Ep 432 – Walking That Fine Line of Friendship and Therapist

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0:01:53.4 Darren Burford: I am Darren Buford and welcome to the ABMP podcast, A podcast where we speak with the massage and body work profession. Our guest today is Cal Cates. Cal is an educator, writer, and speaker on topics ranging from massage therapy in a hospital setting to end of life care and massage therapy policy and regulation. Cal is the current executive director and founder of Healwell, a nonprofit organization that works with children and hospitals and clinical facilities. For more information, visit Healwell.org. Cal is also the host of the podcast, interdisciplinary and Massage Without Borders Found Everywhere Podcasts are available. And Cal is a columnist for Massage and Bodywork Magazine, Which brings us to our topic today. We're talking about an article in the upcoming May, June, 2024 issue titled Walking the Fine Line of Friendship and Therapist, AKA, Did we just become Best Friends? I'm just joking about that By the way. The print version will be coming to a mailbox near you if you're an ABMP member and open online to all of the profession at massageandbodyworkdigital.com. Hello, Cal.

 

0:03:08.0 Cal Cates: Hello. Good to be with you.

 

0:03:11.5 DB: Yeah, absolutely. Repeat pod guest. Good to have you back. Okay listeners, you've not read this article yet as this has not shown up or been made live yet, so I'm just going to give you a little bit of backstory. This is Cal's piece and it's referencing a story. So here's the little bit at the beginning that you should know. This is Cal's words from the piece. "In a recent peer support meeting, one of my colleagues shared that an older client of hers thanked her, "for an excellent massage And the friendship." my colleague was stunned and a bit unprepared for this second appreciation. She had seen this client for many years, but never thought of their relationship as a friendship. She left wondering where she had gone wrong. What had she said or done that let this client feeling like what they have is a friendship?" I feel like, dear Abby or something, reading this like little story. So, Cal, what was your initial reaction to your colleague story and have you had anything similar happen?

 

0:04:09.8 CC: Well it was really funny because it's this great little group of folks who get together on a roughly a monthly basis through Zoom and just share about what's going on in their practices. And we talk about ethical issues and things and this person just sort of shared this and I just, my initial reaction was honestly, oh man, we have been so poorly taught. You know, because she was, she really was like, oh, what did I do? You know, why did she think this? And it really, it got me to thinking about, you know, I have definitely had... I mean, it makes me sad that a client expresses that they feel safe and connected to you and you're like, oh man, what did I do wrong? 

 

0:04:56.6 CC: I mean, I've certainly had clients over the years tell me that I listen to them in a way that like their spouse doesn't listen to them or they've invited me to like a birthday party or funeral or weddings and things like that. And so certainly, dual relationships are not uncommon. But I do, I mean, I can understand how my colleague was sort of taken aback by this client actually saying, we are in a friendship basically. And that I think it sort of points to, and I say in the article that like, we don't call it friendship, but I think the relationship we have with many of our clients, certainly our longer term clients is a type of friendship. And so, yeah, it's an interesting thing to sort of noodle about and wonder about.

 

0:05:39.8 DB: Yeah. In the column, you write, you actually put a definition in there from Britannica, friendship is defined as a state of enduring affection, intimacy and trust between two people. So Cal, how do you navigate maintaining boundaries while still fostering intimacy and trust in your relationship with clients? 

 

0:06:00.8 CC: You know, there are a handful of words that we use in English language that I'd like to just get rid of and boundaries, I think, it is one of them, at least in the way that we use it. I think that when we're taught about boundaries in massage school or you know, in any of the therapeutic professions, boundaries, this big word boundaries is a thing that we talk about. And I think that if we think about the other places where there are boundaries, they're solid, they're clear, there's a, this is in and this is out. And I think we really need a better word, like maybe filter or awareness or maybe even accountability. So I mean, first I think I would say that intimacy is a product in many ways of curiosity. You know, I foster intimacy by showing you that I don't know something, like, something that I couldn't know because I'm not you. And as a person who's caring for your body, I'm gonna show you that I want to learn and I'm gonna ask questions, or maybe I decide to show you something that I don't know how you'll respond, but I... We have, we're building this relationship.

 

0:07:06.0 CC: And so I say something about myself and sort of see how you respond, and we slowly sort of feel each other out in this way and that, I don't know, for instance, like a client says, the client's on the table and they say, well, when I tell my partner about this, I don't know, pain in my hip, let's say, they just shut me down. And so, as a therapist, I could say, and maybe not right in that moment, but like, I hear that and I hear this person saying, what sounds a little bit like, so I should probably shut up about it, right? Like they're sort of saying, I bet I'm making it up. And so I could just say, so when you say that your partner shuts you down, how does that look? And then they say some things, maybe they say a lot of things, maybe they say a couple of things.

 

0:07:50.8 CC: But then I get a sense of just by asking them how does that look? I'm inviting them to consider that maybe what their partner's response is, is not true, and that I can invite them to see that their partner doesn't get to decide what's true about the pain they're feeling in their body without delving into anything like psychotherapy. Just by asking the question, I'm saying, tell me more. I'm interested in understanding how this other relationship in your life is impacting your relationship to your body. We're so afraid to enter into a situation where a client will say something and we, "won't know what to say." because we think we're supposed to answer it or sort of like solve it. And I feel like this is another place where humor is a big tool in my sort of creation of safety and intimacy.

 

0:08:43.6 CC: And when we think about the very human and self-sabotaging things that our clients do that we can very, we can see that we do those things, or at least, we can really understand how those things happen, that I'll say something like, oh yeah, I've heard about people who hunch over their desks, in this way that says, I too am a desk huncher, right? Without, you know, tell me you're human without telling me you're human. So I think there are a lot of ways that we can share about ourselves and connect with our clients without undermining safety in either direction.

 

0:09:17.3 DB: I think listeners, what Cal just did was like an art form a little bit. It really, seriously, it's a tough balance of how you do that without going too far. And in the column, you mentioned that boundary setting, you talk about like flimsy boundaries and those are people who are gonna just release too much information or ask too many things and it becomes like a therapy session. And then there's that super strict adherence to limited interaction, which is like, we don't talk about anything. This is the massage, must be quiet, right? 

 

0:09:50.0 CC: Right, yes.

 

0:09:50.3 DB: I mean, and I think I've had both and I'm sure you've probably been told both as an instructor and as an educator.

 

0:09:57.9 CC: Definitely. Yeah. Well, and I think that so much more has been written about this in like psychotherapy literature and social work literature and that in, I was actually reading a paper recently about this idea that there's sort of, when it comes to boundaries, there are absolutist and there are relativists and that your absolutist, they're your people who are like, dual relationships are unethical, period. I will never enter into them anyone who does is a terrible person. And you know, I guess I would say that absolutist tend to be people who feel that they're not even able to trust their own ability to navigate ambiguity. And that because they feel that uncertainty about their own ability to do that, they just steer clear of it. And certainly, that is a way to go, right? You will not get into tangled relationships.

 

0:10:49.4 CC: But humans are tangly, right? And so, and that's not to say that relativists like have it down, but relativists are more willing to see what's possible. And I think the key is this moment to moment awareness. And we are not taught how to cultivate that skill as care providers. And this is the reason why we tend to default to a black and white sense of boundaries that this is ethical, this is not ethical. And ethics is fun because there's no, it's all about context, right? It's all about all these things that are constantly moving. And so internal awareness, self-knowledge and personal accountability will trump any kind of external code or black and white rule every time. If we're talking about wanting to create trusting and connected relationships, think about when you go to the customer service desk at a, wherever, some shop, and they say, well, that's the rule, sorry.

 

0:11:48.0 CC: And you go, seriously? Like I just told you all these contextual things, that means like this should be an exception. And it's infuriating, right? To think like, but you're not listening to me and what I am going through. And so I think we can make that same connection when we're working with our clients in terms of how we think about, it's not about I treat all my clients the same, it's this conundrum of equity versus equality. Like equality is, everybody gets a bike. Well, the person who's unable to use their legs doesn't need a bike, right? That's not gonna help them get the same place as another person with a bike. But what's the issue I'm trying to solve here is like connection and safety. So this person who comes to my practice with a history of trauma, with a history of whatever, needs a different type of regulation in our relationship to be able to feel that safety and to be able to connect with me in a way that we both get to feel safe in like a way that happens inside our bodies.

 

0:12:46.9 CC: That I think we spend so much time feeling a little bit unsafe in our lives, but we don't actually feel it, so we don't recognize it. And it's hard to have that internal awareness if that's never been prioritized. And I feel like our profession has really let us down in that way that these "soft skills," optional skills of like regulating ourselves and having this moment to moment awareness have really been put on the back burner. And even in some cases, just we've been told, this is not your job. You know, you're not a psychotherapist, you don't have to worry about this. And I'm like, oh man, we're really missing the boat by not showing up to that conversation.

 

0:13:25.6 DB: Yeah, it's really tricky. I think the answer to what you're saying is the world's gray, and you have to kinda lean into that a little bit. There isn't a black and white. Personally me, I'm like one of those people who likes rules. I'm an editor at heart, but I also like to break the rules 'cause that's kind of fun. Right? 

 

0:13:39.4 CC: Yeah.

 

0:13:44.0 DB: So like, and in that is, there's always that wiggle room and you're... I've worked with many people over the years who are like, that's not the rule. And you have to be like, well I mean. And then when we get to massage therapy, I've read everything over the years where, okay, yes, I work with this client and you have a professional relationship, and oh, oh, I just saw them at the grocery store. Don't acknowledge, do not acknowledge, keep walking away.

 

0:14:03.3 CC: Right. Abort, abort. You're right.

 

0:14:07.2 DB: And that just seems so unrealistic. Like we don't have to, like in the middle of the grocery store have a full blown conversation about everything, but we can acknowledge and say hi, right? 

 

0:14:14.8 CC: Like, Hey, how are your glutes? I'm not gonna do that in the first ____ section.

 

0:14:22.3 DB: Yeah, totally. Cal, your article discusses the concept of co-regulation and therapeutic relationships. Can you elaborate on that a little bit about the sense of safety and connection? 

 

0:14:32.5 CC: Yeah, I mean, so the term co-regulation is borrowed from this thing called polyvagal theory, which I am not an expert on the nervous system or polyvagal theory. But you can find all kinds of things written about it. And the basic nugget is that, when I feel safe and like I know what's coming and like I'm being seen, my nervous system goes into a mode where I can connect more, I can perceive and be open to possibilities. And I can come from, and this is as a provider or as the person on the table, I can come from receptivity rather than fear or sort of like a hypervigilance. And there are all kinds of things about the massage relationship that could lead people to start from a place of fear or hypervigilance of sort of like between the power differential, the expectation of nudity.

 

0:15:24.8 CC: The one person is getting paid, one person is paying, there are a lot of things about it that sort of, in other parts of our lives, we'd be like, Hmm, something's wrong here. Right? But we're normalizing sort of things that are not normal outside a massage treatment room. So when we can do that, like as a practitioner, I can increase the chances that my client and I connect in this way where our nervous systems are resonating by slowing down, by listening. And when I say listening, like I think massage therapist, we tend to do this thing where we go, well, I'm a great listener. And you know, of course like, why would I be doing this job if I wasn't a good listener? When we think about listening, what we're saying is, I hear what my clients say and I care about it, but that's like a tiny percentage of what actual listening is.

 

0:16:15.5 CC: I have to be able to hear and sense what my client isn't saying. And you know, by being curious and intentional, I can explain what I'm doing and why, like with my mouth, perhaps also maybe with my hands, with clients who have expressed verbally or non-verbally that they need the drape, let's say, to be really secure. I can use my hands and my words to assure them that I understand and heard this concern and that I will attend to it. There are all these subtle ways that it doesn't work to say, you're safe with me, right? It's like when people say, take a deep breath and relax, you're gonna do the exact opposite, right? So this isn't so easy as saying, it's cool, you can say whatever you want here, I'm gonna make sure and keep you safe. You have to demonstrate that, your actions have to show, and your, the things you don't say are also a way that we can create safety.

 

0:17:10.3 CC: And I think these are, again, things that we're just not really taught. And I mean, we could go down an entirely separate trail here talking about how the way massage therapy education is shaped and sort of codified makes it hard to figure out how to do this and how to include this when we do have to learn all these technical skills and things. But I really think we wind up going into practice unprepared to engage with these gray humans. You know, as you alluded to before, like they're all gonna be really different and we are gonna be different. Even on a given day, I'm gonna need different things to regulate my nervous system. But if I don't ever talk to my nervous system or pay attention to it, I won't even know how to ask, how do I regulate today? What do I need? What does this client do that sort of activates me? Or is this a client who like, the minute they walk into my space, I just feel regulated? And not that you're gonna find a whole practice worth of clients who just, you just naturally feel regulated with and that you fire the ones that you don't, but you really do have to get better at knowing yourself and sort of what you need to find that balance inside you and to support your client establishing that inside themselves.

 

0:18:20.2 S1: Let's take a short break to hear a word from our sponsors.

 

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0:19:03.0 S1: Let's get back to our conversation.

 

0:19:06.5 DB: Are there any examples or techniques that kind of influenced this co-regulation? And you hit on it, and I'll dive in just for a second and say, as the client, subtle things are, the atmosphere, the health intake, the draping is key. You're right, the draping is key. You've heard me, we're doing the same thing, we're communicating. And obviously, I would imagine if you see my body tense up and it's not real, it's not with regards to the actual physical human touch or it is in an uncomfortable way. I'm guessing those are things that you probably notice all the time. Right? 

 

0:19:43.9 CC: Definitely. And I think that we... I mean, we've probably talked even on the podcast before about how therapists like to say, well, I don't know, I just knew to do it. And it's like, but you did know you perceived things with your eyes, with your hands, with your nervous system that made you spend more time in this part of the body, or slow down as you undrape this leg or whatever the thing was. Like, it's not always things that your clients say, but to really be listening as though your whole body is an antenna and that you're getting information constantly.

 

0:20:14.9 DB: When you're getting... So circling back around to the friendship where we started, when people are overly talkative or overly hand... Giving you information that starts to make you uncomfortable, are you just shepherding it back to the massage? Are you ever as blunt as like, let's... Why don't you let go right now? Let's just focus on the massage that are you... How do you like recycle them back when they veer into friend territory? 

 

0:20:45.1 CC: Yeah, I think it really depends. It varies based on the client and based on the topic and based on how the session is going. There are all sorts of silence is definitely one of the tools that I use. And not in a, like, I'm not going to answer your question, kind of silence, right? But that sometimes people are just talking and they're not actually inviting you into a conversation. If you're one who trips easily into conversation, maybe you miss that actually this person is just like decompressing and you can receive, you can nod, you can say uh-huh, you can like sometimes you'll see a client talking, they'll be like, oh, I'm talking too much. And so I might say like, this is actually your hour. If you feel like you wanna talk some more, that's totally I'm here for it.

 

0:21:34.3 CC: So we don't have to demonstrate that we're here for it by saying, oh, I totally agree. You're absolutely right. Whatever the ways are that we might talk in a sort of more casual way. I think in the article, I talk about that in some ways and I'm gonna get hate mail and I'm down. I'm ready for it. That in some ways, our sessions mirror the experience that a lot of people have at the salon where I think you and I were talking and you said it was hairapy, which I can't believe I've never heard that before. But sharing about yourself as a provider is not in itself unethical. Sharing in a way that invites the client to take care of you. If you're talking with your clients about your parenting woes or like the management at the spa where you work, or something else that is likely to inspire them to wanna like, go into problem solving mode and kind of takes the locus of care away from their body, that's not friendly banter anymore. That's poor boundaries, right? That's sort of spilling something that it should be saved for when you go home to your roommates or whomever, but it be laughed together about the terrible parking situation outside your office or how much spam email you get or how neither of you knows how to change the settings on your phone. And you sort of like you start there and sort of like connecting in these basic ways that...

 

0:22:50.9 CC: And you can also, like, you could say things like, yeah like if it organically comes up, obviously, but like I love that my son is so helpful around the house and like this... Now, this client knows that you appreciate this relationship that you have in your life. You don't have to then riff for 20 minutes about how great your son is. But you can sort of drop these small pieces of, I'm a person who does other things besides massage. And you know, that over time, you can reveal things about yourself that show who you are without saying to the client, help me deal with this part of my life or myself.

 

0:23:26.4 DB: See, I think that's where the hairapy is a little different, right? I think that's probably the most extreme example. Then when we all go to a stylist or barber, there's a, first of all, both of our eyes are open and we're looking at ourselves in a mirror, which adds to something where our eyes are not closed. We're not nodding off that thing...

 

0:23:45.5 CC: Totally.

 

0:23:45.8 DB: And we're both looking at the process happening at the same time. So that adds to this thing, right? And by nature, that environment is multiple stylists typically in an area. There's music playing, there's a vibe going, and it becomes funny and talkative, and that...

 

0:24:03.5 CC: Definitely.

 

0:24:03.9 DB: Starts to open up a little bit to counter that. Like past couple of weeks I went to a chiropractor who did this beautiful dance of the therapy, and then would be like, do you ski? Oh, how often have you gone up? Crack. Oh yeah, okay, so da da da da crack. Okay. Shake hands, exchange of money, session over, right? 

 

0:24:07.7 CC: Yeah, yeah.

 

0:24:22.6 DB: It was friendly and I never at one point thought we were friends and we were gonna go skiing together.

 

0:24:28.7 CC: Right.

 

[laughter]

 

0:24:32.5 CC: Yeah. Well, and it's interesting 'cause I feel like the chiropractic session is technically typically shorter than a massage session, right? Everybody has their clothes on. I don't know about you, but I rarely fall asleep while being adjusted by the chiropractor, right? 

 

0:24:48.2 DB: No.

 

0:24:49.6 CC: So in the article, I talk about that people rarely say to their accountant like, thanks for the friendship. Even though the accountant has probably spent a lot of time with you and maybe and has definitely seen your intimate financial details or like your dentist, same, right? Like your dentist wants to be your friend 'cause they wanna talk to you while they have their hands in your mouth, but it's a one way relationship, right? So in some ways, it is a unique sort of dynamic that we do have to navigate, which all the more points to our need to really prioritize the skillset of self-awareness and really being able to navigate this type of relationship, which may be perceived as a friendship, and that, how do we recognize that we are connected to an intimate, and even close with our clients and feel like, yeah, and this is okay.

 

0:25:43.5 CC: Even if I was thinking about like the ways that we connect as well. Like, I will text a client and say how's such and such feeling, right? And if the client tries to like, then we wind up in this conversation, then I just stop responding, right? And I'm like, so we're not now in a text relationship. I just was wondering about your hip or your whatever. And so I think there are a lot of ways that we can, we can invite closer relationship and still hold that line. And like social media, if your clients wanna be friends with you on say, I don't know what the kids are using, Facebook, TikTok, I don't know how it all works. But like on Facebook, I post all kinds of things that are sort of about my, I guess, personal life or just my opinions and things.

 

0:26:27.7 CC: And so if a client wants to be friends with me on Facebook, I might not accept that friend request, 'cause like, that might be a level of transparency that I feel unable to navigate and like a peak into my life that I don't wanna allow for them. So these are questions you have to... I'm not saying don't friend your clients on Facebook. I'm saying think about now when you post on Facebook, who is seeing it. And most of the people I'm connected to there have hundreds or even thousands of friends. You can't possibly be keeping top of mind everyone who's in that list, right? And so you post a thing and you're like, oh, well that's a lot of me out there. So I think we just have to really be mindful about what we personally feel able to navigate in terms of feeling safe, helping our clients to feel safe and still remaining connected, and intimacy can feel quite safe. And I don't know that culturally we're really ready to be with that truth.

 

0:27:27.4 DB: Cal, as we bring this podcast to a close, let me circle back around just that original story from your colleague. How did the group reply to that colleague? And also, how has anything changed if you know the answer to this between that practitioner and that pseudo friendship that was created or acknowledged or doesn't exist or whatever. What, is there any kind of follow up there at the end? 

 

0:28:00.8 CC: Yeah, well, I haven't actually followed up directly with that colleague in terms of like, have you seen that client again? And like, did you address it? Or where are you at with this? But it was interesting to watch this group of people who know each other pretty well initially be like, no, no, don't worry about it. It's fine. I'm sure it's fine. And then slowly come back to, well, so as you reflect on your relationship with this client, like are there places where you feel like maybe you sort of like, let her in too much or she's leaned on you more than... And I think we really find this in part of, I think I can attribute what I feel like are my skills in maintaining this kind of balance, 'cause my whole career has mostly been with people who are pretty sick and the people who care for them.

 

0:28:42.5 CC: And there's a lot of potential for like will you go to the CVS and pick up our prescriptions? Or can you... I know it's, we are supposed to be here in a half hour, but we have this thing, can you come in two hours and sort of constantly deciding like, am I rescuing or am I just showing up and what's the balance here? And I think with this older client, my colleague has been seeing this person for a long time. And so, her first response was just sort of like, oh gosh, I wonder. I don't know. And I think just being willing to be like, huh, 'cause I'm not saying that my client hasn't, or that my colleague hasn't maybe done things that are unethical, feels like such a damning word, right? But just are sort of like less than responsible in terms of managing her relationship with this client.

 

0:29:26.8 CC: But I think when those things come up, the first thing we have to do is to be willing to be like, so what if this is true? Like, what if? What if actually? I could do a little house cleaning here, and are there places where I'm noticing if I really am honest with myself that I feel a little bit unsafe in this relationship? We've been using this word unsafe. It doesn't mean that you think this person's gonna physically harm you or that they're not gonna pay you. Or like, it... Certainly those things are possible as well, but just... It just means that like, you don't feel fully relaxed when you're with this person. You feel like you wanna make sure that things are clear. And when that happens, it causes a disruption that makes it hard to have that therapeutic relationship.

 

0:30:11.2 CC: So, yeah, I really appreciate that my colleague was like, huh, I don't know, like I should... I'm gonna wonder about that. And can we just stay on the wonder side and stay out of the self-recrimination space? That it really is about like, huh, I've never thought about it, and well, that doesn't feel great that I've never even thought about it. But now that I'm thinking about it, what kind of space can I make here for adjustments and how to really cultivate safe, connected, therapeutic relationship, and that will look different with every single client.

 

0:30:45.7 DB: I wanna thank our guest today, Cal Cates. For more information about what Cal does, visit healwell.org. Thanks Cal.

 

0:30:52.8 CC: Thanks Darren.