Key Points

• If massage therapists choose not to prioritize or develop communication skills, they can unwittingly harm their clients.

• Self-aware communication includes minimizing judgment, avoiding offering advice and opinions, and respecting client autonomy.

• Skillful interpersonal engagement with your clients will make your work more clinically effective.

The massage profession continues to prioritize technical, hands-on learning over the cultivation of strong and flexible skills of communication (both listening and speaking) and self-regulation. These skills, however, are the bedrock of our value as health-care professionals. It’s possible that most of us don’t notice it, but this oversight results in harm. In our continuing education courses at Healwell, we have a tongue-in-cheek saying that massage therapists do much more harm with their mouths than they will ever do with their hands. 

The Importance of Harm Reduction

Understanding the importance of harm reduction requires you to open yourself to the possibility that you may be causing harm. The truth is that we all cause harm. Most of it is unintended, but intention and impact are different. 

One of the newest courses offered through Healwell’s online education portal is “Pursuing Sensitive Disclosures: Skillfully Asking Clients Tough Questions to Assess Risk.” The course is taught by Jenn Brandel, a licensed clinical social worker. The course was designed with social workers and talk therapists in mind, and at first glance it may seem to explore situations in which we, as massage therapists, are unlikely to find ourselves—asking clients about substance use, self-harm, and risky behaviors. However, the class is ultimately about helping clients move toward behavior change by using skillful inquiry (which, spoiler alert, is mostly about not talking). It is about the role of self-awareness, self-regulation, and personal inquiry in our interactions with clients as we learn about their lives, health, and choices. When massage therapists choose not to prioritize the development of these skills, we unwittingly harm our clients and impede their chances of maximizing the potential benefits of our care. 

As massage therapists, we spend a lot of time with bodies. We think about, read about, look at, touch, ponder, and palpate bodies all day, every day. An unfortunate by-product of this otherwise awesome way of being in the world is that we tend to become inured to the truth that for most humans, the body is a fraught subject. It is easy to forget when you have massaged hundreds of “sore” shoulders that the “basic” questions we ask our clients are inherently sensitive because their bodies are not typically a topic of discussion with others—and possibly not even with themselves.

The other piece we forget is that, while our physical intervention is important, its impact is directly affected by the nonphysical ways we interact with our clients. How do we ask our questions? How do we respond to what they share? How do we ultimately guide them toward behavior change that will support greater comfort in their bodies? How do we address their concerns without causing additional harm? 

Harm reduction in our client/therapist engagements can be organized into four seemingly simple, but hard-to-implement tenets: 

• Minimize judgment

• Avoid offering advice or opinions 

• Respect autonomy

• Understand the complicated nature of behavior change

Chances are good that you feel confident you already do at least the first three because you imagine yourself as a caring person. And chances are good that you are, indeed, a caring person. Ironically, it is exactly this caring nature that makes you particularly likely to trample right through the first three and to have a limited understanding of how and why the fourth piece about behavior change is relevant to this conversation at all. It seems simple. But people are never simple. 

Minimize Judgment

So, what does it mean to minimize judgment? First, we have to unpack the word judgment. Nobody likes to be judged. When we have been or are being judged, it’s a uniquely uncomfortable feeling that undermines our ability to trust the person who is judging us, and often that judgment even turns us on ourselves. Most of us know this feeling, and because we know it, we feel confident that we wouldn’t do it to another person; certainly not to a person who is paying us to be good to them. 

Keep in mind that leaping to “Oh! That’s upper-cross syndrome!” in your mind as a person describes their symptoms is judgment. It’s leaping before looking. It’s jumping to make this person similar to others you have touched. When you decide that a person will always have a certain type of dysfunction because they work at a desk or because they have what you consider poor sleeping habits, that’s judgment too. 

Minimizing judgment requires that we own that we are wired to judge. It’s what our minds do. It’s so automatic that we don’t notice we’re doing it. We think we’re simply seeing the world the way it is. We miss the fact that the way we see the world is not truth. It’s perspective and it distorts our ability to see the world of others with clear eyes. The moment a client enters our space, we are judging them—their clothes, their apparent “health,” the way they talk or walk. (I’m not talking about assessment, friends. I’m talking to you about a thing every human does.) We are trying to make sense of them. We think we are wondering, “Who is this person?” We are actually and imperceptibly thinking, “What type of person is this? What boxes and categories do I already know and feel I understand that I can apply here?”  

It will do no good to pretend this isn’t happening inside you. In fact, pat yourself on the cognitive back if you judge people. It means your brain is working the way it was designed. And while it’s “normal” for our brains to do this, meaningful therapeutic relationship demands that we choose to notice this and interact differently with it. We must begin to say to ourselves, “This person’s clothes smell like cigarettes. I notice that I hate that smell. I know that I think people who smoke don’t care about their health. How will that challenge my ability to interact with this person from a place of openness and curiosity so that I can really hear what has brought them to me for care?” You are unlikely to train yourself to stop judging others altogether, but it is absolutely within your grasp to notice that pattern and soften it, slow it, and redirect it to facilitate greater awareness and deeper connection. 

Avoid Offering Advice or Opinions 

Let’s talk about offering advice and opinions. This is yet another invitation to be honest with ourselves. When we offer advice and opinions, we do it for a variety of reasons. We want to help. We want to feel smart. We think we have good ideas that will support our clients’ “progress.” We are afraid to say, “I don’t know.” There are certainly more reasons, and you may have your own that are not mentioned here. Regardless of your motivation, the harm that is unwittingly wrought by advice and opinions can be avoided by cultivating confidence in what you do know and are able to share within your scope and in the value you bring within that expansive scope. 

Most of us offer opinions and advice throughout the day in all sorts of ways to friends and loved ones. It’s a habit. And habits are things that, once established, happen without our conscious engagement. Opinions are part of how we interact. We imagine that the sharing of our opinions is one of our tools of connection. It may seem counterintuitive, but particularly when we are interacting with our clients, offering advice and opinions can have a silencing effect that quietly undermines their ability to work things out for themselves. 

We offer advice typically because of one of two dynamics. Either a client directly asks for our opinion, or we are inspired by something a client has shared (“I can’t find a comfortable sleeping position” or “I always forget to get up and move during the day.”) and feel like we can intervene with “helpful” information. More than chin-wagging, these situations call for patience and self-awareness. 

When a client says, “My doctor says I should (insert doctor’s advice here),” or “My boyfriend keeps saying I need to (insert boyfriend’s advice here),” and follows it with a “What do you think?” it’s time to get curious. Even if every fiber of your being is shouting, “Your boyfriend is an idiot! That’s terrible advice!” you need to want to help this person find their sense of how they feel about the advice they’ve been offered. They’re asking you because they don’t totally agree with the other advice. When a person asks what you think about advice offered by someone else, they are really saying, “I don’t totally agree with this.” Intuitively, they know this advice is not likely to be effective for them. You can help them access the wisdom that lies in that knowing, but you’ll miss that opportunity if you weigh in with your activated response and desire to help.

I try not to invoke G.I. Joe as a general rule, but “knowing is half the battle.” You’ll have to make a conscious decision to begin inserting questions like, “Am I about to offer advice when I could be inviting inquiry?” . . . or some version that works for you. The beauty is that whether we find ourselves about to offer our opinion because we were asked directly or because we feel like we “need to,” the practice to break this habit is the same. 

When a client says, “I always forget to get up and move during the day,” this is not a request for your opinion, but you’d be in the minority if this statement didn’t inspire some desire to share tips and tricks to increase the likelihood of this behavior changing. The most important question is, “What’s mine to do/say in the face of this statement in this moment?”

In most cases, you will have time. You will be seeing this person again. And if you’re in an environment where it’s not likely that you’ll see them again, you’re highly unlikely to inspire lasting behavior change with some tip or opinion you offer during your 60-minute interaction with a naked stranger. Whether you think you’ll be working with this person over time or not, your first and most important job is to listen. Fully. Just hear what this person is saying. Listen for what they’re not saying. People say things like the statement above to head off your advice at the pass. They tell you their low back is often sore or painful, but they’ve already been told by countless other well-meaning people that they just need to set an alarm, get up every time they get off the phone, or some other advice that clearly hasn’t stuck. They don’t want or need more tips. They need you to hear them. 

Western culture is constitutionally averse to believing that not talking is a great way to build trust and rapport, but it’s true. People report enjoying their “conversations” with others most when those others use their name and ask them questions about themselves. You have to regulate your inner response and be able, in real-time, to notice if you’re about to speak because you feel like what you just heard “needs fixing” or if you want to invite the person talking to think more critically about the situation and bring their own wisdom to bear. 

Respect Autonomy

That leads us to respecting the autonomy of our clients. If you’re wondering what that means or if you’re thinking, “Of course, I do that!” you’re not alone. Unfortunately, respecting a person’s autonomy is not as simple as refraining from “forcing” them to do things. When you respect a person’s autonomy, you actively move away from your commitment to the idea that something will work for them because it worked for you. Respecting a client’s autonomy means believing that, between the two of you, the client holds the greatest degree of wisdom about what will work for them in their life, in their body, in their circumstances.  

This understanding of autonomy makes it easy to see how judgment and advice-giving both undermine a person’s autonomy. If you decide to engage in the shifting of those habits in yourself, your ability to honor the autonomy of your clients will take a measurable leap forward. This matters because, even though they won’t be able to describe it to you in so many words, your clients will come to trust you and share their process with you in a way that is fulfilling and beneficial for both of you and in ways that your advice and judgment have been preventing. Simply put, skillful interpersonal engagement with your clients will make your work more clinically effective. 

Understand the Complicated Nature of Behavior Change

So, how does this all connect to behavior change? I don’t know how much time massage therapists spend thinking of themselves as agents of behavior change, but we really do have that potential, when we’ve made the time to invest in the cultivation of a connected therapeutic relationship. 

A 2016 Harvard Business Review article about what makes exceptional listeners tells us, “Making suggestions is not itself the problem; it may be the skill with which those suggestions are made.” It goes on to say, “People perceive the best listeners to be those who periodically ask questions that promote discovery and insight. These questions gently challenge old assumptions but do so in a constructive way.” 

You can’t challenge people constructively if they don’t trust you, and if you’re leading with judgment, advice, or “I know better than you” energy, trust is going to be hard to cultivate. We have to remember that the ways and things that clients share with us are deeply vulnerable. People tend to present casually, saying, “Oh yeah, my hamstrings are super tight.” What they are saying is, “I’m worried about my body and its ability to help me do the things I want to do. Please tell me it will get better.” They are experiencing a level of dissatisfaction and even loss of trust with their body. They don’t know they’re feeling these things, but you need to know it. You need to have the tools to receive that information with curious compassion. You and your skills—verbal, nonverbal, and clinical—are only half of this picture. Every client who seeks you out is, on some level, seeking out change, improvement, or relief. 

In Brandel’s course, she talks about Pochaska and DiClimente’s Stages of Change. The first stage is pre-contemplation. It’s the stage when a person may describe a behavior to us and, while we may judge it to be “unhealthy” or not supportive of their stated goals, changing that behavior isn’t even on their radar. This is the stage where we just listen. We note things they share, and we try to hear what they’re telling us. Meanwhile, we take a step back and notice the gap between our desire for that client to change their behavior and the client’s lack of awareness that there is a possible benefit to change. 

We must keep it in the front of our minds that change of any kind is a deeply personal experience. We are being invited into that experience, but not as the drivers. 

When we find ourselves participating in this cycle with a client, we can introduce ambivalence. Yup. Just to help them wonder if maybe behaving differently would lead them in the direction they have said they want to go. That’s it. Without judgment. Without opinion. Our inspiration must be about empowering them to choose something different, not about the direction we hope they will go or that we imagine is possible for them. It’s about supporting them in what they want for themselves and about creating the conditions for them to come to that decision to begin the next step in the process of change. 

We can ask simple questions like “What are the benefits of staying at your desk without getting up?” Then . . . make room for them to wonder. Maybe they respond aloud. Maybe they don’t. If they do respond and they’re engaging in the inquiry with you in real time, maybe you ask, “Are there any drawbacks?” And then make space for them to work it out . . . or not. You are a facilitator of possible shifts, not a changemaker. 

Practice Makes Perfect

A single hour with a person is a potentially complicated and fruitful journey, but the fruits don’t happen by accident. They can fly right past you when you rely on habit. Just like actual fruit, this relationship harvest relies on careful tending. It is the result of seconds, and then minutes, and then hours of practice just noticing—noticing your judgments and slowing down and owning them; noticing your habits of communication and slowly choosing to shift them; noticing that choosing to ignore these skills is resulting in harm that you’re ready to stop causing so you can open the way for healing.