Anxiety, Crisis, And Recovery As A Massage Therapist


**The author of this post asked to remain anonymous, however, it is such an important topic we thought it VERY important to share and I can’t thank them enough for being brave enough to write this for all of our benefit. 


I made the mistake of going to a cadaver anatomy class, not really thinking if it was something I was fit to be doing, and signed up like you would any other continuing education.

I was at the height of a generalized anxiety disorder crisis that had been building for months, and my cognitive functioning was not letting me make the best choices.  I also failed to mention it to my psychologist who I had been seeing for three months and have a great relationship with. 

It wasn’t until I walked into the cadaver lab and the smell hit me, and I saw the people in bags on the tables that I realized I might have made a bad decision.

The bodies all looked like my Father, who I watched die and be put into the same bag two years before.  I was surrounded by them, laid out on stainless steel tables among buckets of tools from the hardware store and fans.

For some reason, because the money was non-refundable and I needed CEUs, I  justified staying when I should have left. I stuffed my nose with vaporub, put on a mask, and took breaks every 15 minutes.

We were able to touch, move, and dissect.

I kept my distance and observed, and forced my way through. There are many things I saw, which I feel today I should not have exposed myself to, although there are a few things I learned that were positive and do inform my massage therapy practice.

After throwing out my clothes and changing in the bathroom, I was tired and worn out. I drove home, showered, and went to bed.

Anxiety And Spiraling Negative Thoughts

The next day I was in shock without really understanding I was, I took a walk down to the lake. As I was walking I had some anxiety-provoking conversations on the phone with family and was in a complete daze.

As the day wore on, I got more and more anxious, and by 10 pm I was holding on just waiting for my partner to get home from work. Something snapped in me, feeling like I was full of anxiety on the inside like a container and it was everywhere all around me, there was no escape. 

I left the house and started walking really fast, blindly retracing my earlier walk. I was going to throw myself into the lake to escape the anxiety, thinking that hypothermia was the only way out.

I got to the lake but I could not see how to get in because it was dark and I was on an edge with a rock wall and vegetation, I didn’t want to mess it up. If I was going to do this I had to get it right. Delayed in confusion, I sat for a while on the ground.

Just then my partner called me.

I had left them a voicemail saying I was sorry and I had done everything I could, but it was too late. 

They kept alternating in a calm voice asking me where I was and telling me they loved me until I was able to respond and say where I was.

They came to get me and brought me to the hospital where I was put on a 17-hour hold. This was on a Tuesday when I was supposed to be in my university classes. On Wednesday I was let out and had an appointment with my psychologist, and was unable to really think or move or speak and was just wiped out mentally, emotionally and physically.

Massage Therapy Providing Comfort

The only thing I knew to do then was to keep moving through the things I normally do and had set up for the week, despite fully letting go of everything and giving up in my head.

I let myself physically go through the motions of doing things. On Friday I had a hair appointment, and the following Monday receiving a massage.

The feeling of being physically handled when you have given up is a thing I can’t describe. It’s like you have decided to fall into a giant hand and let it protect you. During each, I knew I could no longer comprehend caring for myself and was relying completely on the outside world, and the people touching me and making contact. 

It was complete helplessness with someone holding on to you.

I sunk deep into those hands and the relief I experienced with being able to shut down for a while and let others take over is the deepest relief I have ever felt in receiving massage and compassionate touch. I also kept all of my massage client appointments during this time, no matter how I felt or how long it took to get me to work. Once I was at work, I threw myself into my work and found extreme relief caring for others.

I spent most of the year working with my psychologist unraveling my anxiety that was now paired with suicidal ideation. 

I am proud to say that my anxiety is very much managed with my preventative care as well as my suicidal thoughts. This involves being vigilant about checking in with myself about my stress and anxiety levels, and determining what I need in terms of self-care for the day, and following through. I also make time regularly to reach out to the supportive people in my life and connect.

Showing up no matter what to my massage appointments and doing the work saves me, connects me to clients through touch and our therapeutic relationship. No matter how I am feeling, generally within 20 minutes of working on someone I feel better, and a day at work always makes me feel great, as well as the clients. I am so grateful there can be comfort on both sides, and I can make a massage session all about the other person while receiving human connection. I am also thankful to have worked with an amazing psychologist during that time and having school to occupy my mind, and a fantastic partner.

Massage continues to save me. Those days that I wake up and feel not quite like myself, when I get to work and focus on clients it brings me back, and generally, at the end of the day, I feel amazing and lucky. I also continue to feel a tremendous amount of relief from anxiety as the massage client.  I am unsure if it is the connection to people, or the actual massage process, or both that brings relief to me. I am grateful to massage therapy for helping my clients and helping me. 

If you are struggling with anxiety or suicidal ideation, it is important to reach out to someone. It can be difficult to break through the guilt and shame or even be able to talk about it. But, taking the first step is necessary because it is difficult to think clearly in that temporary irrational state, and you need the help of someone else to get through it. I have learned you don’t need to explain, just be clear and direct, and say, “I am having thoughts about ending my life.”  Start with calling or talking to someone you know, or if you can’t, go to or call your nearest community mental health center, or hospital emergency room. There is also calling 911 or the National Suicide Prevention Hotline, 1-800-273-8255 (U.S).

If you know someone that struggles with suicidal thoughts, call and check in with them occasionally, or spend some time with them. What keeps people well is human connection. 


Resilience – What It Is And Why Is It A Big Deal For Recovery?


Resilience is a term used more and more by therapists, some might suggest it is a buzz word, so I wanted to put down my thoughts about this complex subject. I have wanted to write this blog for a while and the struggle I have had here is to keep it bloggy, not too academic and above all not too long! I have tried to strike a balance between research and also some personal experiences of resilience I have collected.

Before we get into it, there are 3 main points I would like to make in this blog.

Firstly, resilience is NOT about manning (or womaning) up, it is NOT SIMPLY about just keeping going. It’s a flexible, adaptable state that recognizes the importance of specific actions, mental or physical, that have a positive impact on life.

Secondly, resilience is not a binary state between resilience and not resilient. It is a continuum that we move along dependent on a balance of internal and external factors.

Thirdly that resilience looks and feels different between people. What you may regard as resilience MAY NOT be the same as the person you are working with.

What Is Resilience?

Resilience is defined by Sturgeon *HERE* as,

“Maintenance of positive physical and emotional functioning in spite of significant difficulty or challenge”

So resilience is both a physical and a psychological thing. It is important that we don’t separate the two, however (much like pain!). Although physical things often signify resilience, they require a strong psychological component to achieve and also give a lot of psychological benefits.

This is also a good read *HERE*

Karoly *HERE* defines resilience as (2006) as

“Effective functioning despite the exposure to stressful circumstances and internal distress”

Both definitions use the word FUNCTIONING and ‘in spite’ or ‘despite’ of pain.

This makes resilience a REALLY individual thing that looks quite different between different folk. We should not make the mistake of assuming what signifies resilience to us is the same as someone else’s.

Pain is definitely a stressful circumstance for many, and it really becomes a problem when it interrupts our functioning. Focusing on the stressor, pain, however, could be part of this problem. Essentially resilience should be seen as a problem of function rather than pain. This is an important distinction, as identification and engagement of functions must form the key focus (IMO) rather than the focus that many can have (patient & therapist), pain itself.

Sturgeon writes;

”Attempts to control a chronic stressor like chronic pain are often counterproductive and can magnify the negative effects of the stressor”


Goubert & Trompetter *HERE* introduce the concept of sustainability; this is defined as:

“ability of a person to move towards long-term positive outcomes in life in the presence of adversity”

Here is a nice graphic outlining sustainability vs recovery from their paper.

Screen Shot 2018 10 26 At 07.32.40

Sustainability targets the PERSON in pain rather than the pain itself. Perhaps sometimes the focus can be on the pain going away before function is resumed, but we could view this the other way around with functioning through resilience being the first step.

The concept of sustainability is important, as it looks more at positive traits rather than risk factors. This is a bit like Antonovsky’s Salutogenic approach *HERE* that focuses on health rather than disease.

So to sum up resilience, it is about PEOPLE and FUNCTION more than pain and withstanding pain (IMO). Working through ANY pain or injury will require some element of resilience. Acute back pain, one of the most prevalent painful issues, probably exemplifies the need for resilience, with the first-line treatment for back pain being the advice to remain active and engage in your normal activities *HERE*.

Perhaps initial resilience may mediate the transition to more persistent pain states?

Adaptability & Flexibility

Resilience should not be seen as a brick wall. A resilient person is not simply a cold piece of rock impervious to any stressor. It is not about toughness, it is instead a flexible and adaptive state.

It could be quite the opposite, in that resilient people might be willing to seek out help instead of the strong silent type who may not be as resilient as they appear externally, unable to appear weak or vulnerable by asking for help. Resilience may be the ability to open the pressure valve and allow the excess to release and lower the stress by identifying things that allow them to do this or provide a balance with stressful situations.

Pain Relief Vs Resilience

Therapy has long been driven by pain relief, and whilst there is no doubt this is a reason why people seek care, they also seek care because pain is disrupting their lives and functioning, perhaps even more so for this reason.

This paper by Ferrara found that disability was a greater reason for care-seeking than pain intensity *HERE*

So perhaps to understand resilience we have to understand to understand our patients functioning and what THEY view as key markers to signify resilience. Traditionally VAS scales and physical measures such as strength have been used to measure clinical success. But do these measures capture valued activities and what resilience might mean for the person? Perhaps not. This paper looks at this subject of what is measured clinically vs peoples ACTUAL goals *HERE*.

So in order to help people BE resilient a good place to start is to find out more about how THEY view resilience, what defines their effective functioning and how we might bridge the gap between their current and desired states.

Resilience Is Personal

Valued activities may provide balance during stressful situations. Especially people that suffer from persistent pain can lose sight of things they used to do and the things that might define resilience. These are the people that may need a guide or a coach to find some meaning or goal again.

The sustained engagement in cherished activities, or stuff that MEANS stuff, seems to be a huge marker of resilience. To get a better idea of some of the meaningful activities, I asked some of the folk on social media (not in-depth research I know) to let me know some of the things they found important during painful times.

Exercise seems to be a really important sign of resilience for people and it was amazing to hear so many success stories against some pretty adverse situations. On a side note, communicating patient success stories to other patients, delivered at the right time and in the right way, can be a very powerful tool in my experience.

  • Weightlifting
  • Capoeira
  • Yoga
  • Pilates
  • Boxing
  • Bike riding
  • Crossfit
  • Running
  • Walking
  • Bouldering
  • Various sports
  • Gymnastics
  • Dancing
  • Making things
  • Hiking

Work also featured heavily. Just day to day functioning seemed important. Much like exercise, our working lives are pretty varied from being a therapist to nursing to simply driving. The concept of family also featured heavily with helping and providing for them forming an important part of resilience for many.

Resilience seems to be a rich tapestry of different things. The clinical implication of this is being able to effectively listen and ask a few questions that allow us to find out more about what activities may signify resilience and then be able to guide someone towards them and also provide planning and support for engagement.

Here are some example questions I use:

“What would your perfect day without pain look like?”

“What have you stopped doing because of the pain?”

“Are there things you feel are important that you avoid because of the pain?”

I also picked out some quotes. I have not used any names : )

“For many years, my default position was to isolate myself, try to power through, and go out of my way not to seek out resources or strategies. I thought that was the way I was supposed to do it; “man up” and push through. For me, I think I discovered (still am) resilience when I learned about acceptance. Getting to acceptance, and I think I still struggle with that a bit to this day, was a difficult time as I had to admit that I could not do this on my own. I hated that feeling”

“Resilience is in all of us, but sometimes we need a guide to help us find our path forward, but there is always a path forward”

“I would say the thing that made me the most resilient was asking for help. From my mentors, friends, counselors and family. Vulnerability helped me be more resilient”

“I love riding my bike but on a steep hill climb, my pain would escalate 10 fold. I persisted and after 30 mins or so of cycling it would go back down to normal levels. The bike ride was more important for my mental well being than the back pain maybe that is why I persisted”

“Resilience for me is knowing that there are things you can and can’t control and you put energy and focus into those things you can control/accept”

“Resilience is I get up every day and work with injuries on others. Sometimes leaving bed is the hardest part”

 It could be balancing the stressful parts of life with things that bring us happiness and joy is most important and when we lose this balance is when we start to become more vulnerable and our job may be to help with this process.

What Components Make Up Resilience?

Both Sturgeon and Goubert outline some positive elements AND some risk factors involved in resilience.

Lets first start with the positive elements.

Optimism & Positive Emotions

Optimism appears to be a key characteristic, with optimism being related to lower levels of pain and this may support why predicted expectations are related to outcomes. Optimism should be viewed both from a clinician and patient viewpoint and withou,t doubt both viewpoint will interact within the ‘third space’.

Here are some good papers *HERE* & *HERE*

Questions we can ask ourselves:

  • Are you a generally optimistic clinician/person?
  • How optimistic are you about a positive outcome?
  • Do you discuss what a positive outcome might look like, especially in regards to improved function?
  • Can we highlight positive aspects from the person’s story/history, previous positive experiences to be optimistic about?

Although it is important to not seem disingenuous, the need for positivity and a positive emotional perspective on life and activity should be highlighted, although this should probably come after a validation of normal negative responses to a tough situation such as persisting pain.

I feel it is also important to highlight the negative aspects of negative thinking and behaviour.

Pain Acceptance & Sustained Engagement In Valued Activities

Pain acceptance is defined as acknowledging that one has pain, stopping attempts to control pain, and learning to live a richer life in spite of pain. This in turn can lead to more engagement in valued activities.

Sturgeon writes

“individuals with greater levels of activity engagement are better able to bolster their positive emotions through sustained pursuit of valued activities despite their pain”

This appears to be a key factor, both highlighted in the research and also in the in depth qualitative research I performed above on social media ; )

Social Support

People who actively seek out social support seem to have lower levels of pain. We know from work such as Riikka Holopainen’s *HERE* that people with persisting pain reported that their circle of life had shrunk and they had given up doing things they used to enjoy.

Pain can interrupt positive social interactions that are important for resilience, however, pain can also narrow our ability to identify these positive social interactions and positive resilience resources in general.

Risk Factors

Pain Catastrophisation & Avoidance

Higher levels of pain catastrophizing and fear are linked to higher levels of pain and pain catastrophizing can also lead to ineffective coping strategies such as an avoidance approach to coping. This behaviour is consistent with the affective-motivational side of pain that can often motivate people to avoid things such as social interactions and physical activities. Essentially this can limit the enjoyment and positive aspects gained from valued activities, often for fear of pain, and can reduce resilience behaviours. This prolonged avoidance can also lead to depression and disability.

I feel it is important to highlight avoidant approaches and also help someone to rationalise if they are actually helpful for them or not.

But it is also important NOT to simply label people avoiders. Avoidance like all things is complex. Some activities may display avoidance behaviours whilst other things are engaged in. It is a touch harsh to take an area of someone’s life they are struggling with and use it to define them.

Resilience Or Vulnerability

We must be mindful that resilience does not appear to be a stable state. People are not simply resilient or vulnera,ble. Instead they appear to have components of both aspects co-existing in a sort of balancing act. Sometimes we maybe more susceptible to vulnerability, even the most resilient is resilient until they are not. We may also be vulnerable in some areas of our lives but not in others. We could be physically resilient but emotionally vulnerable or the other way around. It could switch from day to day. The one thing we know about the experience of pain, and all the dimensions that go into it, is that it pain is predictably unpredictable.

Resilience should really be seen as a continuum. Different injuries may require different levels of resilience and the person will have a current resiliency state dependent on many factors in their life. Some people may be super resilient or the injury type or state may not require much resilience. As with all painful problems, this relies on clinical reasoning to apply the right care at the right time.

Screen Shot 2018 10 26 At 07.40.13

Take Homes

  • Resilience IS NOT TOUGHNESS
  • Resilience is about adaptability and physical and psychological flexibility
  • Resilience lies on a continuum
  • Resilience looks and feels different to different people
  • Optimism is key
  • Sustained engagement in valued activities is key
  • Pain catastrophization and avoidance behaviour are risk factors

All Hands On Deck


Bell Let’s Talk has come, with all it’s social media fanfare and buzz, then gone taking with it the conversation that hardly ever happens. In a few days, the social media world falls quiet again.

The awareness raising campaigns do their thing and for a brief window, it is hip and popular to pay lip service to mental health problems… meanwhile, people living with mental health disorders continue to live with these disorders, quietly, privately, knowing full well the reality of living with mental disorders does not go away after a day or two of token buzz.

At first, I wanted to try and get on board with the bandwagon, jump in when the chatter was hot but something didn’t feel quite right about it so I did not push it.

Maybe it is my own mental disorders I live with getting in the way, maybe it is an as-yet unarticulated sense of “this isn’t the way I want to do it” thing. Whatever it is, I did not write a blog, a series of blogs or long-winded post on social media about mental health and mental disorders.

Probably because it is so damn important to me; if I am going to write about it at all, I MUST do it justice.

You see, I’ve been wrestling with this thing for years, this feeling, this itch, in my career.

When I first chose this path, I couldn’t quite articulate it, but now, I can. I became a Massage Therapist because I want to comfort people when the shit hits the fan. I wanted to provide a space where a person could arrive with armfuls of pain, gritted teeth and hunched shoulders and just put that down for a minute or 90, have a moment where they could just… breathe.

No hard questions, no pushing for deep thinking, no demands for change or healing, only kindness, compassion, acceptance and attention. I wanted to help people find a sense of peace and safety in their bodies. I wanted to help people learn that their bodies could be nice places to be, that it was possible to feel good being in a body. To me it seemed obvious; that’s what Massage Therapists do.

Our scope of practice is clear; we treat the soft tissues of the body to relieve and prevent pain.

We now know that pain and mental health problems can and do travel together [1,3], that childhood traumas (ACEs) are a strong predictor of negative adult health outcomes [2]. And while I may be extrapolating a little bit here, I think it is fair to say that trauma can be an outcome of severe pain experiences, especially those that persist.  

Taking all of this into account, I can’t help but feel certain in my firm adoption of the idea that all healthcare providers, and especially those who choose to work within an evidence-based, biopsychosocial framework, need to learn how to navigate the therapeutic alliance with awareness for managing the intersections of psychological and somatic health problems.

Canadian Mental Health Stats

When I look at the numbers, I wish I could say my heart breaks but the fact is, I see myself in the stats. I see my friends and my family members.  

In any given year, ⅕ Canadians are living with a mental health problem [5], it could be anxiety or depression, it could be an addiction, bipolar disorder or schizophrenia, it could be PTSD.

Regardless of the diagnosis, it’s COMMON; 3.5 million Canadians seek services from hospitals and physicians for mood and anxiety disorders annually [4]. Mood and anxiety disorders are the most common mental illnesses in Canada and worldwide. The highest prevalence is among men and women aged 30-54, with the 55+ group bringing up a close second. Youth and adolescents are the most rapidly growing group of people affected by these disorders. Possibly most painful of all is the fact that an average of almost 11 people dies from suicide PER DAY.

After accidents, it is the 2nd leading cause of death among young people aged 15-24 [5].

Our Role In Human Health Care

So what is a Massage Therapist doing talking about these things, seemingly drifting from out of her lane?

I firmly believe that, currently, the mental illness crises our communities have been living with for decades (upon decades) demand an all hands on deck approach. We can no longer afford the luxury of letting it be someone else’s problem.

It’s a problem that affects us all.

1/5 Canadians will experience a mental disorder, including addiction, in their lifetimes. That means every single one of us knows someone who is presently – RIGHT NOW – dealing with something that can make everything else that much more difficult. And they are often trying to do it privately because either they don’t want to burden you OR they are afraid you will drop them.

Stigma prevents 40% of Canadians living with a mood disorder from seeking medical help [6] risking unnecessary consequences to their mental health. As an RMT, I am a front line health care provider. As a member of those professionals governed by the RHPA, I have a responsibility to care about all of the health of my patients.

As an RMT I may even have a better opportunity to note changes in the health presentations of my patients, including changes in mental health. This reality behooves us, all RMTs and other health care providers, to learn about mental disorders, pursue mental health first aid training, and to destigmatize our practices.

Often when discussing these ideas with my colleagues I encounter pushback; the worry about crossing a scope of practice line emerges, obstructing progress towards a health care system that is fully capable of addressing human health concerns. Our scope of practice is focused on the somatic experience. Given the relationship between mental health and physical health that is emerging, it is clear that, for some people, their ability to access care, follow through with home care plans and overcome the mental hurdles of dealing with a pain problem can be impeded by mental health problems.

Practitioners who work with the soma exclusively may need to consider these additional hurdles, ensuring that they are:

  1. not contributing to the fear of stigma or retraumatizing in their conduct and language and
  2. recognizing when a mental health problem may be a barrier or yellow flag to the patient’s ability to move forward with their pain management strategy, and when it might actually move them backward.

This is no easy task; stepping into a new level of discomfort, digging deep into your humanity to find compassion, understanding, and the ability to walk with your patient through the discomfort, fear, and shame that health problems, mental or physical, can bring requires a great deal of mental and emotional labour. It asks for empathy and boundaries held in close proximity and it asks us to be much better connected to the health care community we are oft surrounded by, but isolated from. And it asks us to address our own biases about mental health and pain and uncover the ugly heads of the stigma that exist within us and our practices.

The time for us to start giving a shit about these problems and SHOW UP to the table has come and gone, over and over again since the days of Freud. It’s time for All Hands On Deck, because we all, ALL of us, need each other if we’re gonna make it through this at all.


If you’re still with me here then thank you for reading. Below are resources I have been using to inform my own practice and dismantle the barriers of stigma and incompetence when working with mentally ill and traumatized populations. These resources are all free as of this writing.

Trauma + Trauma-Informed Practice:

Trauma Informed Practice Guide

Handbook on Sensitive Practice for Health Care Practitioners

Trauma and Recovery by Dr. Judith Herman M.D. (1992)


Sexual Assault:

Addressing Past Sexual Assault in Clinical Settings

Recognizing and Responding to Commonly Misunderstood Reactions to Sexual Assault


Addressing Stigma – CAMH (scroll to the bottom)


  1. Currie, S. R., & Wang, J. (2004). Chronic back pain and major depression in the general Canadian population. Pain, 107(1), 54-60. doi:10.1016/j.pain.2003.09.015
  2. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine, 14(4), 245-258. doi:10.1016/s0749-3797(98)00017-8
  3. Mcwilliams, L. A., Goodwin, R. D., & Cox, B. J. (2004). Depression and anxiety associated with three pain conditions: Results from a nationally representative sample. Pain, 111(1), 77-83. doi:10.1016/j.pain.2004.06.002
  4. Report from the Canadian Chronic Disease Surveillance System: Mood and Anxiety Disorders in Canada, 2016
  5. Mental Illness and Addiction: Facts and Statistics; Centre for Addiction and Mental Health. (https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics) accessed February 2, 2019
  6. Addressing Stigma; Centre for Addiction and Mental Health. (https://www.camh.ca/en/driving-change/addressing-stigma) accessed February 2, 2019


Four Meaningful Ways To Work As A Massage Therapist During Tough Times


You’ve just gotten some terrible news, news that brings you to your knees, news that makes you unsure about the future, news that breaks you open.

Perhaps a loved one has died or been diagnosed with a disease. Maybe your partner has lost their job. Maybe you have had a miscarriage. Maybe your child was in an accident.

Life throws us challenges that bring us down and may cause many emotions: anger, fear, sadness, grief.

As Massage Therapists, we are told to always check our emotions at the door. To enter our treatment rooms with a kind heart and open ears. To provide space for our patients. 

But what if we don’t have space for ourselves? What if our devastating news has left us unable to have empathy or to listen to complaints that now seem trivial? How do we care for other people?

In September 2018, I was diagnosed with breast cancer. I was 36 years old, had a one-year-old daughter, and had just gotten married. I had a busy massage practice, had applied for grad school and had big plans. I was so angry.

I love being a Massage Therapist. I love to listen to people’s problems. I loved to hold space and allow them to speak. I love to help people to feel better or get them moving again. Suddenly, I didn’t want to go to work. I was struggling to fight back tears when someone was complaining about the weather. I didn’t feel empathy.

In the coming months, I had a mastectomy, appointments at the cancer clinic and another mastectomy. I had a toddler and an amazing husband to care for. I had massage patients to care for and lastly, myself to care for.

Four Strategies To Get Through A Workday

While I know that we as health care providers are supposed to be present in our treatments, I also know that during times of challenge it is near impossible. So I came up with four strategies to help me get through a workday.

1. Allow Yourself To Grieve

While this post is not about grief I think it’s important to acknowledge that you might feel shock, anger, fear or denial. There have been many days that I have cried the entire drive to work. Once I got to work I was able to move on with my day. 

Cry, yell, give yourself space to be mad and sad.

2. Do Something For Yourself Every Day

After my first mastectomy, I worked hard to regain strength and some form of normalcy in my life. I am a gym rat, I love to lift weights. I could just sit in a gym and feel good. 

So,  just a few days after surgery I was in the gym working on my range of motion exercises. It felt SO good, it felt normal. 

I added in body weight leg exercises and eventually more intense rehab movements. I was back to work after a month and lifting heavy weights within three months. Getting back to doing things you love is so important, it can give you a sense of normalcy during a time that is far from normal. Find one thing you can focus on for yourself and make a point to do it.

3. Find Support. Talk About It

At first, I didn’t want to tell anyone I had cancer because I didn’t want my problem to be bigger than anyone else’s. I quickly learned that people care. People want to help. As hard as it is, let them.

You don’t have to tell everyone what is going on in your life. But it is important to find support from people who can give you coping strategies.

I joined several online young women with breast cancer groups. It has been so nice to have others who completely understand what I was going through. Reading other’s stories and comments and asking questions has been extremely helpful.

There are online support groups for various conditions and stages of life, I highly recommend seeking them out.

4. Trust Your Hands

I recently attended a workshop where the instructor said, “your hands are your brains”. It was much more eloquent than that, but I related to that statement.

Some days after my cancer diagnosis I didn’t have a lot of focus, I was too concerned with how long I was going to have to be off work, and if I could even afford that. I was too sad that I was losing my breasts. Did I mention I was angry?! On those days, while I tried hard to be present, I also just let my hands work. They know what to do, so I let them. Give your mind a rest and let your hands do what they are meant to.


Real life is hard. Everyone has something going on. Many massage patients come to us not just for us to rub their skin, but to share the good and bad moments in their lives with us. It takes a lot of energy.

Try to allow yourself time to grieve, focus on an activity you enjoy, give yourself permission to talk to someone and believe in your knowledge and skill to get you through your workday.


Articles Of The Week April 14, 2019


People will do all sorts of popular treatments for different parts of their body. There is a new trend where women are getting laser therapy on their vagina for a variety of reasons, but is the treatment actually valid? Well…there is still research to be done.

“Do Vaginas Need Rejuvenating?” – Sandy Hilton

Patient education and communication is a crucial part of treatment, but how much of what we say do they remember? This is where effective communication may be using short simple messages to help with education retention.

“Pain Science Education” – Lynita White

When it comes to our mental health, it turns out exercise does more for it than money. Although I’m sure most of us would have guessed that, there’s actually research out of Yale and Oxford that prove it.

“Exercise Makes You Happier Than Money” – Ruqayyah Moynihan

Continuing with mental health, how about its relationship with food? If we were to include education on nutrition as part of mainstream healthcare is there a potential for real change? This article argues it would.

“Why Isn’t Nutritional Therapy A Primary Therapy For Mental Illness?” – Eirik Garnas

Research is showing us that one of the best things we can do for arthritis, is loading the affected joints. When loaded properly we can actually combat the effects arthritis has on the joints.

“Arthritis And Movement: Your Weightlifting Prescription” – Mike DeMille, DPT, and Erin Murray

Next Time You Treat Low Back Pain, Be Sure To Provide Reassurance


When the patient came into the treatment room, I sat down and welcomed them to do the same.

They refused, preferring to stand, as sitting hurt their lower back too much. When asked how long this pain had been going on, it was an astonishing two years.

Unfortunately, they had been run through the medical system for the previous two years, had seen every kind of practitioner and been given competing advice from all of these medical professionals. When asked what has worked well in the past, getting massage seemed to be the most beneficial. While this sounded great, there was still a lot of work to be done, which had nothing to do with what technique I could use to help ease the pain.

There was now an education and confidence building process that had to take place.

This person was so scared of their pain, they were afraid to sit (even though they had just comfortably driven their vehicle to the clinic).

How could I help this person? What kind of education would help? Would I be able to help?

Clinical Guidelines For Low Back Pain

Looking at the studies on the clinical guidelines for low back pain,  they revolve around primary care settings, which can be described as the “first point of contact regarding patient care”, so generally thought of as doctors in medical clinics or hospitals.

Fortunately, there is a lot of good advice about managing both acute and chronic low back pain.

Unfortunately, when we look at the European guidelines it says “they cannot recommend massage therapy” for the management of low back pain. But when we dig a little deeper when it refers to treatments they cannot recommend “it is owing to lack of/conflicting evidence of effectiveness” and while many of these treatments may be effective, they require the use of more studies to prove their effect (which is a big reason we need more research on massage therapy to be done, we know it’s effective).

But, massage isn’t alone in these studies as the modalities that “aren’t recommended”, there is quite a long list of things they would not recommend which we see used quite regularly:

  • Radiographic imaging for chronic non-specific low back pain.
  • MRI, CT, or facet blocks for diagnosis of facet joint pain, or discographies for discogenic pain.
  • EMG as a diagnostic procedure.
  • Wearing lumbar support.
  • Ultrasound.
  • Laser Therapy.
  • Traction.
  • TENS machines.
  • Acupuncture.
  • Nerve blockers, or corticosteroids.
  • Injections

However, it does recommend:

  • Looking at: work-related factors, psychosocial distress, and patient expectations.
  • Supervised exercise therapy.
  • Exercise programs that do not require expensive training machines.
  • Group exercise.
  • A short course of spinal manipulation for chronic low back pain.
  • Brief educational interventions.
  • Mulitdisiplinary biopsychosocial rehabilitation.

What the article doesn’t really mention is the interaction between the massage therapist and the patient.

While the above information is from the European guidelines when we look at the updated overview of international clinical guidelines they are consistent in recommending a focus on the identification of red flags (which we have written about HERE) and ruling out specific diseases. The only time medical imaging is recommended is when a serious pathology is suspected.

However, consistently across all of the recommendations is that patients should be reassured they don’t have a serious issue, and they should remain active.

Beliefs Regarding Pain

Sometimes it can be difficult to convince a patient they need to remain active, as they become fearful of moving because they associate it with pain.

In fact, there is a hypothesis where those experiencing low back pain fall into two different classifications: confrontation or avoidance, and this is determined by a persons fear of pain.

Those who confront their pain view it as a nuisance and are quite motivated to get back to normal activities. Whereas those who fall into an avoidance response tend to reduce physical and social activities, have a more prolonged disability and have adverse physical and psychological consequences. There is actually a correlation between avoiding activities because of the expectation of pain rather than actual experience or feeling of pain during activities.

There is even speculation that fear avoidance during an acute episode of low back pain can be a prognostic tool in identifying those who are more prone to developing chronic pain and may be the most important factor in determining the transition from acute to chronic low back pain. 

These fear-avoidance beliefs are even consistent for patients with work-related low back pain and the time it takes for them to get back on the job. Most return within one to two months after injury, but those who take longer are less likely to return to work.

Before I became an RMT, I was an industrial first aid attendant in a sawmill and I can remember having discussions with WCB (workman’s compensation) rep about employees returning to work. He told me their studies had shown if someone went 18 months without returning to work post-injury, they were likely never to return to work (I’m citing this from memory, I have no data to back it up other than remembering a conversation). So, looking back, this conversation makes a lot more sense to me now as many people returning to work were worried they would get reinjured on the job again.

Part of what contributes to fear avoidance beliefs is well…us.

All too often it is the messages patients get from health care providers who still rely strictly on explanations around pain being the result of tissue damage along with structural, anatomical, or biomechanical problems (yes these still play a role but there are other factors to consider as well). This is further reinforced by practitioners who confidently express their methods and services are the only way to relieve pain. 

So, we then have to consider how we can better help our patients with this increasingly common issue. The first step is; reassurance.

Providing Reassurance

As we have been discussing, peoples perception of pain has a massive effect on how they deal with pain.

One study shows that reduced feelings like helplessness, catastrophizing, pain being harmful and disabling, along with increased belief in control over pain can predict positive treatment outcomes.

Unfortunately, a lot of these feelings are due to things people have been told in the past (often by practitioners) that their back is ‘weak from a past injury’ or their pain is a result of genetics, lifestyle, or some other physical trait. These beliefs also bring about concerns they will reinjure or damage their back even more with activity.

There is strong evidence that these views are directly related to interactions with clinicians who also have high levels of fear-avoidance beliefs. Part of the difficulty with this is when patients go see multiple practitioners and are getting a different story from each one, this results in more frustration and an increase in those negative beliefs.

However, if we start to use language and descriptions that reassure and empower the patient, we can start to positively influence their pain beliefs. 

Once red flags are ruled out we can reassure the patient how things should get better over the next few weeks because the symptoms are benign in nature and this issue quite often resolves itself. More importantly, reassure that they do not have a serious disease! Along with this, we should endeavor to offer some level of education to the patient about their pain and how to self manage, otherwise, a dependence on the therapist could develop, where the patient always needs to be taken care of.

We need to start changing the narrative patients are given. 

When someone comes in who has had an x-ray or MRI and is stressed about the results I like to say something to the effect of:

“Don’t let that freak you out too much, if they took an x-ray of me right now it would probably look similar, yet I’m not experiencing any pain, your back is just sensitized right now and we just need to calm it down”.

Or when someone with chronic pain comes in I’ll say something like:

“Since we know pain is a safety and protection mechanism, your tissues have been protected for a long time now, which puts them in a safe place, your chances of re-injury is minimal”.

Now, this isn’t always going to be easy because they could be getting different messages from different practitioners. So, it may take a while to get your message across. But, for that patient who is afraid to sit down because they fear re-injuring their back, this is a good start.

While these are just a couple of examples I have used with people, they are just examples and won’t necessarily work for everyone. We need to tailor our message for each individual according to their beliefs and relationship with pain. We also need to build up our therapeutic relationship with them and provide appropriate homecare to decrease their dependence on us while reinforcing self-efficacy. These patients are wanting to be heard, have a better rapport with their practitioner, be given reassurance and education, so they know they are going to be okay. These are things rarely given by ‘primary care’ practitioners because they are given such a small amount of time with them, so this creates a valuable opportunity for those of us fortunate enough who get to spend on average an hour with each patient. Even though the clinical guidelines on low back pain could not recommend massage therapy, when we look at what they do recommend, Massage Therapist should be at the top of the list.

Leave a comment below with the language you use, or things you say to reassure your patients, we’d love to hear from you.