercises that I’ve already shown them. Other times, I guide them through a simple self-massage routine. It might be as simple as breathing or stretching together — helping them take time out to pay attention to their health, to listen to their body.
I acknowledge that this is new to me and I’m willing to improvise in helping them. People are grateful for the support and happy to pay. Because it feels a bit less focused or reliable than our time together in person, I’m not charging my full rate for these sessions.
Placebo response? Bring it on!
I appreciate that a big portion of the benefit is the connection we have. I want to give a big shout out for the role of placebo in healing. In standard clinical culture, placebo is either ignored or disparaged because it doesn’t link with an external, clearly identified “mechanism.” What gets lost through this analysis is that there are measurable, physiological changes–placebo responses, not effects–that bring greater health and well being (sometimes greater than the drugs/treatments being tested!). Rather than being a sham, placebo responses represent ways that the body-mind connection can be stimulated toward health.
Often alternative/complementary medicine is also disparaged as being overly influenced by placebo dynamics. I say, Bring it on! If there are ways that I conduct my practice such that the client’s body is engaged and stimulated into healing, I’m glad for it.
It may be a little counter-intuitive, since our work is fundamentally about touching, but I’ve had good success with the few e-sessions I’ve done. If your clients are open or interested, I hope you give it a try. See how your knowledge can translate across a new kind of connection!
My next post will look at how we take care of ourselves during this time of isolation and the coming phases of opening up our practices.
See earlier posts relating to COVID-19 by filtering to Announcements.
This is a 3-part post covering topics relating to re-opening our bodywork practice. Thanks to Cinny Burrell for prompting me to write this!
Essential but not Emergent:
Over the past month, I’ve been thinking a lot about this designation “essential” or “non-essential” as it has been handed down through our public health system. I understand and deeply appreciate the difference between what we do and the kind of medicine that doctors and their teams offer in hospital settings. On a regular day; let alone during an emergent crisis. What I want to share in this post are thoughts about a wider sense of medicine and healing — one that we can more easily embrace once the curve is flattened and isolation orders are being lifted.
Because LMTs in WA state are listed as health care providers, and therefore ‘essential,’ we are authorized to continue working. Even though this is the case, most of us have closed or significantly diminished our practices during this time. Some of us decided to close our practices out-right for a considerable time (a month or more); others have had enough cancellations that their practices are only marginally operating.
Practice Guidance from the State:
On April 6th, the WA State Board of Health has given those of us still working with clients some guidance:
• Only provide massage to patients with urgent medical issues.
• Cancel non-urgent massage appointments.
• When treatment is medically necessary, screen patients for symptoms of respiratory illness (e.g., fever, cough, difficulty breathing)…If a patient has respiratory symptoms, do not provide treatment. Instead, refer the patient.
• Consider instructing patients to implement self-care measures such as rest, hydration, light stretching, light or moderate activity and self-massage.
• Make sure patients practice social distancing of six feet in waiting rooms and other areas.
• Closely follow CDC Guidelines for hand hygiene and clean equipment and facilities between patients.
• Remind sick employees to stay home.
• Consider wearing a face mask or cloth face covering when providing massage and when within six feet of another person. Provide face covers and request use by clients when close proximity is necessary.
I will write about the practicalities of implementing these guidelines in my next post.
A New Normal:
Here I want to speak to the underlying perspectives about massage/bodywork that this Health Alert reveals. These underlying issues hold within them some of the keys to how we can decide which patients to work with and when. This is especially important because, experts agree, we will not emerge from this public health strategy of social distancing all at once. We will emerge slowly, over time. In all likelihood that means we all will be practicing at a middle-ground level: more than now, less and differently than before.
There will be many versions of acceptable practice during this time. Most of us work with relatively healthy people (not the kind of challenges seen in an emergency room), who are looking to amplify their well-being. Working with health gives us MORE options, not fewer — this is a good thing. But it also demands consideration on our part. I’d like to speak to how we can figure out what’s best for our own circumstances.
What we do:
• Consider the kind of work you do. If there is a spectrum of general to technically specific, where does your work fit? How unique is this skill set (can a PT do it, an OT, a trainer)?
• What are the consequences of NOT doing your work with clients? For example, if you practice manual lymphatic drainage, your hands on work is a primary treatment for people’s edema, one that can’t be replicated easily. Not receiving your care could leave clients with long term lymphedema.
• Can it be replicated at home? If so, consider doing tele-health sessions with your clients — teaching them self-care massage, the simple things. This can empower them in the meantime and build a bridge with them for the future. They know you’re out here and thinking of them.
Who we work with:
• Do you work with a specific population? Kids, elders, athletes, tech workers, cancer patients, construction workers, etc.
• How is COVID effecting them? Some may be sitting idle for the first time in their lives; others might be working overtime under unusual stress, physical, emotional or psychological.
• Do you have a steady private practice, with on-going clients relationships, or do you work in a more generalized setting: a clinic or spa that handles all the scheduling for you, chair massage at events or public venues?
• This matters because the ‘new normal’ of mutual disease precautions might be easier to implement with people you know (or with people you don’t know). If you work for a company, making sure the managers have your back about what to do if clients don’t want to be screened or use precautions is key for your own sense of safety.
When is our work necessary:
• Current phase of social isolation/COVID emergency:
For acute challenges: orthopedic/soft tissue injury, lymphatic, neural, physiological, psychological, etc… Consider shorter sessions during this time. Just enough to keep people out of the ditch and/or from having significant side issues. Can they ‘get by’ with 1/2 hour every 2 weeks, even though they want 1 hour every week?
For example, I’ve been working with babies who are having significant breast feeding challenges. Waiting 4 weeks is really long for an infant, and usually the sessions can be short and spaced far apart. I’ve also been working with a couple of clients who have significant anxiety/depression; this COVID time has become such a risk factor for their overall health that their counselors are telling them to get care.
• Middle phase of COVID emergency: coming out, but not all gone:
As the curve is flattened for a longer time, we can start considering people with significant challenges that will require more time to treat. Those that need weekly appointments and/or challenges that they can partially tend on their own, but having your care once a month really helps.
In this category I’ll also put the many, many workers who are overextending themselves right now. Tech workers working long hours at home with poor ergonomics; first responders of all kinds; parents and teachers – oh my!; store clerks and delivery people. There are a lot of people who could use our support in the near future. I’m considering a reduced rate for front line health care providers for a period of months this year.
All clear (and/or between this time and the next time):
When I feel afraid about being self-employed and not working on anyone for yet another week, I try to breathe and remember this: touch heals. Touch helps our immune system, our sleep, our sense of connection and well-being. Touch helps relieve the effects of cumulative stress: achyness, stiffness, poor sleep, impaired digestion. Touch can help reduce the effects of psychological and physical isolation, including depression and anxiety. All the reasons people have been coming to us for years are present now. One of the ways to move fully from trauma to health is to move beyond fear and pain, and recover our ability to perceive pleasurable sensations and emotions.
This is where I find myself coming up against the clinical assumptions in the Health Alert — essential/non-essential. These categories fit for an emergency situation, however, if all we ever have is emergency medicine, our health will suffer, our quality of life will suffer. Alternative methods tend to stress fostering health rather than fighting disease. When the dust has settled and it is more reasonable to be moving about with fewer precautions, the work of alternative care providers, like us, will be sorely needed. My hope is that this extreme time with COVID-19 gives us many (oh so many!) insights into how we can improve our health care system, including an appreciation for how alternative care can be complementary care.
My next post will look at how practically to implement the practice guidelines.
Looking for some solace and expansion during this ‘at home time,’ I’ve been reading Gathering Moss, by Robin Wall Kimmerer, a Environmental and Forest Biology professor and member of the Potawatomi tribe. (Gathering Moss, University of Oregon Press, 2003) You may have heard of her other book–which is fabulous, BTW– Braiding Sweetgrass.
In both books, she speaks to our relationship with the natural world, weaving together both a indigenous cultural perspective and a scientific one. Both are ways of deep knowing that she claims. For my heart and mind, she carries that lovely balance of being specifically grounded in knowledge and experience, with an expansive understanding that allows all things their inherent place. A perspective she often attributes living close to nature.
Here’s this that spoke to me this morning:
Draw closer to this carpet of green light and shadow, and slender branches form a leafy arbor over sturdy trunks, rain drips through the canopy, and scarlet mites roam over the leaves. The architecture of the surrounding forest is repeated in the form of the moss carpet, the fir forest and the moss forest mirroring each other…
Learning to see mosses is more like listening than looking…Straining to hear a faraway voice or catch a nuance in the quiet subtext of a conversation requires attentiveness, a filtering of all the noise, to catch the music…You can look at mosses the way you can listen deeply to water running over rocks. The soothing sound of a stream has many voices, the soothing green of mosses likewise. Freeman House writes of stream sounds; there is the rushing tumble of the stream running over itself, the splashing against rocks. Then, with care and quiet, the individual tones can be discerned in the fugue of stream sound. The slip of water over a boulder, octaves above the deep tone of shifting gravel, the gurgle of the channel sluicing between rocks, the bell-like notes of a drop of falling into a pool. So it is with looking at mosses.
Wow! The book continues with short chapter/essays about various aspects of moss biology, environment and properties. I’m not yet done with the book, but I’m so enjoying it. Nearly every page has dog-ears for me to come back to: a sentence, a paragraph, ideas about nature and its balance and beauty.
I can’t wait to get back out into our lush northwest forests so I can look and listen again at this incredible bounty!
Thank you, Dr. Kimmerer for your work in bringing this book to us.
In this time when we aren’t able to practice with clients in person, I’ve had the opportunity to work with a few people on Zoom. This was not something I ever thought I’d do. I’ve been surprised and intrigued about the kinds of changes these clients have experienced. (Something I’ll be pondering and exploring for a while yet!)
All of this is done only as long as and if it remains comfortable for them. You can improvise smaller steps, other props or just stay with breath and awareness. I’m working with people who are relatively healthy and stable in their healing process. It’s important to screen out people with severe and dynamic symptoms, especially neurological signs/symptoms.
Here are some ideas strategies that have been working well:
Initial set up:
Zoom rules apply: if they can have a quiet space without a lot of ambient noise or commotion, that’s best. I like them to stay ‘unmuted,’ so I can hear any quiet murmurings and responses from them as we proceed.
What I’ve found is that we start with a little chatting – a usual intake time. Then I invite them to lay down in a comfortable position. I like them to be propped to their own comfort, as close to neutral spinal position as possible. They can use folded blankets or towels rather than big, thick pillows for neck or knee support.
It helps me if I can see their body, so I ask them to adjust the angle of their laptop/phone. They don’t need to see me — just hear my voice.
Passive positioning and restfulness:
The first phase is letting the body settle, letting the ANS begin its shift from a ‘social engagement’ or mobilized state (ventral vagal/sympathetic) to a more safely-immobilized state (dorsal vagal in safety/deep parasympathetic). Guiding their awareness of breath, through several cycles, can assist this process.
For a blended Core Link/Cups and Domes, I invite them to use their hands as props. First place their hands under their sacrum, palm to the resting surface (forearms pronated). Become aware of how the lumbar spine falls away from the sacrum/pelvis, since it is lifted a bit. The breath can do the work for several cycles.
Next, they can put their hands under their occiput, cupped. I don’t have an opinion about whether or not they interlace or overlap their fingers. Again, let the breath bring small movements into the upper neck, allowing the upper cervicals to gentle settle, heavy, to the table.
Next, they can bring their hands to any (all?) of the torso diaphragms: low belly/pelvic floor, respiratory diaphragm, and upper chest/thoracic inlet. Feel the weight of the hand as it settles, emphasizing the exhale (parasympathetic). Let the breath come in waves, maybe invite a sigh or yawn (don’t stifle them!).
You can stay with them as they notice body changes and/or emotional content rising. If they become aware of areas of particular tension, you can invite them to bring their awareness, energy, breath, vibration, colors — whatever feels available and evocative to them — to the area. Allow several breaths, time and attention to begin to change the area.
Small circles or combing with finger tips, gentle pressure or squeezes with palm of their hand or using a roller or pad can help people address stiffness in their soft tissue. Good areas: sub-occipitals, temporalis/masseter, hands/forearms, neck, feet. Caution: their hands will get tired well before ours might — they haven’t had the practice! Under treat rather than over treat.
For the spine, people can lay on a rolled towel or foam roller and gently shift their weight side to side. Bent knees with feet on the resting surface provides good stabilization. One client decided to change to Child’s pose for this — we were able to direct her breath to the various stiff places she felt.
Vagal Nerve Release:
Taken from Stanley Rosenberg’s “Accessing the Healing Power of the Vagus Nerve” (read it if you haven’t yet!), the vagal release technique is simple and remarkably effective. It’s short and you can find lots of versions on line. Here’s one that I like.
This usually takes us most of the way there. You can build off this in lots of ways depending on their particular symptoms:
• self ear-pull for vertigo/tinnitus
• self Sutherland’s grip for migraines
• self frontal decompression for headaches
• warm compress or warmed hands over the eyes for eye strain
Slowly transition to sitting and help them orient to the room. Simple closer and coordinating payment (I’ve been charging a bit less than my in person sessions) and you’re done!
Stand still. The trees ahead and bushes beside you
Are not lost. Wherever you are is called Here,
And you must treat it as a powerful stranger,
Must ask permission to know it and be known.
The forest breathes. Listen. It answers,
I have made this place around you,
If you leave it you may come back again, saying Here.
No two trees are the same to Raven.
No two branches are the same to Wren.
If what a tree or a bush does is lost on you,
You are surely lost. Stand still. The forest knows
Where you are. You must let if find you.
by David Wagoner, in Traveling Light
4000 Aurora Ave N, Suite 114
Seattle, WA 98103
116 NE 194th St.
Shoreline, WA 98155