I read Cal Cates’s article, “What’s Going on with Massage Therapy Research?” (Massage & Bodywork, March/April 2023, page 78), with great interest. I am a massage researcher who developed a research protocol called Mindful Awareness in Body-Oriented Therapy (MABT) 20 years ago to study the benefits of helping people develop their capacity for body/interoceptive awareness. MABT is designed to facilitate engagement with inner-body experience to support client use of mindful interoceptive awareness in daily life for improved self-awareness, self-care, and emotion regulation. I continue to teach and study this approach, examining the benefits when implemented by licensed massage therapists in the community care of substance-use disorder treatment, trauma recovery, and/or chronic pain. 

I wholeheartedly agree with Cates that massage research protocols need to reflect real-life care. Most importantly, research protocols must be flexible in order to examine the ways massage therapy, when skillfully delivered, is attuned to the needs of the client—a “best practice” of massage therapy. Examples of this include pacing and depth of altering the strokes or manipulation of tissue to allow the client’s nervous system to receive the work. Alternatively, it might be reflected in the therapist spending more time working with one area of the body and less in another in order to address high levels of tension and muscular holding. It might mean pausing and asking about the client’s emotional experience if they are clearly tearing up and then collaboratively deciding what would be most supportive for the client going forward in the session; this could look like simply holding the client’s hand while they cry, or it could mean moving to their feet to help with centering/grounding if it is near the end of the session.

In most health-care professions, best practice guidelines are published and used to guide education and clinical care and are updated as needed with evidence from research. Likewise, best practice guidelines can and should guide basic tenets of intervention research protocols in the related discipline/area of care. In 2010, a group of about 30 experienced massage therapists (educators, researchers, and clinicians) were brought together for a couple days by the Massage Therapy Foundation. We were asked to work together to identify best practices for the delivery of massage therapy. It was a remarkably productive meeting, and I have one memory that stands out—the overwhelming agreement among the attendees that a fundamental best practice of massage therapy included educating the client with a focus on the promotion of well-being. This aspect of care cannot be itemized in a protocol. Rather, a protocol can be designed to allow the individualization needed to ensure the massage is sensitive to the needs of the client, or that the massage is (a) person-centered and (b) trauma-informed. In other words, the MT is not a technician, but a therapist. It was the intention that the outcomes of this 2010 meeting would be published as best practice guidelines; however, according to the Massage Therapy Foundation website, this has yet to occur.  

As Cates points out, the study of massage is often done by researchers outside the profession, and massage intervention protocols are often designed as a relatively simple sequence of specifically described strokes. There is, perhaps, a question about what best constitutes massage therapy; best practice guidelines would indeed help provide a foundation or framework to address this. Based on my experience developing and studying a touch-based research protocol, it is entirely possible to design a protocol that provides a standardized structure within which there is room for individualization and a person-centered approach that reflects clinical care. The protocol must be written to describe how and in what circumstances one would individualize the protocol to meet the needs of the study participant/client. There is undoubtedly more training needed to accomplish this, as there is more supervision needed to address fidelity of such a protocol (i.e., to ensure the therapist is delivering the protocol as it is designed). This can be done in multiple ways. 

In MABT research, we ask the therapist to complete a process evaluation form after each session. This form has itemized key components of the protocol and the MT indicates whether these components were delivered. The therapist is also asked to indicate if there was any aspect of the intervention that was changed, or not delivered, in order to meet the needs of the client (for example, due to a lack of time because the client was late, or due to client request). We also audio-record sessions. These recordings are used to inform clinical supervision of the research therapists, as the protocol has an educational component (is aimed at developing the capacity for inner-body/interoceptive awareness) and the study participants we serve often have multiple mental health conditions and/or chronic pain, so there is a lot the massage therapist has to navigate. This also means, as in real-life work in medical settings or with highly distressed clients, the therapist will often encounter and need to address the bio/psycho/social/spiritual aspects of care of the participant/client they are working with. 

Attunement to the client or participant involves being present and engaging with a compassionate heart, listening ear, listening hands, and openness to what will unfold during the session. Can a massage or touch-based protocol allow for this? From my 20 years as a researcher, I say yes, but only if we develop protocols that explicitly address these issues and train and support massage therapists accordingly. Doing so will promote the professionalization of our field and align with some of the best practices identified for our profession over a decade ago.