Key Points

• Massage therapists aren’t supposed to diagnose. There is some variety from state to state, but for the most part, we are allowed to “assess” but not to “diagnose.”

• When practitioners define and declare, we: (1) narrow our ability to see the whole client, (2) narrow how our clients see themselves, and (3) narrow the possibilities for our work together.

• There are practical ways you can work with clients to create a sense of expansiveness and possibility, before, during, and after your sessions.

When a client walks into your treatment room, they are asking for your hands to help them. But oftentimes, they are also asking—whether explicitly or implicitly—for us to tell them what’s happening with their bodies. They are asking us to translate what our hands feel into words that make sense to them. In that request—and in our endless desire to help as much as possible—begins our trip down one of the slipperiest of the many slippery slopes of our profession.

Because, more often than not, that request is for a diagnosis—or at least, the confirmation of their own diagnosis. And as we all know—but sometimes conveniently forget—diagnosing is one of those things we cannot do. And yet, we do it all the time. Sometimes explicitly. Sometimes without meaning to. We share our opinions, but it is easy for those opinions to sound like something more.

You already know you aren’t allowed to diagnose. I want to explore the much bigger and much grayer area of all the ways we talk to our clients. The things we tell them, the recommendations we make, the way we project our authority. It is in this murky realm where our good intentions can have unintended consequences. When we tell our clients what is happening in their body, we rob them of one of the greatest benefits of getting a massage: the chance to get to know your body more fully and to change your brain’s narrative about your body.

The Downside of Good Intentions

As caring, committed massage therapists, we focus a lot of attention on what we do during a massage. We study the body, we learn new techniques and cutting-edge modalities, and we try to make each stroke meaningful. But there is another element of our work we largely ignore—what we say to our clients, both during the session as well as before and after. These moments can have a larger impact than we realize; the things we say can either enhance—or limit—the effectiveness of our hands.

Your relationship with each new client almost never begins with touch, but rather, with talk: the questions you ask and things you say, the comments you do or don’t make, both when you first meet or book the client, and then in your treatment room prior to their session. Depending on where you work and the kind of work you do, you may have an elaborate discussion with each client during their health intake, or you might barely have time for more than a question or two as you whisk them from the spa’s waiting area to your treatment room. Then, during the session, you might tell your client what you are feeling in their musculature, or (more often than we care to admit) other random thoughts and observations that come to mind. And then after the session—again depending on the “what” and “where” of your work—you might push a cup of water into their hands and rush to change your table, or you might sit and chat. At each of these junctures, you decide what to say, or not. Those possibilities hold true for every subsequent session with that client as well. Except for a few brief hours during massage school and the occasional continuing education course, we don’t explore these crucial moments all that often. After all, who wants to spend time on this stuff when we could be learning cool new techniques! I want to change that.

We all know massage therapists aren’t allowed to diagnose. There is some variety from state to state, but for the most part, we are allowed to “assess” but not to “diagnose.”¹

Yet I believe diagnosis is more of a gray area than we would like to think. You’ve probably never declared to a client that they have a brain tumor or irritable bowel syndrome. Those are obvious instances where it would be not just unethical, but impossible, for us to test for and thus make a diagnosis. But beyond these obvious medical conditions, this is a slippery slope—one of the many parts of our profession where our best intentions get us into trouble.

Maybe you’ve never told a client you are positive they have carpal tunnel syndrome. But has a client ever self-diagnosed something—carpal tunnel or something else—and you have agreed? You are on that slippery slope. And chances are you have definitely told a client—if not most clients—they have “really tight” muscles, or some other similar observation. Again, you are on that slippery slope. Rest assured, you are in good company. You and I and every other massage therapist who cares about their clients—we all live on this slippery slope.

Sharing our thoughts is a natural impulse. After all, we want to help! And the rationale is pretty simple: Who else is going to give them this information? You can barely talk to your doctor for 15 minutes before they run to their next appointment. And besides: We feel a lot of muscles. We know about posture. We can tell when the body isn’t working right. Right?

Unfortunately, no. The longer I work, the less sure I am about how sure we can be about the declarations we are fond of making. And just as important, I’m not convinced that telling your client they are really tight actually does any good. I suspect that, at least some of the time, such words confirm some of the same problems that are baked into diagnosis itself—it confirms not just a temporary medical condition, but something essential about who that person is.

I think we as a profession do too much defining and declaring, and not enough exploring and allowing. I believe when we tell a client we “know” what is wrong with them, we are not only violating our ethical boundaries, but more importantly, we are foregoing one of our greatest assets as therapists: the ability to be present with our client—to not tell them what is happening in their own bodies, but to encourage them toward a greater understanding of their own bodies. The consequences are not obvious, but they are powerful nonetheless. When we talk with our clients in these ways that aren’t helpful, we:

• Narrow our ability to see the whole client

• Narrow how our clients see themselves

• Narrow the possibilities for our work together

These threads are complex and interwoven with each other, so let’s try to untangle them one at a time.

Narrowing How We See Our Clients

One of the most profound advancements of our profession in the last few decades is the infusion of scientific research and critical-thinking skills. We now have an increasing sense of rigor in how we understand and treat the body. We are dispensing with massage myths daily. Science is, again and again, our guide.

But it is easy to lose sight of the limits of this knowledge. It is natural that we want to tell our clients all the awesome stuff we know. On a base level, we want to impress the people we work with. We want to be taken seriously, both as individuals and as a profession. As massage therapists, we fight hard to have our expertise recognized, and to elevate the reputation and seriousness of our profession. As it should be. We have knowledge and abilities in certain areas that rival what doctors and chiropractors and physical therapists know. But in our efforts to become more “advanced,” it is easy to lose sight of what we offer and how we benefit our clients. We are not doctors. And we shouldn’t be thinking like them.

If we “think like doctors,” it is easy to start to see our clients as a bundle of symptoms and label them as a series of conditions. But who does this sort of myopic thinking ultimately serve? A client comes into your office and complains of finger numbness. You may assess and palpate and suspect your client has thoracic outlet syndrome. Knowing that is very valuable as you approach the session. Nevertheless, that is just one tiny portion of who this client is. We want to treat the whole client.

Similarly, if we focus too much on medical conditions, we risk creating a hierarchy of clients. Is that client of yours who has cancer more valuable or worthy of a massage than that other client who sits at a desk all day, or that other client who doesn’t have a terminal illness but has twin toddlers? Of course not. All of our clients are equal. And yet it is easy to start prioritizing the ones who have X disease or Y condition or Z ailment, because they seem to be more worthwhile, and they have the potential to make us seem like more advanced therapists because we work on them. But that is a wrongheaded and counterproductive way to think about our clients. We must give ourselves equally to every single one of them.

One of my favorite assignments while I was in massage school was to sit in the park and watch people go by and identify their postural distortions. I felt like I was decoding a secret part of the world. I did this religiously for a few weeks. But then I realized that this way of looking has its limits. After a while, the world just starts to look like a sea of upper-crossed syndrome, tipped pelvises, and compressed lower backs. You start to see everyone as problems, rather than as individual people.

The purpose of diagnosis is to pinpoint one specific thing out of a huge amount of information, to narrow down the possibilities of why something is happening, in order to arrive at the cause of that problem. You are reducing the vast complexities of the daily life of a person down to a few details. That kind of reduction is really helpful when you are trying to figure out a serious issue. When you think you might have cancer, you want your doctor to do all the lab tests possible to narrow in on precisely what is happening and figure out if you do indeed have cancer.

But diagnosis is arguably not helpful in much of our lives, which are inherently amorphous, full of ambiguity, and always changing. We must use all of our assessment skills, and all the wisdom that comes from our palpating hands, but we must use it in the service of the whole person. We must attend to their carpal tunnel symptoms, and then attend to the rest of them as well! Similarly—and too often forgotten—we can dig into specific muscles all we want, but if we are not working with an awareness of their nervous system, and trying to enable the “rest and digest” functions of the parasympathetic branch, then we have no hope of making any lasting change. 

Here’s another way to think about this differentiation: Diagnosis is all about narrowing. I think massage should be about expanding a client’s sense of who they are and who they can be in their own body. The massage session should be a place where they can simply revel in the feeling of feeling good in their body, not to continue to label that body as one problem or another.

A massage session should be a reminder of the possibility for change that is always around us. When we get too focused on labels and diagnoses, it is too easy to lose sight of this much deeper and more pervasive reality: We are always changing. The best thing we can do is enable, rather than preclude, the inevitable evolution of life. To do so, we want to expand our understanding of our clients, rather than narrow it.

Narrowing How Our Clients See Themselves

The second reason to be mindful about how we think about, and talk to, our clients, is because the words we offer can impact how our clients see themselves. We humans are, first and foremost, storytellers. We are always constructing narratives. And one of the most detailed, and most important, narratives we construct is the story we tell about ourselves. That story, in turn, can build our own resilience and help us stride through life, or it can become a trap—something we get stuck in and are held back by.

Unfortunately, I see more of the latter in my clients than the former. Again and again, I find we are drawn to the stories we tell ourselves that hold us back—I am always so stressed out. My back is always tight. My shoulders are a mess. I am falling apart. On and on and on. I think one of the most crucial gifts we can offer our clients is to help complicate this narrative—to expand it, to allow for a wider array of possibilities in the story of the body. And yet, I think the words we offer can all too easily reinforce this narrative instead.

I am still surprised at how often a new client comes in for a session, and during our intake mentions something a previous massage therapist has said. It is always something along the lines of, “I can’t believe how tight you are” or “Your muscles are full of tension.” Who knows what that previous therapist was thinking about—chances are, their assessment of this client was more complicated. They may have given a great massage, and may have offered all kinds of other helpful ideas. And yet, this small phrase is what stuck. My muscles are really tight. This small phrase became part of this client’s narrative of who they are.

The downsides of that statement, as best I can tell, far outweigh the benefits. Did that client start a new stretching routine based on what that therapist said? No. Did that client start meditating, or doing tai chi, or change the setup of their desk, or start looking for a new job, or otherwise reshape their daily life? Probably not. But they did internalize this notion of tightness.

We seem almost eager for this kind of self-understanding—this monologue of pain and tension. As if it validates us. There is something comforting in knowing things about ourselves, even if those things are problems. The world is changing all the time, and change is scary. No surprise, then, that there is comfort in what is familiar—painful or not. I think there is something appealing about this story of tension in this particular moment. We are facing historic levels of uncertainty, and a seemingly growing list of global crises, and at the same time we are constantly urged to be our own best selves and innovate our lives and be entrepreneurs and live perfectly curated, made-for-social-media lives. That perpetual stress and tension we talk about is proof we are striving to do all the right things, regardless of how much we are actually succeeding.

We massage therapists have the chance to work against this perception. And yet, our good instincts often lead us astray. And in turn, that client’s perception of self becomes even more narrow and calcified.

To be clear, many of us work with clients who are dealing with significant, diagnosed issues—from cancer to carpal tunnel syndrome, from fibromyalgia to a recent surgery, and on and on. Obviously, our work must take into account any and every condition a client presents with. In my plea to try and expand, rather than narrow, the client’s narrative, I am in no way suggesting you contradict that narrative.

Everything your client tells you is valuable and should be treated with respect. Everything a doctor has told them should be taken seriously and integrated into your treatment. After all, having a diagnosis can be far better than just having unexplained pain. But for these medically complicated clients, we have an even more important job. With our touch, we can remind them their diagnoses are not the limit of who they are. They may be going through chemo, but they can still feel ease in their body.

Possibility Not Prescription

Where does all this leave you and your good intentions? I hope with this article to prompt your own reflection on your built-in habits and to encourage you to make small changes that will enhance the benefits you already give to your clients. See “How to Provide Possibility” on page 53 for a list of specific changes you can make. Here, I want to reflect more deeply on the possibilities for shifting our own perspective on the work we are doing.

Doing less and saying less can make it seem like we are giving less—like we are letting our clients down. But I want to assure you the opposite is true. If you don’t believe me, listen to the wonderful Diana Thompson, massage therapist and educator: “It is a blessing not to be able to diagnose, leaving us free to see clients as human beings to partner with, whose stories lead us on a path toward wholeness, rather than only relating to the illness—something to name and conquer.”² If we think about our work with clients as a partnership, the possibilities only grow.

As we deepen our scientific understanding, and as we improve our stature as a profession, we are at risk of losing something equally valuable: the recognition of all we don’t know. I believe our ignorance makes us as valuable to our clients as our knowledge.

The great (and underappreciated) gift we can give to our client is the fact we often can’t tell them what is wrong with their bodies. We can’t give them the answer. (Oftentimes, doctors can’t either, but they have a much harder time admitting that!) This not-knowing seems like a disadvantage, but in fact it is a source of strength. Because in our not-knowing lies the capacity to empower the client toward their own self-discovery. When we know less, we deepen our partnership with the client, and enable the client to learn more.

When we tell the client we don’t know what is happening, we create a dialogue. When we tell them we know what is wrong with them, we are telling them they don’t know what’s happening inside their body. We’re telling them they need to rely on an outside expert—that they can’t be an expert of themselves. (And also important: We are telling them something is wrong with them. That’s a problem in and of itself—more on that to come.) Instead, when we involve them in the process, we are telling them they are a part of their own healing.       

Furthermore, I don’t want to tell my clients there is something wrong with them, because on some deeper level, I don’t believe that. The trouble with the realm of diagnosis is that it is geared toward uncovering disease. No one gets a diagnosis of being a mostly content person who is making their way in a difficult world and mostly doing OK. Instead, we get diagnoses of cancer and gout and arthritis and diabetes. Therefore, it is especially important we engage with all medical conditions as necessary, but we also keep our focus on the larger picture. We don’t want to perpetuate the all-too-frequent feeling our clients can have that they are broken or that something is fundamentally wrong. Instead, we want to further a deeper truth: Life is hard; the body hurts sometimes; there is always something we can do to feel a bit better.

Helping Clients Feel

The advantage of massage is we can’t tell the client exactly what is happening in their body. We can’t—or rather, we shouldn’t—declaim and declare. We can only give the client our impressions, our sense of what is happening in their body at this very moment. (And if we are doing our job right, when we do tell the client these things, we are making clear what we are telling them is just our opinion. It is not The Truth, and it is not The Only Answer.) The result? We give the client our own limited understanding, as a way of encouraging them to further develop their own much greater understanding. We help the client become a part of the process of inhabiting their body.

Or to put it a bit differently: We can help the client feel something, rather than to know something. And then once they feel it, hopefully they have a better chance of incorporating it into their life. Because when we feel something, rather than just being told something, we have far more capacity to make it our own, to integrate it into our lives. And that’s one of the many reasons why we as massage therapists are valuable—there is little we can tell the client, but much we can help them feel.

How to Provide Possibility

These are specific and practical ways you can work with clients to create a sense of expansiveness and possibility before, during, and after your sessions.

Before

Get all the condition-specific information you need during your intake, but also make sure to think big and ask broad questions. Whenever a client is particularly focused on telling me about their specific “issues,” I also make sure to ask a general question—“How is the rest of you feeling?” or something like that—to prompt them to think about their whole body.

During

The single most important thing you can do during your session is slow down. If you want your client to be more engaged in how their body feels, you can’t rush through your strokes. You need to give the client the time, literally, to feel each stroke, and to feel how their body is responding.

Talk Less

If you have observations you want to share, save them until the end of the session. Because you are the authority, if you do talk during the session, the client will immediately pay attention, which means they won’t be paying attention to what’s happening inside their body. Allow your client to maintain their focus on what they are feeling.

After

Give the Client Time to Talk

I know we are often rushed between sessions. But even just a couple minutes of conversation can be very useful. (My solution is to invite the client to chat with me while I am setting up the room for the next client.) It is in this post-massage moment that you can encourage the client to explore how they are feeling and what they noticed during the massage, which can start to change their standard narrative.

Celebrate Their Successes

After the session, particularly for those clients who are adamant about how tight they are, I try to also mention a particular area of the body that seemed to respond really well to the massage, and that seemed to lengthen or loosen or soften as we worked. The point here is not to rebut or deny their own focus, but just to give them another perspective—to remind them there are parts of their body that have just shifted. I am planting the seed that this transformation is possible elsewhere.

Give Specific Description and Simple Action

Instead of making big generalizations, give specific description and simple action. I don’t think there is any point in saying, “You’re really tight” or “Your shoulders are like boulders.” Instead, I try to offer more specific descriptions of what I felt. “The area around your deltoid felt congested to me” or “The lower back seemed to resist the pressure today, like it wasn’t quite ready to release.” And then I pair those descriptions with a possible action—either something they can do or something we can do together: “If you have a minute, I can show you a shoulder stretch that might be useful” or “Maybe in the next session we can give that area more specific attention.”

Acknowledge Your Opinions

Very little we tell the client about their body is verifiable fact. Pretty much everything useful we will tell them is just our (informed) opinion. We should be clear about that.

Acknowledge What You Don’t Know

It is easy to think the client needs us to answer every question they have. But we are actually more credible authorities—and more useful therapists—when we are honest about the things we aren’t sure about and the questions we can’t answer.

Acknowledge that Your Client is the Expert

When it comes to the client’s body—and the client’s experience of being in that body in the world—they know vastly more than you ever will. Clients often need to be reminded of this!

Talk in Shifts, Not Absolutes

I don’t think telling a client they are really tight is helpful; but furthermore, I’m not even sure it is a particularly valid statement. After all, they are tight compared to what? It seems to me there is no standard, no average, across all people, for what differentiates a “tight” muscle from a not-tight muscle. (Our profession can’t even agree on whether trigger points exist; how can we have any definite standard of what constitutes “tight”?) Hence, try to avoid these kinds of declarative statements. Instead, use statements that suggest change. “It feels to me like you are holding tension in this right shoulder blade today.” A statement like this is specific rather than global, and it also implies this situation could be different tomorrow. For clients you see repeatedly, you can use what you’ve felt from previous sessions and make comparisons over time. “Your upper traps feel tighter to me today than they did a month ago. Have you been doing something different in your days? Have you been feeling particularly stressed?” That’s a lot more valuable than just, “Wow, you are really tight.” And this language of shifts opens the door to figure out ways they can make shifts in their own life to feel better in their body.

Notes

1. Associated Bodywork & Massage Professionals, “Massage Therapy State Licensing Requirements,” accessed November 2021, www.abmp.com/practitioners/state-requirements; National Certification Board for Therapeutic Massage & Bodywork, “Standards of Practice,” accessed November 2021, www.ncbtmb.org/standards-of-practice.

2. Diana Thompson, “The Case for Case Reports: Writing and Sharing Your Research,” Massage & Bodywork 26, no. 1 (January/February 2011): 114,  www.massageandbodyworkdigital.com/i/77424-january-february-2011/116.