Avoid Becoming A Bully Massage Therapist

June 20, 2016/2 Comments/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

He pulled me to the side and I was immediately uncomfortable.

It used to happen all the time. One of my friends dad when I was growing up was a bully.

He was REALLY old school and believed that he was always right. It didn’t matter if he was blatantly wrong.

The worst part was when he would force his opinion on you and expect you to respect whatever his opinion was. He would regularly use intimidating factors to push his way around, especially if you ever had the nerve to question him.

Then the day came that I had enough.

When he pulled me aside that day, we were at a graduation party in a different town and he didn’t like the environment and the way other people were conducting themselves.

The reality is he just didn’t understand their culture so that made it wrong in his eyes.

However, he was going to enforce his opinion and demand this group of people change their behaviour and do what he thought was appropriate. The worst part was, he wanted me to go tell them to change, he didn’t want to do it himself.

I got my back up and wanted to go toe to toe with him (except he was way bigger and I don’t know how to fight). When I told him I wouldn’t have anything to do with it, he got angry and I mean really angry. He got in my face and looked at me saying “I’m a parent, not you, what I say goes”.

I had to put my foot down and tell him he could do whatever he wanted, but I would have no part of it.

A Balance Of Power

In this case there was a major imbalance of power.

This guy thought he had the right to impose his opinion on not only me, but every other person who was at this graduation party.

The problem is, he was blatantly wrong.

According to bullyingstatistics.com these type of people use their strength or position to harm, control and manipulate others, especially when those others have a difficult time defending themselves.

Do we consider this when we are dealing with our patients? Is there a balance of power there?

According to the College of Physical Therapists of BC “There is an inherent power imbalance in favour of the physical therapist, because the physical therapist has a disproportionate amount of knowledge compared to the patient, and the patient relies upon the therapist for care”

When we have a patient on our table we have to be careful of our communication and whether we are expressing opinions or fact. The two could be easily misinterpreted.

We must not impose our opinions on our patients.

It’s not only wrong, it’s against our ethics as Massage Therapists and healthcare professionals.

We see a variety of patients every day who walk into our clinics, some of us see a new person everyday, especially when we are trying to build our practice. Regardless of your background each one of the people who come to see you have a different background or come from a different culture that you may or may not be familiar with.

Whether we disagree with their lifestyle, religion, sexual orientation or anything else, we are medical professionals that must treat each person the same regardless of our opinion.

This also applies when speaking to them about other healthcare practitioners. We have to choose our words carefully.

We have all wanted to look at a patient and say “well your doctor is an idiot” but again this would be expressing an opinion, which could be potentially damaging to not only our relationship with the patient, but the relationship they have with other practitioners.

Remember the patient relies on us for care, not our opinion.

Applying Research

Staying up to date on research can be a difficult road to navigate.

Quite often it is going to challenge some long standing beliefs we’ve had, which can also change the way we treat and our relationship with a patient.

However it is part of our responsibility as healthcare professionals.

I saw a quote on Facebook the other day where someone said they had lost the passion for their practice because research has proven a technique they loved wrong. This could be debilitating for some, especially when we are talking about some long standing beliefs.

It is important to understand that the technique hasn’t necessarily lost its effectiveness, but our explanation of what is happening has to change. If our understanding has changed and we don’t relay the information to our patient this could be considered a form of harm.

Our patients look to us to stay informed and assume that we are doing everything in our power to provide quality care.

With so much information readily available to us nowadays we should be able to find a few ways to incorporate research into our practice for the benefit of our patients.

Whether it’s via Facebook groups, blogs or just searching for research online we should be making this part of our regular practice.

Take some time and check out a couple of blogs and websites. A few that I like are painscience.com, the international journal of therapeutic massage and bodywork, pubmed.com and rmtedu.com which all have some great information on various areas of research and evidence based resources.

Photo by: Foundry

Communication Outside The Treatment Room

“If I wasn’t standing there, they would have had my daughter booked in once a week for the next two months!”

When I hear things like the statement above I think a little piece of me dies inside.

There is a drastic difference between a treatment plan and fear mongering.

Telling patients that they must come in for extended periods of time, without even knowing how a person will react to your treatment is a bullying tactic and it has to stop.

So does using terms like “well I only have one spot left, so you better take it before it’s gone”.

I get it, we all want a full practice but trying to tell someone you know how their body will be reacting two months down the road isn’t a treatment plan, it’s ego.

A proper treatment plan involves continual assessment and re-assessment to gauge progress.

As we move towards a patient centered healthcare system, these choices will more and more be the patients decision. Laying out a sound treatment plan and then incorporating the patient as part of the decision is how we will gain more respect in our medical community.

A patient should never feel pressured in making their healthcare decisions. We have to remember, even though it may not seem like it, there is a balance of power between us and our patients. We have responsibilities not only with our treatment but also in the way we communicate. Using any kind of communication where a patient feels pressured to book back in is an abuse of that power differential. As we strive to be more a part of mainstream healthcare all of these factors come in to play. Staying on top of relevant research can be intimidating but it improves not only our relationship with patients but also with other healthcare practitioners. It is our duty to stay informed and keep our patients informed so they can make the best decision for their healthcare. Just make sure you’re never in a position where a patient has to put their foot down with you.

Using Movement To Teach Resilience, Not Fragility

June 13, 2016/3 Comments/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Cory Blickenstaff

Movement is a very important component in the treatment of painful problems.

It makes sense that if someone has a movement problem that movement will be key to their recovery.

Pain is very effective at taking things like movement away from us. And it often leads to a search for “good” movements to be encouraged and “bad” movements to be avoided.

It can seem sensible, especially when the pain seemed to originate with a particular movement or activity, and many a well-meaning provider is all too happy to help a person identify them. But let me tell you that one of my biggest frustrations is when I get people who have become scared of movements and actively avoid them because they’ve been told to!

“My PT said that my lumbar degenerative disc disease is probably related to all of the bending that I’ve done in my life. So, now I avoid bending whenever I can.”

This, folks, is avoidant behavior, one of the biggest indicators of poor prognosis, that was ENCOURAGED by something a person was told.

We can do better than this. Much better!

Movement Is Education. Teach Resilience, Not Fragility.

It can be tempting to separate the things we do into divisions such as manual therapy, education, exercise, motor control movements, etc.

Certainly there are plenty of examples out there of “making sure to include education into your treatment.”

I would submit that you can’t avoid educating your patient even if you try.

Everything that we do informs the patient in some way or another. Even the timing and body language used when we take notes or make eye contact informs the patient about what we consider to be important about their case.

“He looked concerned and started taking notes when I mentioned my old auto accident. That must be important!”

Our tests, screens and the way we react to the findings provides education. When we apply our hands to the patient we are educating them about their condition.

“He looked at my spine and when he pushed on it I noticed stiffness.”

Movement is no different.

When we discourage certain movements we are sending a message that those movements are a threat and may create harm. When we encourage other movements, we are providing education as to what may be “good” or “helpful.”

Sometimes this may be appropriate but we must be careful because, if on one hand we tell the patient that “pain is an output of the brain” and that their problem is not explained by an orthopedic “issue in the tissue” but then on the other hand dispense movements based on tissue strain principles then we are sending a mixed message.

Or, worse we may be sending a consistent message of threat that implies fragility.

Be careful of passing on themes of fragility through movement programs.

Use movement as a way to demonstrate resilience, build confidence, and regain lost territory of function.

People Don’t Look For Explanations, They Look For Confirmation

If we are going to educate and communicate with people effectively we need to have some understanding of behavior.

One of the most important aspects of human behavior that we must always keep in mind is called confirmation bias.

It is the tendency to look for things that support the position that we already hold and we ALL do it.

What this means for us is that people 1) tend to come in with some idea of the problem already and 2) are looking for confirmation of this idea.

This is scary for us because it means that these messages of fragility may be getting passed on without our even knowing it! You may have no intention of passing on the “poor posture” message, but they may find validation in something you’ve said or done anyway!

Beyond this is another related behavior known as the backfire effect.

If you try to talk someone out of a position that they already hold it is very likely that it will only cause them to entrench in the very belief you are trying to discourage.

This means that if you were to make the effort to tell your patient the many reasons why their pain likely has nothing to do with their posture, there is a very good chance that this will only make them even more confident in their notion of the poor posture problem!

C’mon now! What are we to do?! We need to take a third road.

One form of learning that is currently thought to be one of the more powerful mechanisms behind the success of exposure based approaches is that of inhibitory learning (here and here).

Think of someone who has a fear of being bitten by a dog.

They may think that if they sat in the same room as a dog for 10 minutes that their chances of being bitten would be 100%. So, if they sat in a room for 10 minutes and weren’t bitten, this finding would be surprising.

Evidence indicates the outcomes that drive lasting change are those that are unexpected.

It appears that the more surprising the result, the bigger the effect. When a person is confronted with a surprising result, they no longer look for a confirmation but instead look for an explanation. This is good timing to apply verbal education.

We can easily apply this principle to movement.

When they can demonstrate to themselves resilience they did not expect, the surprising result offers an opportunity to refute the notion of fragility.

Reassurance Is One Of Our Most Powerful Allies

“To live a year without a memorable bout of back pain is abnormal” ~Nortin Hadler MD

Why is this so important?

What is often implied in our approaches, either implicitly or explicitly, is that pain is never normal.

This is just not true. Pain happens and has a role.

The average person will experience a memorable bout of back pain every 1-2 years (here, here, here, and here).

When we imply that the presence of pain is by default abnormal we may validate the presence of threat implying that something is wrong. Pain appears to be based on the perception of bodily threat. So, in that case, when our treatments work it is likely through a process of convincing that the threat has been removed or resolved.

In certain cases, like fractures and lacerations, that is certainly appropriate.

However, in the absence of a true threat, we should be careful about potentially validating the abnormality of pain.

Encouraging the avoidance of certain movements can drive fear and confirm that scary things exist along that continuum of movement.

This gives us a valuable role in re-assurance.

What is typical and expected? What would we see if this were something more concerning?

Photo by: Roger Mommaerts

Consider Yourself In The Role Of Contextual Architect

I have long considered that my primary role as a physical therapist is to set up scenarios in which people can come to certain conclusions.

We are architects of the context in which change occurs, at best (here). We are not responsible for the change itself, only the patient can bring change.

This is why I am no fan of the descriptors of “healers” and “fixers.”

We can set up and progress “experiments” which can refute fragility and encourage resilience. We can use movement in the form of exposures to first disconfirm the limitation and then use graded activities in varying contexts to consolidate and strengthen the disconfirmation.

It becomes a form of confidence building.

So, be mindful of the messages being sent by your interactions. Be aware that your patient is looking for any signs to confirm their worst fears, even if you are not purposefully sending that message.

Use your understanding to set up experiments in which they can demonstrate to themselves a surprising resilience.

When it occurs be ready for the opportunity to explain it. But…

Be Mindful Of The “Safety Signal”

Returning to the dog bite fear scenario, there are a few different ways that we could set up the experiment so as to bring about the surprising outcome.

But, not all options are equally good.

For example, we could put the dog on a chain. Or we could give the person a shield or a taser or something to use to defend themselves. We could stand there with them providing assurance that if the dog were to attack we would stop it.

These are examples of what are known as “safety signals.”

The safety or lack of the feared result is credited to something other than themselves: the chain, the defense, or the helper person. While these things may serve to give the person a sense of safety, it may not be a sense of safety that they will feel they brought about for themselves.

So it is not likely to last because it only serves to confirm that the threat was real in the first place.

The best outcome is when they feel as though they’ve successfully navigated the predicament of their own accord. The best outcome is when they feel that they have the resilience to be in the presence of the dog themselves.

In the case of movement treatments, we need to be mindful of this as well.

Did they feel that they navigated the steps successfully, or did they they do it because of the tape they were wearing protected them?

Were they able to successfully work in their garden or was it just because someone had “fixed their alignment.”

Again, look for opportunities to portray themes of resilience, not fragility and vulnerability.

Practice

Practice becomes a time when repetition gives reinforcement. Gradually increasing loads build confidence. Differing contexts and scenarios provides consolidation. And regaining of lost valued functions provides motivation.

Mental Health First Aid For Massage Therapists

June 6, 2016/4 Comments/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

My first exposure (that I can remember) to mental health issues was back in 1988, I was 12.

We got the news that my uncle had taken his own life.

Flash forward several years and it happened to my best friend’s dad, then one of my mentors from the firehall, then last year it was my brother.

In each case something happened with these otherwise healthy people, where the pain they were experiencing was just too much. They couldn’t take it anymore.

Every time things like this happen, it comes as a shock to the people around them.

Over the years on the fire department we have responded to several scenes where mental health has been an issue and possibly the cause of someone’s death.

We decided we should learn more about mental health to understand how to respond more appropriately. We set up a mental health first aid course.

It was like the words leaped off the page and slapped me in the face.

Symptoms of Major Depressive Disorder:

unusually sad mood most of the day and nearly everyday
loss of enjoyment and interest in activities that used to be enjoyable
significant weight gain or loss, even when not dieting
sleeping too much or too little everyday
moving more slowly or becoming agitated and unable to settle
lack of energy, chronic tiredness
inappropriate feelings of guilt and worthlessness everyday
difficulty concentrating, making decisions nearly everyday
recurring thoughts of death.

But we don’t talk about that stuff.

I’m supposed to be tough and I’d be a total wimp to bring it up.

So many of those thoughts and feelings had been running through my head for years.

I wasn’t excited about the things that used to get me worked up. Playing hockey, exercising and even volunteering with the fire dept wasn’t as fun as it used to be.

Classifying Mood Disorders

There are times when we’ve all felt a little down.

I’m sure we can even notice it in our patients, especially when it’s a patient who we’ve been seeing for a considerable amount of time.

Perhaps something has happened at work, in life or they have suffered a loss and just aren’t themselves.

However this doesn’t classify as a mood disorder, it’s just part of life.

The above feelings become a mood disorder when people feel that their emotions and feelings are no longer under their control, they begin to feel adversity in their social and work life functions.

There are a couple types of mood disorders – depressive and bipolar which can then be broken down further in to subcategories:

1. Depressive disorder

Clinical depression
- Major depressive disorder.
- Has a depressed mood or loss of interest with enjoyable activities for more than two weeks.
Post Pardum Depression
- Starts within four weeks of having baby.
- Symptoms are more severe and last longer than typical depression.
SAD (seasonal affective disorder)
- Symptoms of depression occur typically in darker times of the year (fall, winter).

2. Bipolar disorder

People experience extreme mood swings with depression and mania, but can have extended periods of a normal mood in between.

In addition, sometimes mood disorders can be related to medical conditions and/or substance abuse.

How many times have you seen a patient dealing with chronic pain, a motor vehicle accident or a chronic medical illnesses come in to your clinic that have feelings like they are never going to get better and can’t deal with other issues in life i.e.: work, family, finances?

As research develops and we understand more with the biopsychosocial pain model, there is a direct correlation between these mood disorders and the other pain our patients are dealing with.

It is imperative that we can understand and recognize when these symptoms are developing in our patients.

Massage Therapy Scope Of Practice

There is debate about wether treating depression is within our scope of practice.

Studies have shown that massage can have some positive benefits in helping with depression, but what about recognizing depression as a healthcare practitioner?

There are things we can do to help those with depression, but we are not treating depression. The specific treatment of depression needs to be referred to a medical doctor or appropriate mental health professional.

However, it IS our responsibility and within our scope to recognize patients with symptoms of depression.

Locally our legislation and bylaws state:

Massage Therapists must act in the best interest of the patient.
Massage Therapists must provide complete and accurate information to enable the patient to make an informed decision regarding the need for, and nature of, therapeutic services. This includes answering any questions that the patient may have, in an understandable manner.
Massage Therapists are responsible for recognizing their personal and practice limitations.
Massage Therapists must request consultation or refer a patient to colleagues or other healthcare professionals when such actions are in the best interest of the patient.

I’m sure we have all had patients on our table who like to talk. In fact I’ll bet it’s most of our patients.

But what about when that talk takes a negative angle or starts to take on a self-depreciating or self-harm mindset?

You may hear someone who is depressed say negative things about themselves like:

I’ve let everyone down
I’m a failure
It’s all my fault
It’s not possible to love me
Things will always be bad
Life is not worth living
I’m so alone

There is a tool that can be used called the Goldberg Depression Scale.

It contains questions that can help recognize if one of your patients or friends could be having symptoms of depression. However it is just a screening tool, not an assessment.

If a person is asked the following questions and ranks high, then they should be referred to their doctor for help.

Arguments can still be made as to wether this is within our scope of practice. When communicating with a patient we are required to discuss their healthcare. If you’re using the Goldberg scale, the questions are all related to the persons healthcare and are well within our scope to ask.

Have you had low energy?
Have you had loss of interests?
Have you lost confidence in yourself?
Have you felt hopeless?

If a person answers yes to any of the above questions, then ask them the next five questions:

Have you had difficulty concentrating?
Have you lost weight (due to poor appetite)
Have you been waking up early?
Have you felt slowed up?
Have you tended to feel worse in the morning?

The scale recommends that you give a value of one point for each “yes” answer if those feelings have occurred a majority of the time over a 2-4 week span. Someone who scores 2 has a 50% chance of a mental health problem and with any scores higher than that, their chances continue to increase.

Their outward appearance can also be altered in both physical appearance and with attitude accompanied by the description of being emotionally blunted or numb.

If any of this is present, we now have a responsibility to our patient.

Photo by: SolGar

Mental Health First Aid

Okay, so now we have established there is a risk of depression with someone.

What next?

We need to assess if there is a risk of suicide or personal harm. The Mental Health Commission of Canada gives us a great mnemonic to use for a situation like this called A-L-G-E-E

Assess the risk of suicide or harm
Listen non-judgementally
Give reassurance and information
Encourage the person to get appropriate professional help
Encourage other supports

Assess

Engaging the person in a serious conversation about their feelings can help you to determine what’s going on with them (and let’s be honest, most of your patients are already having conversations with you and there is a level of comfort there).

If you are trying to assess for risk of suicide or harm, it can be a scary thing to start asking about.

However we learned on the course that it is okay to ask directly wether a person is having these kind of thoughts. It is often believed that asking about that is taboo and could lead a person to having those thoughts.

In reality, asking about it shows you care and the fact that you show a wiliness to talk about it can bring great relief.

If the person confirms they are having these thoughts, you need to determine if they have the means to do it, or a plan in place to make it happen.

Do they have the necessary equipment to be able to do it (firearms, pills etc) and is their plan imminent?

There is a big difference between someone who’s planning this today and someone who says they’re thinking about doing it in a month.

If you think there is a risk that this could happen soon, they need professional help and you should call 9-1-1 and make sure they are not left alone.

The most important thing in all of this is your personal safety. While the person should not be left alone, if your safety is in question, this takes precedence and you should try to observe the person from a distance (but still call 9-1-1).

If you figure there is no risk of harm, you can move on to the next step.

Listen Non-Judgementally

This is a skill we as Massage Therapists should be skilled at.

Imagine your intake interview whenever someone comes in for their first treatment. Give the person time to vent their frustrations and realize they are trying to cope with this issue.

As with any other time when they come in, don’t offer advice, leave that to the professionals.

Listening non-judgementally can be tough with mental illness, especially if you’ve never had to deal with it, so remember not be critical or say things like “suck it up” or “cheer up”, this will only make matters worse.

Give Reassurance And Information

Remember, in this case that you are a medical professional and your patients look to you as such.

They are probably more comfortable talking to you than their family doctor. They will probably be looking for some sort of advice from you.

The thing you can do is remind them there are treatments for depression and they should see their family doctor for more guidance on what to do.

It is okay to give them reassurance about depression being a medical condition, common in today’s society.

In fact it is so much more recognized now than it was years ago and the available assistance is at their fingertips.

Encourage The Person To Get Appropriate Professional Help

No, this doesn’t mean another massage.

There is so much help nowadays for depression. Beyond the family doctor, there are counsellors, mental health therapists, clinical psychologists, psychiatrists, volunteer organizations and telephone helplines.

Just make sure you get them to some sort of appropriate help.

It might even be a good idea to start a referral relationship with a counsellor in your area, just for this type of situation.

Encourage Other Supports

Have them reach out to family, friends or co-workers for some solid emotional support.

People who get this support from family can recover a lot quicker.

In addition, exercise and massage therapy are a couple of other therapies that are recommended as treatments that help with depression.

We are at the forefront of being able to help people with this kind of illness. When our patients get on the table they talk, they talk because we have a different relationship with them than other healthcare professionals do. If a person is unsure of wether they are dealing with a mood disorder, there is a greater chance of us picking up on it than the family doctor because they typically see us a lot more. This gives us a large responsibility that must be included as a part of our scope of practice, not to treat but to recognize and refer. While this blog post is just a little bit of advice on the topic, I venture to say it’s something we all need to learn more about. As the biopsychosocial model of care becomes more prevalent and we understand the relationship between pain and psychological issues we stand to see a greater degree of this happening in our clinical setting. As I mentioned earlier, how often do you have someone come in to see you who has been in a car accident or experienced some other injury who has lost a degree of hope and is in despair? I know I’ve certainly seen it. I hope I never have to deal with a patient who tells me they are considering harming themselves but the reality is, we will all probably have to deal with this at some point. Take some time and do some research for your area to gain some knowledge about available resources someone may need. If you handle it appropriately, not only will your patients thank you, their family will too.

Massage A Variety Of Patients For A Better Practice

May 30, 2016/1 Comment/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

When I decided to become a Massage Therapist all I wanted to do was work with athletes.

While in college, I signed up for every sport outreach available and started volunteering with a local hockey team.

I remember my first hockey game, there was a certain pageantry about it. I was so excited to have the opportunity to be a team member behind the scenes.

Immediately I texted buddies because of the sheer excitement of being there. This was what I wanted, this is what I went to school to do.

Then I started signing up for more sport outreaches. Anything or anyone I could get my hands on with sport, I was in.

I graduated and started working at a rec centre, all with the hopes of working with athletes and sport minded people, helping them perform better. Then I sat quietly in my clinic room. I watched people work out in the gym. The odd time they would come up and ask me questions in the hopes of getting some free advice. None of them booked in.

Then I met an elderly gentleman one day.

He told me he used to get regular massage when he lived in Edmonton. We got to talking for a while and he booked in.

He booked in every two weeks for the next few years.

But I wanted to work with athletes?

A Lack Of Funding And Sport Massage

Pride and dreams are a funny thing.

I stood proud during that first hockey game, proud that I had taken the chance to ask and was taken on by a team as a student. Proud that I was working in my favorite sport. Proud that I was the only one in my class doing this kind of thing.

As I progressed with that team, each week I would work with the team Chiropractor, Athletic Therapist and Sport Med Doctors.

I never brought up the issue of money, I was a student gaining experience after all.

But the topic did come up one day. I learned that all of those healthcare professionals were there volunteering their time. The common theme among all of them “We do it for the kids on the team”.

WHaaaaa?? No one is getting paid?

Things started to get clearer. Working in sport was not going to be the sole way I could earn my living as a therapist (at least to start). Amateur athletes don’t have much money and the majority of the money they do have, comes from funding from other organizations.

This changed everything.

Athletes have become something in my career where I make decisions based on my heart rather than my pocketbook.

While I get a variety in the clinic that are athletes, most of them have other jobs where their benefits package is paying for their treatments. Working with teams in the area is something I still get to do and is still one of my favourite things to do but have to work with them based more on my passion for it instead of basing my income on it.

Quite often teams are underfunded or don’t have the extra funds to put towards a full time Massage Therapist.

In order to work with teams it has become either a strictly volunteer option or part paid, part volunteer, but nothing I could make a full time living on.

Sadly the pocket book has to win out.

Extended Benefits And Massage Therapy

I have often said a Massage Therapist around here could build a practice on hospital workers.

Their benefit plan is phenomenal. They get unlimited massage therapy as part of their benefits package. That’s right, UNLIMITED.

But that almost changed.

Recently their union was at the bargaining table and one of the topics for discussion was their benefits. Rumour has it, there were some in the union that were billing a ton of massage therapy hours to their benefit plans and the company wanted to scale it back.

Last I heard everything stayed status quo.

What if it had changed? What if they did scale it back?

It would have affected the businesses of probably every Massage Therapist in the province.

If all of a sudden this population of people who came in for regular treatment couldn’t afford the same frequency, there was the potential for a massive drop in business for every Massage Therapist.

Several other insurance companies put a cap on the amount of treatment one person is allowed to use throughout the year and they book in according to what the plan covers unless they suffer some sort of injury as the year progresses.

It never fails at the end of the year, people book in around November and say “I’ve got $500 I have to use up, book me in until it’s used up!”

While that’s great business wise for a month or so, it’s not sustainable because you usually don’t see these people until the same time next year.

Cash Based Massage Therapy

That elderly fella that booked in every two weeks was a gem.

Going through college I hadn’t focused much on different populations, just sports.

Other classmates were signing up for outreaches that focused in these areas, working in old folks homes, extended care medical facilities, other charity events and whatever their interests entailed.

I wanted none of it.

Since being in practice and meeting people like the elderly gentleman I mentioned, I realized how much fun it can be working with the elderly. In fact now, some of my favourite, most regular patients are elderly people. The beauty part is how much you can learn from them. I love how most of them don’t really care what people think of them, they’re comfortable in their own skin and pretty much say whatever they want.

I find if refreshing (and pretty damn funny).

While many of these patients have extended health that covers them, the majority don’t.

But they still love coming in for treatment.

Could you build an entire practice on them? Maybe, but it’s doubtful, or would take a lot more time.

This enters into the realm of cash based therapy.

There are a few different blogs out there that specifically target marketing ideas and methods of setting up a cash based practice.

To some, the title is probably a bit off putting, thinking you’re just getting patients in the door for cash. But this couldn’t be further from the truth.

The reality is, you probably have to give these people more value than those with benefits.

I know some people are losing their minds reading this and saying “you can’t treat one patient different than another, you have to give the same value to everyone”.

While this is true and I totally agree, the point is more to the fact that people who are paying cash out of their own pockets (who don’t have extended health benefits) aren’t as likely to come in for a weekly maintenance appointment to stay on top of things.

They are probably going to come in when something is wrong and need it fixed asap. The luxury of maintenance appointments to stay on top of things isn’t typically something affordable for them. When they come in, chances are it’s because they really need it as opposed to having the luxury of benefit coverage.

This is where many of your other skills (assessment, clearer communication, interviewing) come in to play that aren’t always used for those regular maintenance patients.

There are more insights to setting up a cash based practice that can be found in Paul Potters blog if you want to check it out.

Chances are we all have different interests when it comes to our practice and would like to focus on something specific. Over the years if you can build up a patient base that is predominantly part of your interest it will make going to work a lot more rewarding. However there is still the ugly side of life where we have to pay the bills. Focusing into one specific population may make that a bit tougher, I’m not saying it can’t be done, just that it will be tougher. Don’t be too quick to rule out different populations as a group that you’re not interested in working with. They could end up making your practice a more profitable one. The other thing is that you never know what you can, or what you need to learn from various populations booking in with you. Yeah I love working with athletes, but the amount I learn from my elderly patients far outweighs what my athletes have taught me. Not only about life but also about being a therapist. Usually when I work with my athletes they come in, look at me and say things like “I need my gluts, quads and low back worked on”. They are in tune with their bodies and know specifically what they need more often than the general population. It’s with my elderly people, weekend warriors and everyday office workers where I need to do orthopedic testing, muscle tests and sharpen my interview skills. Take the time in your practice to see several different populations of people. Remember variety is the spice of life. And it will probably help the business too.

“World-Class” Communication In Your Massage Therapy Clinic

May 23, 2016/1 Comment/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Robert Libbey

Communication is key with massage therapy patients.

New research is starting to show that in some cases, it may even be more important than the actual treatment.

But what about in the aspects of being a Massage Therapist outside of the treatment room?

Can the way we communicate on the phone, or even when re-booking make a difference?

It’s a skill that needs to be developed and can be the difference in not only hiring practices, but also the reputation of your clinic.

Develop The Habit of Providing “World-Class” Communication

Ok, you’ve worked your proverbial butt off to become a medical practitioner, you’ve invested time, money, blood, sweat and tears (no not the amazing 70’s music group), you dress for success and your patients love you!

You strive to ad value and content to your patients lives and you are passionate about helping someone in pain have better quality of life.

The phone is ringing off the hook and you need to hire front-end staff and a receptionist.

Vitally aware that on average, front end staff can make up 65% of your outgoing costs after paying wages, income tax, benefits etc… how are you going to afford that?

You want to hire the best, but recognize their expected income is wayyy outside your financial comfort zone. Or it might be the case that you are cheap as chips!

Let’s think that you are the first example.

True story:

A friend of mine owns and operates his own medical clinic.

He hired therapists who are the best of the best, not hiring when he needed to make rent because the wrong people presented themselves, and in the end he has an amazing team around him… except for his front-end staff.

Don’t get me wrong, they are nice people, but they are not trained specifically for that position.

Lots of businesses hire well meaning people/staff based on the assumption that common sense will prevail and although they have no formal training in being the front line impression of the clinic, they are generally nice and this should come out over the phone or when in person.

The problem is, this rarely happens.

People have good intentions, but when stress levels increase as the business increases, people handle themselves with the attitudes and homegrown habits they already have. This may show as someone becoming a little short or curt over the phone, becoming less helpful to those requiring more assistance, becoming intolerant of uninformed potential patients and so on.

Not quite what we are going for in representing your “World Class” clinic.

So what do you do when you start receiving comments from your patients saying that they love you, but hate dealing with your front end staff?

They would rather book an appointment online or through you rather than through your front end staff.

Constant Reflection To Improve Your Massage Therapy Clinic

Remember that people emulate those that they look up to or perceive as being a leader.

How do you handle yourself in stressful situations, on the phone, in person with your patients?

Is it possible that your staff is mirroring you?

Do you see yourself in the way they communicate with your patients?

It happens more often than you think. Maybe you need to develop or change some of your own habits first before asking someone to change or implement new habits themselves.

Rather than taking the time to role-play how your receptionist should communicate with patients, you must initiate the formation and implementation of good communication habits.

Instilling Belief

Remember, habits are more easily formed when there is a strong belief they are beneficial and positively impact you or someone’s life.

You must communicate to your staff your passions, your beliefs, and your purpose for helping people. More importantly, you must show this in everything you do.

Remember those mirroring neurons?

Remember that a leader lifts people up with him/her rather than pushing and prodding. Be the leader that pulls the best out of your staff, by encouraging them to perform to their highest potential.

It only creates an environment of success, caring and professionalism.

Photo by: geralt

Changing Massage Therapy Communication Habits

You need to determine specific scripts for what you want to be said when different scenarios present themselves.

First, think about the kind of experience you want when contacting a business. How do you like to be treated? Remember, you want to be known for providing “World Class” service right?

Sure you might think you are communicating appropriately, but have you actually listened to yourself as you communicate with someone?

Reflect on how you want your staff to communicate.

What do you want them to say? How do you want them to say it? What kinds of scenarios will your staff be in and what different ways of communicating do you want them to utilize in these scenarios? Think of questions you ask when you contact a healthcare professional.

What do you want said every time for each of the following?

Sit down and quietly write out the clinics introductory speech for phone calls, basically how do you want the phones initially answered?

What do you want said when a new patient calls wanting information on your services?
What do you want said when they are interested in booking an appointment?
What do you want said when talking to returning patients over the phone?
What do you want said when a lawyer calls looking for information for a patient?
What do you want said when an insurance agent calls looking for reasons to provide coverage for a specific treatment?
What do you want said when a patient calls in to complain or inform you that they are in more discomfort after your treatment?
What do you want said when a patient has to cancel an appointment either within or outside your cancellation policy?
What do you want said when contacting your cancellation list to offer appointment times to them?
How do you describe your rates, your hours of operation, your location?
What do you say when returning a phone call and have to leave a message?

Once written, you need to test them out on your existing patients.

Ask them what they like to have said to them when contacting a business. Fine-tune your scripts. Your patients want you to succeed and to represent professionalism just as much as you do.

Show your patients you care about their experience and the experience of those potential new patients they refer to you.

Once you’ve got the scripts perfected, print each one out on their own individual pieces or paper.

Give them to ALL your staff, including those who rarely answer the phones. Everyone has to be on the same page as what is expected to be communicated and how.

Next take these papers and post them right in front of the receptionist. It’s easier to refer to them rather than try to remember exactly what to say.

Remember that forming or changing habits takes time. Research estimates that it takes a minimum of almost a month and a maximum of almost 2yrs to solidify a habit. Putting in this small amount of effort will have a dramatically positive effect on your practice.

As your staff get used to saying the same scripts over and over, it slowly becomes committed to memory and before you know it, it just becomes a habit of effective “World-Class” communication!

Communicating Massage Treatment Information

Concerning specific treatment and expected outcomes, you know your staff is not expected to know the detail you do, but you can create scripts to provide general information.

When writing these scripts out, be as succinct as possible, limiting the info to just 2-3 sentences/modality. Your staff and the patient on the other end of the phone won’t remember more than that.

Make your list of techniques/treatments you provide.

In your first sentence, describe the technique.

In your second sentence describe why it can be used.

In your third and final sentence describe what the potential outcome expected.

Remember to keep communication clear, simple and succinct. Developing the Habit of “World-Class” communication doesn’t happen overnight.

It takes self-reflection, thought, dedication, belief and time.

Massage Therapy And Direction To Pay Contracts

May 17, 2016/2 Comments/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

When I met the lawyer and he found out I did massage therapy, he immediately asked: “do you do direction to pay”?

“No”, and then I gave him a list of the reasons why I wouldn’t do it.

Mostly it was just things other friends had told me about why to avoid it.

He just stared at me blankly, then proceeded to give me shit.

As our conversation developed over a hockey game and we got to know each other a little bit we continued to discuss the topic. I was intrigued by his reasoning. He was pretty persuasive, (he is a lawyer after all) and assured me that most of my doubts were unfounded. I sat there and listed several reasons I have heard about why this was a bad idea.

He listed the reasons why I should do it, but the main one: “you’re leaving money on the table”!

We set up a time to sit down and chat and I figured I might as well hear him out.

That day forever changed my massage therapy practice.

Generating Massage Therapy Referrals From Lawyers

Direction to pay is where a lawyer sends patients to your office for treatment after they have been in a car accident, workplace injury or are on some sort of an insurance claim and need help from a therapist.

But you don’t get paid until the claim is settled with the insurance company.

I have heard horror stories about this and was advised by several RMT’s over the years never to do direction to pay.

And I’ll be honest, my opinion of lawyers was pretty jaded.

As I sat in the lawyer’s office and spoke with him and his associate, they wanted to know every reason why there is such a bad reputation with this type of thing among Massage Therapists.

I listed off most of the reasons that had been told to me in the past:

The lawyer calls back and tries to negotiate less money
You NEVER get paid
Sometimes it takes YEARS to get paid
You’re constantly chasing around the people in order to get paid.
If the insurance company doesn’t settle, you won’t get paid.

The lawyer sat there in disbelief.

He was shocked to hear that anything like this had ever happened. As much as I believed it was a bit of a slight on Massage Therapists when these things happen, he considered it just as much a slight on his profession.

As the meeting went on he addressed each of these issues and pointed out why some of those things could happen and then why they wouldn’t happen in our dealings.

He gave what was probably the biggest piece of advice that convinced me to get involved with him:

“just look at it like a forced savings account, honestly the first year is going to suck but then you’ll all of a sudden start getting cheques rolling in every month”

His associate (who is a former car insurance company adjuster) looked at me and said “you’re leaving a huge marketing opportunity on the table by not doing this”

Now granted, they’re also trying to get me to help them with their business, so they’re going to be persuasive. Since they were taking the time to actually have an appointment with me in their office and take time out of their day, I figured maybe there was something to this. What did I have to lose?

It was at least worth a try.

I reluctantly agreed.

Direction To Pay Contracts For Massage Therapists

Together we developed a contract that would be an agreement between the two of us.

The patient is only part of this contract in that they agree to the stipulations provided within it. The contract itself is between me and the lawyer.

It took a little time to develop and I used some information from our local association as they provide things like that for us. Eventually we came up with a contract that I would go on to use with every patient he sent me.

Here is a pdf copy of the agreement for you to download in case you’re interested in doing this kind of work (just make sure to use your name and clinic name etc). The patient fills out the first part when they fill out their intake form. They put their name in the first part, then they lawyers name and the date of their accident.

The form is sent to the lawyer to sign the bottom half of the form. I keep this on file with any other document regarding the patient.

The nice part about this arrangement is the patient cannot take off without paying their bill at the end of the settlement.

The lawyer negotiates a settlement with the car insurance company only after getting the invoice from you and adding the total to the claim. Your invoice amount is added to the claim and the money is deducted by the lawyer before the patient sees any money from the settlement.

With so many therapists that I talked to over the years, one of their biggest complaints was that once the settlement was done, they would never see the patient again and the money was gone.

However in most of these cases, the therapist entered into the agreement with the patient, not the lawyer.

The patient would come in and make claims like “yeah my lawyer said to get you to just do direction to pay and we’ll pay you at the end”.

In many cases, the therapist didn’t even know who the lawyer was and also went on a verbal agreement with the patient without a signed contract.

Do not let this happen. If this is something one of your current patients wants to do, make sure to get the name of the lawyer and enter into an agreement with them, not the patient.

Unfortunately even though you may have built a relationship with a patient over the years, it doesn’t mean they are always going to be honest.

Make sure you protect yourself first.

Massage Therapists On A Team Of Experts

As I mentioned before, the lawyer was trying to get me to help him with his business.

This brings up a very valuable point.

Entering into an agreement like this is helping the lawyer with their business, so they want to do things right. If at any point something goes wrong in this agreement it looks bad for them and their business.

When they have a new claimant come in for their advice and are able to lay out how they are going help them deal with the insurance company and can say they have a team of practitioners who will help them through all of this, how do you think that looks to the new claimant?

It instantly puts the persons trust in the lawyer, knowing their best interests are being taken care of.

However you also need to make sure your best interests are being taken care of as well.

Make sure if you are going to enter into this type of arrangement with a lawyer, that it is a reputable lawyer.

There are lawyers out there who will take on any case in the hopes that they’ll make a buck off of it. Seek out a lawyer who focuses in this area and maintains a good reputation. If they are sending people to other practitioners in town (i.e.: chiro, physio, other massage therapists) ask if you can contact them to see what the experience is like.

In fact some lawyers actually consider having you and other practitioners as a “team of experts” on their side in representing their clients.

One of my friends asked me “what if the claim doesn’t ever settle?”

In asking the lawyer the same question, his response: “we don’t take on claims where this is a possibility of no settlement”.

Remember, the reputable lawyers are looking out for the best interests of their client but are also looking to build a successful business. They don’t want false claims or bad dealings with their network to harm that reputation.

Here are a few resources to use if a lawyer approaches you, or you’re looking for a lawyer to work with.

Photo by: unsplash

Getting Paid

It is true that sometimes it can take a while to get paid for your work, depending on how long a settlement takes.

One of the things that got me hooked when starting this, was when he said “look at it as a forced savings account”.

The first year was tough as he predicted. A few times a month I would get an email telling me that a new person would be coming in for treatment.

That has consistently built up over the past year or so and now various claims are starting to settle.

Cheques are coming in and I’ve had the opportunity to help some people that I may not have never met otherwise.

Now as the settlements come in, I’m able to take that money and apply it to my tax account or designate some of it for holidays or any other savings/purchases that I need to cover.

One of the great things about this is, at the beginning when you start with a new patient you can take the time to explain how the whole process works to them. Explain that if they no-show an appointment it will still be billed with their settlement. They are much more likely to show up for appointments if they know they are going to be billed and paying for the appointment.

Remember, the contract is with the lawyer and part of the contract is that no-show appointments are still paid.

I do have some accounts that will take well over a year to settle and some that may go longer.

But so far, for every claim that has settled, I’ve been paid in a very reasonable amount of time.

As I’ve mentioned so many times before, a big part of being a Massage Therapist is building relationships.

The same applies here.

I’ve taken the time to build this relationship with the lawyer and there has been very regular communication between us throughout this whole process. He’s even given me free legal advice on some other questions I’ve had.

He considers me to be an important part of his business, but more importantly, an important part of helping his clients get better after an accident.

While this type of work may not be for every therapist out there, it’s definitely worth taking a look at. I honestly wish I had started doing this right out of college, it would have gotten me busy a lot quicker. When you look at different avenues to market your business and how much it costs, this is a very lucrative form of marketing. It doesn’t cost anything, just some patience and money management while waiting for payment. However when I think of the first couple of years while I built my practice, there was typically several spots a week that were empty (especially at the start) which could have easily been filled by the lawyer. I wasn’t making any money in those spots anyway, so I could easily have used a “forced savings account”. If you do decide to get into this type of work, take the steps to make sure you’re dealing with a reputable lawyer. Ask friends and patients, consult legal websites, cross examine the lawyer and get your questions answered by them. Don’t be like me, don’t listen to every massage therapy rumour out there, do the homework and research for yourself, it can make a significant difference in your practice.