In my early years as a personal trainer, I tended to focus a lot on the type of exercise equipment or modality that was popular at the time to market myself and to apply them to almost all of my clients. Whether it was bodyweight training, BOSU, kettlebells, or core training, I pretty much learned to use the equipment or system instead of learning the groundwork of human movement and physiology, cognitive learning, and client communication skills.
Once I learned to use the equipment or system, I believed that it was a better way to train and improve function and performance. Well, I was wrong.
Earlier this year, I read an article on PainScience.com that is titled “Modality Empires,” and it got me thinking: Shouldn't our services be more about the client or patient rather than the therapist?
The issue with ego-centered care (or sometimes called ego-driven) and client-centered care has been up for discussion more frequently on social media recently, and it is gradually changing the way I work and communicate with clients and peers. Three massage therapists and educators — Dr. Ravensara Travillian, Beret Kirkeby, and Matthew Pardini — share their expertise with these concepts and how we therapists and trainers can apply these to our work.
Ravensara: On your right is a picture of what my personal model of client-centered care looks like. The client is at the center and is also at the very top, meaning that the client’s interests are the highest priority.
To picture ego-centered practice, I would just swap the client label and the massage therapist label in this image. Practicing in a client-centered way means that we have to be the one to step back, if our ego or interests ever come into direct conflict with the client's interests.
Matthew: I think I'd like to answer this by reframing the concept a bit away from client-center vs. ego center to model-based vs. modality-based therapy. I hope this is OK for your article, but the client-centered vs ego-centered has too many nuances in meaning (especially around ego) to be understood easily and to create constructive dialogue.
Modalities are methods of employing a model whereas models are the actual conceptualizations of what is happening during therapy. Rather than therapists focusing on learning modalities, they should be focused on refining their models.
When massage therapy is understood via modalities first (or modalities only), the therapy loses a client-centered focus and becomes about whether or not a modality itself works.
But what if the modality is rooted in a model that is wrong?
Models are inherently client-centered as they seek to understand the client better and more accurately. If they are wrong, they are easier to refine than a modality because models are inherently about what is right. A modality is inherently about delivering a model. Often times that model is wrong, as most models are, but it is not well understood or articulated clearly enough to be refined because all of the focus is on the modality, not the model.
Modalities are actually fine to work through so long as they arise out of a model. But when they become the model itself or they lead the development of a model (a model based on a modality), we end up with therapy that no longer has the client at the center of what we do.
The client is replaced by the modality.
Ravensara: In normal practice, since we’re always required as professionals to put the client’s interests above all else, then the only possible exceptions that I can think of are crises. So the need to swap the client and the massage therapist in the image — which is how I think of “ego-centering” — we must be in a situation that is already not normal.
For example, the client’s right to expect privacy and confidentiality from you is — normally — without question. But imagine that you are massaging someone, and they have a strong emotional reaction on your table. In tears, they confide in you how awful and guilty they feel because they’re under so much stress at work. Although they don’t want to, they sometimes hit their child too hard because the stress gets to be too much for them, and they just can’t take the child’s behavior anymore. They lose it.
Is their right to expect confidentiality from you still the highest interest in this situation?
Morally and ethically, as a human being, plus legally if you live in a state where you’re a professional mandated reporter, then no. Your positive duty to protect a child who is currently at risk of being abused is far higher priority than keeping your client’s statement about child abuse confidential. So you promote your interests in living up to your conscience as a good human being, as well as in not getting in trouble with your regulatory agency, above your client’s interest in expectation of confidentiality.
That’s the closest example I can come up with to a justified example of ego-centered practice — of placing your conscience and your interest in staying out of trouble above your client’s interest in confessing privately to you. But even then, that’s not really ego-driven practice because what’s ultimately driving it is protecting a child from abuse that is currently happening. So while there is an apparent ego-centered aspect of the situation, it really isn’t when you get to the heart of it because it’s the other interests — the child’s — that are the most important in this situation.
So I’d have to say that no, even for crisis situations, I can’t come up with an example of where ego-centered practice is justified over client-centered practice.
But “ego-centered practice” is not the whole story about ego and needs either. We have an idea going around that we should somehow aspire to be absolutely selfless. I think that not only is that an impossible idea to succeed in attaining, but also that the very attempt causes a great deal of damage.
I believe massage is effective as a therapy because it is a medium from which the therapist can engage the client. It is likely that from this therapeutic engagement come the benefits of massage.
Because of this, modality-based therapy will work just fine if the therapist chooses the right modality based on the individual client. Through the development of clinical reasoning skills, a therapist can hone in on what a client needs and what a client can expect through the application of massage. There are times when one modality will work better than another.
Beret: Here's an example: you have a client coming in who has been treated for the last two years with trigger point therapy, needling, and saline injections for severe calf pain and tightness. He comes in expressing this is a known problem and he is cleared for massage. He wants treatment only for this problem at his calf. You say ok, that's great! We can treat that but let's include that with a nice massage, too. He agrees and while you are massaging, you notice he has a really distinct range of motion loss of internal external hip rotation on the side that his calf complaint was on. To find out more about the ROM, you ask him to contract against you in internal rotation and find that when he does so, he experiences the pain in his calf. You modify the treatment, treat both hip and calf, and continue with the massage. The clients walks out with a reduction of painful symptoms.
Was the doctor who saw him egocentric? No, she did what he wanted. She was actually client-centered. He expressly wanted only calf treatment and she provided that.
Was the therapist more egocentric? Yes. The therapist totally did what she thought she should do to best solve the issue at hand.
You end up explaining that their calf probably did feel tight because the body perceived pain there. The client probably favored the leg and developed and antalgic gait, which further tightening of the calf. But that pain was probably due to a condition further up the leg.
It's not a client-centered or ego-driven approach. Clients do not know what is best for them because they have limited understanding of the possible outcomes, benefits, side effects, and damages associated with pain, injury, treatment or not getting treated. Technically licensed professionals are advocating on behalf of the client to guide a process. Best serving what the client wants is not nessisarly the right choice....although it's a part!
“Massage therapy is terrific. It requires no magical thinking to make sense of how it works. It is safe. It feels good. People love it. It works. And it is time for massage therapy to believe in itself.” – Dr. Christopher Moyer, “When Will Massage Therapy Believe in Itself?”
As decent, caring, human beings, massage therapists don’t need to have any shame about getting their needs met, including the ones involving ego toward the top of the pyramid. It’s when we don’t get those needs met in our personal lives, outside of practice, that we are at most risk of trying to get them met by our clients in some unprofessional way.
For example, massage therapists who already get their own needs for financial safety met can find it much easier to avoid selling clients products that they don’t need, than a massage therapist who is wondering how next month’s rent is going to be paid. A massage therapist whose needs for love and belonging is getting met in their personal life is very likely at less risk for violating a client’s boundaries by initiating a intimate personal relationship.
A massage therapist who truly takes these words to heart and lives them everyday:
“Massage therapy is terrific. It requires no magical thinking to make sense of how it works. It is safe. It feels good. People love it. It works. And it is time for massage therapy to believe in itself.” – Christopher Moyer, “When Will Massage Therapy Believe in Itself?”
Beret: Therapists need to undertake training that is more about biological function, aka modality free so that they are able to accurately critical think. It's building a treatment bottom up rather than top down. Maybe that is what it is rather than ego or client. It's more bottom up than top down.
Ravensara: I love the way Bronnie Lennox Thompson summed it up: “Client-centred says ‘what does the client want?’ and ‘how can I help them achieve it?’, while ego-centred says ‘I know what this client wants’, and ‘I will give him/her what I think is needed’.
For example, a therapist tells a client, "Wow, your shoulders are the tightest I've ever seen." Conveying a nocebo that can distress the client, just because the therapist needs their ego boosted by the client acknowledging their palpation skills and experience, is the opposite of client-centered.
If the message to the client is one of blame or fault, then that’s a very likely red flag for ego-driven practice. But I don’t want to leave the topic on that negative note.
It’s true that we have a lot of work to do to ensure that all massage therapists have clarity on what client-centered practice is and what resources are out there to support us in performing it.
For example, if I am working in a trigger point modality, everyone that comes in to see me gets trigger point therapy. If I get someone with forearm pain, my way of treating them will be to find the trigger points in the arm and “release” them. I might say, “Let me know when the pain is at a level between a 6 and an 8,” and I hold that spot until the pain drops down to a 2 or a zero.
But let's say that this person comes in with forearm pain that is a bit more unspecified, chronic, and that they describe the pain as "deep in the bone," somewhere in the forearm, but it isn't possible to determine exactly where– it's more like a region than a spot– and it hurts worse in the morning and less at night. They've tried everything under the sun, and now their neck is starting to ache.
Through the modality of trigger point therapy, the problem is that this person has trigger points somewhere and the treatment is to press into them. But under a more accurate model of chronic pain and neurological conditions, we might understand that this person likely has central sensitization issues and painful applications of pressure need to be avoided. Under the trigger point modality, there is no room to approach this problem with what the client needs. But from a model of chronic pain and touch that includes best known neurological phenomena, we can see that the client may benefit from the gentle stimulation of mechanoreceptors and proprioceptors (MFR, PNF, AIS, MET). This is how a therapist can benefit from moving away from modality-based therapy and into model-based therapy.
The experience reminds of that famous quote by Bruce Lee:
“Be like water making its way through cracks. Do not be assertive, but adjust to the object, and you shall find a way around or through it. If nothing within you stays rigid, outward things will disclose themselves. Empty your mind, be formless. Shapeless, like water. If you put water into a cup, it becomes the cup. You put water into a bottle and it becomes the bottle. You put it in a teapot, it becomes the teapot. Now, water can flow or it can crash. Be water, my friend.”
Would you like to learn more from these experts? They have contributed to our Summer and Fall issues, covering sports massage, client consent, and pain.