WHITE HOUSE COMMISSION on COMPLEMENTARY and ALTERNATIVE MEDICINE POLICY
Testimony – Monday, May 15 2001
MR. SICKELS: Members of the Commission, thank you first of all, for inviting me to come to speak with you today. This morning I am not trying to represent any group or organization. I offer only my personal viewpoint and experience, a view from below, in the trenches of a fast-growing, young, and ancient profession, after 16 years of practice and teaching in the field of therapeutic massage and bodywork.
My primary concerns focus on what may be lost in the complete absorption of manual/manipulative therapies, somatic or body-oriented education and facilitation methods, into the belly of modern medicine and the mainstream health care payment and delivery system. I also find myself questioning some assumptions about, and motivation for, getting into the health care payment and delivery system.
When I teach massage therapists, I teach that there are two kinds of touch, procedural touch and expressive touch. Many of my own clients implicitly know this difference and come to me precisely because I am very conscious of the difference and I am skilled at doing both.
Professional therapeutic massage, when most effectively and ethically applied, marries the two. The health care payment and delivery system only recognizes the procedural form and application.
I have come to recognize that much of the potency and value of what I do comes from the fact that I work with people, and not on them or pieces of their anatomy, and that this is true no matter the technique used or outcome sought. I believe that this is precisely the alternative that the lions’ share of people who seek our services find so complementary with or without reimbursement.
I worked in a doctor’s Physical Medicine and Rehabilitation office alongside a physical therapist early in my practice. Cases involving auto accidents, falls, cervical strains, herniated discs, and chronic pain would be sent to me to work on the neuromuscular and myofascial components of their painful and guarded conditions.
When I left the doctor’s practice for my own, the physical therapist wanted desperately to know what was it that I had been “doing to” the patients that I had seen, what techniques was it that I was using, so that she could perhaps go and learn them, too.
I had to honestly say to myself and to this colleague that if there was anything consistent and identifiable about the time that I spent with these people, that it was not the application of a particular manual protocol or technique, rather, it was the quality of the time that I spent with them, listening carefully to their stories and experience both with my ears and with my hands, validating and supporting them in their process of letting go gradually of their holding, guarding, and fear.
I helped them become aware of what they were doing and choices that they might have. Various massage and neuromuscular protocols, which were always carefully recorded for tracking patient progress and keeping the treatment record, were the platform and excuse for them to receive safe, responsive, intelligent, caring touch.
These skills cannot be learned from books, published studies, and the hard sciences. These are the softer arts, and they, like expressive-type touching and exquisite sensitivity to boundaries, are mostly set aside in the mainstream health care service industry to make room for the efficiency of procedures.
It has also been my experience that perhaps a majority of persons in our culture have largely and sometimes exclusively experienced touch that communicates primarily one of three things: expectation, demand, or threat.
This includes much of the touch that passes between persons in private and intimate relationships, as well as the typically procedural type touch provided in medical exams and rehab intervention. I tell my students that for some of their first-time massage clients in particular, it may be the first time in their life in which they experience a quality of touch that does not only express and communicate some form of expectation, demand, or threat.
Keep in mind that most procedural touch is focused primarily on the desired outcome but not the person. It breaks, loses or never even establishes real contact with the person, but instead emphasizes the separation, difference, distance, power differential, and, of course, the outcome or goal that is being focused upon.
This is quite naturally and often received as a subtle aggression, from a position of power-less-ness and vulnerability – doing something to someone to make them other than they are in that moment.
It has been my role, and I suspect the role of numerous other alternative health care professionals to, in Bevis Nathan’s terms, “counteract the level of vulnerability conferred upon the patient by the curative processes and associated technical administrations.”
The demands of the health care system as it is currently structured and oriented will lend even more momentum to a tendency I already see within my profession as it grows and seeks mainstream legitimacy.
That is to focus primarily, and often exclusively, on techniques and theory for the application of those tools in fixing and curing presenting problems, just like the physical therapist whose entire focus and only question was what technique had I used, what had I been doing to the patients that we had both been seeing.
With the theory comes research justification sought and framed within a mechanistic medical model, expressed only in the language of physiology. Meanwhile, contact with the interpersonal, expressive, and phenomenological qualities of the interaction and skill development in observing and relating in this regard, fall to the back of the curriculum, or off of it entirely.
So, we learn techniques to help and fix, things we do to someone for them, with less focus given to teaching or developing the skills of presence, attention, listening to, being with and educating.
Techniques are then strung together into protocols and procedures used on anatomy, no longer persons, by health care providers, including massage therapists.
Nathan points out that, “Holding, rocking, rubbing and stroking touches are procedurized versions of expressive touch forms.”
While we ascribe physiological rationales to our techniques in an attempt to become or remain scientifically acceptable and to gain access to the mainstream medical reimbursement system, we must continue to recognize, as Nathan puts it, that our “therapeutic pedigree is rooted in primitive and instinctive healing behavior of the expressive touch variety.”
We cannot expect all our answers and justifications to come from the language of anatomy and physiology. Nathan suggests that in fact, “We may have become over-reliant upon a small physiology section of a very large library of the human constitution. An answer may instead arise in terms of the meaning of a caress, rather than the physics of it. The meaning of a touch to an individual is a far subtler notion than is the mere stimulation of a postural reflex pattern.”
How do we quantify, control, and/or reimburse for the meaning someone makes of an interaction during a carefully and ethically contained therapeutic session?
I support and encourage integration, coverage, and reimbursement for the minority of persons who really need alternative and adjunctive services such as massage therapy, and cannot afford to pay for them. But my experience is that this is only the case for a small minority of persons who actually seek and use our services.
The most common application and use of massage therapy does not meet the “medically necessary” criterion for coverage. This is not to deny the validity and value of forms of medical massage, some of which I am trained in, for those who truly need it, provided for and reimbursed by the system.
What is more in question is the limiting definition and control of these and other alternative care services through integration, in a way that compromises some of their essential ingredients and redirects some of their most creative focus and gifts, in effect limiting both quality and access.
These essentials for massage therapy and somatic education lie in the area of expressive contact and presence, strategic, responsive, interpersonal interaction focused on the whole person. They also lie in exquisite attention given to boundaries and to a person’s physical and emotional responses to the caregiver’s presence, pace, contact, and intervention strategy.
It has also been my observation that quick and uncritical allegiance to the “benefits of access” to the health care payment and delivery system has often had more to do with the profession’s and professional’s access to, and control of, market share, than the real interests and needs of patients and clients in their pursuit of resources for health and healing.
Many therapists are sold on the idea of becoming a “preferred provider” and gaining (the assumption and packaging says) easier access to more clients as referrals are provided you through the network.
Meanwhile, many have little awareness of the implications to their practice, time and attention, and their possible dependency upon and costs of securing this effortless marketing and referral source.
I look forward to learning more from the perspectives and understanding of many of those, and many of you here, who have a different view and experience. These are interesting times in the world of alternative and complementary care.
I once again thank you for this opportunity to offer my simple and personal perspective.
DR. GORDON: Thank you very much and especially for the articulation of much of the spirit of the work that all of us do.