The two largest detractors I felt that were impacting critical thinking in the workplace were time and money, and each directly effects the other. To make good decisions, you need time to make them. The standard turnover in New York City is 15 minutes between clients. With sheet changing, assessment, checkout, and all of the other things that a therapist has to do between clients, it is really a back to back session. We set up a system where the client roll over is 30 minutes between clients. That means for each shift we actually book one less appointment. It is a financial loss for both myself and the therapist, but it is a huge gain in quality of care. Without the need to book as many clients as we can, therapists have an opportunity to sit down in the room with their clients and talk eye-to-eye before treatment. For many of our patients, this will be the first time that it has ever happened to them in a clinic. For the therapist, they have ample time to ask, explore, question and plan. We choose as medical professionals to measure success by quality of care rather than profit made.
The second problem I felt needed to be addressed before we could tackle critical thinking is the social aspect of how massage therapy is perceived and treated as a career choice by the public and by employers. For many therapists here, there is no upward mobility and it might not command the same sort of respect as similar health care jobs. To change some things, you have to give back first. Admitting you are wrong—and having the humility to make good decisions—requires that you are okay with who you are. People who are disrespected, marginalized, and in doubt of where they stand do not make good choices. They often make choices that make them feel better. The minute resentment or the need to command attention about who you are enters the picture, your choices become skewed. So in our space, we stack the cards in the therapists’ favor. Each therapist is asked to dress the part of a medical professional, and we have set up our intake in a way that sends a clear message to the client that this process is totally different than other massages you have had. We also ask therapists to pick a field of expertise, something they can own, be comfortable in, and educate other therapists within the company. Everyone gets a chance to teach which helps them define who they are and everyone gets a chance to learn new skills. We all move forward together, or no one does.
When it comes to the actual critical thinking, it is important to remember that it is a process by which we learn not a formula. My very first step is to set some ground rules for the process. When we meet the first time for training (if a therapist needs it) we ask them to step away from the idea of assessing ‘conditions’ because when you put a name on something it gives you a preconceived idea of what the treatment for that is. This idea of course is only for use in cases where we know the client is safe for treatment. In these cases, we are not talking about red flags we are talking about musculoskeletal conditions possibly treatable by massage.
The reason for removing labels of any kind is any a great therapist has made poor decisions simply based on the fact when you label a condition, you are immediately bias to a modality, treatment or research. Instead we ask them to pose the question, “Why would the body want to create this sensation given what we know?” When you start to think about why, you move beyond structure and possible condition and more in terms of biological response.
If you are just starting out, one of the big challenges is to get out of a massage routine and away from a one dimensional passive treatment. Orthopedic massage uses passive, active, and resisted activities. At first, we just ask that for each muscle group you use your normal passive techniques, one active technique, and one active resisted technique (assuming it is safe to do so) This gets you thinking down the line about how to incorporate more than one activity into a massage fluidly because they have to think ahead based on the clients’ needs. Once you have mastered a regular treatment, the real work begins.
You go through a process for each massage that treats treatment as if it were an experiment. We use the traditional SOAP notes, pain scale, goals, and RoM charting to start the process. The intake is essentially structured after a simple experiment. It consists of a question, a possible solution, the enactment of the experiment, and then a return to the original question to compare the data and the treatments effectiveness. Remember that the postulation should not be a condition, like this “poor range of motion because of pain in X joint.” As you become more experienced, you are able to add limits to their experiment, like “poor range of motion and pain at X joint, but client cannot move the joint and is sensitive to touch”
At that point, they have to go back to the patient/client, choose a goal, and submit a consent to treat. This is the most important because this is what you are testing. It is the place where the therapist has to think about what might happen during the treatment. Then you are asked to clearly state what you believe the problem is, how you would like to treat it, the possible outcomes (good, bad, side effects, and worst case scenario), and then ask the client if he/she can proceed to treat based on what they have decided. Thus, one of two things happens: you proceed with the treatment, or more information might come to light and you will begin the process again. If the client agrees, you begin the treatment.
Since we are not actually in a lab, and dealing with people who deserve compassionate care, at any time the treatment might change during the process as new information comes to light, but at that point the therapists are asked to re-state their consent to treat so they can move forward with a modified treatment plan.
Photo: Beret Loncar
“The reason for removing labels of any kind is because therapists could make poor decisions simply based on a labeled condition. Thus, you are immediately bias to a modality, treatment, or research.”
32 massage & fitness magazine