Archive for the ‘Psychological Issues’ Category

My first couple of massage therapy jobs were in spas and health clubs. Although it did not happen often, I would sometimes encounter a client who crossed a line into inappropriate sexual behavior.

Little did I expect to encounter that kind of situation in hospice work.

It was my second session with this patient, a man in his 40s with metastatic cancer and intractable lower back pain. The week before, I had spent a half hour massaging his back; the massage treated his pain so effectively that he announced, “this is better than any medicine they could give me.” He responded so well to the massage that I even taught his wife, who was in the room the entire time, some basic techniques she could use.

When I arrived on the unit for the second visit, the nurse warned me that the patient was starting to act a little “weird.” He was asking staff to run errands for him, and seemed to be struggling with some serious psychological issues that might be contributing to his intractable pain. I was prepared to say no if he asked me to go to the ATM for him, but I did not feel it necessary to raise my guard any higher.

The patient turned onto his side so I could massage his lower back, as I had the previous week. Within a few minutes he had started moaning. Since he had reported being free of pain before I started, I became concerned.

“Is this hurting you?” I asked. “A little,” he replied. I cautioned him that if his massage was causing pain, we would need to stop. He said it was okay and that I should keep going.

Not only did the moaning continue, but he started squirming around. Still, I suspected nothing unusual, but I became worried that he could no longer tolerate massage. I was concentrating on the sounds and movements he was making, and then I noticed that most of the motion was coming from his lower body. He was holding his legs tightly together and rocking his hips back and forth, rhythmically, and side to side.

Suddenly it occurred to me that the moaning was not pain at all, but pleasure. We all want our patients to experience pleasure while having a massage, but he was turning the pleasure into a sexual experience. Once I recognized this, I calmly announced that the massage was over.

I didn’t make a big deal out of it, and neither did he. But I did report it to the nurse, who was not at all surprised, given his other inappropriate behaviors. Due to what I had witnessed, along with the other behaviours, she arranged for a consultation with a psychiatric nurse; his meds ended up being adjusted and the inappropriate behavior stopped.

This patient’s sexual acting-out was linked to unresolved anxiety. Massage therapists working in medical settings need to report unusual behavior, even if it makes us uncomfortable, in order to help our patients get the care they need.

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Watching people die, day after day, makes for a challenging job. When patients die of age-related conditions and I am able to use massage therapy to help make them comfortable, the job does not seem as hard. But working with young patients who have devastating illnesses can be overwhelming.

Most people who work in this field share a basic personality characteristic, in that we are all, at heart, caregivers. Working alongside others who are driven by the need to care for people inspires me on a daily basis. Sometimes that need can become unhealthy. This is when boundary maintenance counts the most.

Joe was a patient in his mid-30s with an aggressive cancer. His wife was pregnant with their second child. When I met him he was still conscious, but very weak, and spent his time in the hospital surrounded by family and friends. He was clearly going to die soon.

I entered the room and introduced myself, explaining that I was offering massages for family members. At first, no one wanted to take me up on it. Finally Matt, Joe’s brother-in-law, agreed. I brought him out of the room to a semi-private area and invited him to get into the massage chair. During the session he shared a little bit about his heartbreak at seeing Joe so sick. I felt my heart breaking along with his.

Matt helped me convince Joe’s mom and sister to come and get massages. His mom was stoic but his sister sobbed the entire time. As someone who has one, precious younger brother, I found myself identifying with her. I felt a deep terror creeping into me at the idea of facing the loss of my brother. At that point my boundaries began to strain and crack.

I went back into the room to offer Joe his own massage. At first he said he wasn’t up to it, because he thought it meant having to reposition himself and he was too tired to move. I explained that he could stay right where he was and I offered to just massage his feet. He agreed, and I got to work.

Throughout the session, Joe was watching TV and playing with his PDA. I’ve experienced this before with young patients who are dying: the need to stay plugged in and connected seems to be a way to cling to life. His mother came in and I showed her what I was doing. She told me that she also massaged Joe’s legs, and I encouraged her to do so whenever she could.

When I finished, I thanked Joe and his mom, and went about seeing a few other patients. I was getting ready to leave for the day when Joe’s wife arrived. I heard the nurse ask her if she wanted a massage, and she said she really needed it, but had to eat something first. I realized that I might end up having to stay late, and wrestled with my boundaries once more.

How, I wondered, could I take care of this woman and also take care of myself? I had an important meeting that afternoon and I couldn’t be late. I gave her 15 minutes, then went to check in. Although my instincts were calling me to put my own needs aside, I forced myself to let her know that I wanted to work with her but I had to leave soon. I was able to work with her and still leave with enough time to get to my meeting.

Most of the time I visit this inpatient hospice unit once a week, on Wednesdays. That week, however, I had scheduled time there on Friday to train one of my volunteer massage therapists. Because I had been so emotionally involved with his case the last time I was there, the first person I went to see was Joe.

Once again, he only wanted his legs and feet massaged. He told me that his mom and wife had also been massaging his feet and legs. He was still weak, and seemed more tired and anxious. His mother later told me that she had been up with him all night as he processed the information that his death was imminent. He was scared, she said, and she had tried to comfort him. I tried to imagine what that must have been like, and again my boundaries began to give way.

When I got home from work that night, I broke down in tears over a petty disagreement with my husband. I needed to show him, and to show myself, that this case had gotten to me, that the cumulative effect of so much death and dying sometimes overwhelmed me. It was the first time in nearly a year on the job that I had ever cried about it.

During the weekend I found myself thinking of Joe and his family from time to time, as much as I tried to let it go. When Monday came along I thought I might end up stopping by the inpatient unit to see them after spending the morning in the office. As the day went on, I tried to get clarity about the situation. Joe was being cared for by nurses, doctors, social workers, family, and friends. His mother and wife were massaging him. Did this family really need me, or did I need them? Was I planning to make a special trip because I needed to feel important, to prove my dedication to my work?

I confessed my ambivalence about the plan to my husband and told him I thought I might be setting bad boundaries. He said he agreed, and reminded me that I should try to treat all patients the same. In the end, I chose to stay at the office and finish the important program development work that I had set out to do that day.

I know that some cases will affect me more than others. I can’t control that. I can only observe my emotions, find a way to let them out, and try not to lose myself in the process.

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A geriatric care manager once referred a 90-year-old man to me for massage. He was a retired surgeon, recently widowed, who was experiencing age-related physical problems but whose mind was still perfectly sharp. His care manager told me that he was rather depressed, and she thought that massage might help with his psychological issues. She warned me that he’d never had any kind of massage therapy or other body work, and that, as a surgeon, he is skeptical of “alternative medicine.”

When I met Dr. P., it was not for a massage, but for an interview. Along with his care manager, we met to discuss his condition and how massage might help. He agreed to give it three sessions, which we were to start the next week.

During the first session he had a difficult time positioning himself comfortably on the table. He was very nervous about falling off the table when it was time to turn over, so I made a point to stand so that my body would block any chance of him falling, reassuring him that he was safe.  He asked me a great deal of questions about what I was doing and why. By the end of the session, though, he seemed to have let go a little bit and he admitted to enjoying the massage.

The next two sessions proceeded similarly; he would ask me questions about massage, asking me at one point: “under what diagnosis are you treating me?” During these sessions he had shared a bit more about his mental state, and I realized that, in his case, the primary benefit of the massage would likely be psychological.

I explained to him that the massage would help with his circulation and stiffness. In addition, I responded, “You’ve reported to me that you have been feeling depressed. Massage is known to help relieve depression and anxiety. Fundamentally, I am here to help you feel better.” I felt I was being honest and forthright with this man, who was showing a kind of vulnerability that must have been very difficult. At that, he stopped asking questions and seemed ready to receive what I had to offer.

At the end of the third session I asked him how he would like to proceed. He responded, “I’d like to try three more.” In the six years I’d been in practice, this was the first time I had encountered this kind of extended trial period. On the one hand, it felt good to have “won him over” in part. On the other hand, I felt like I wasn’t sure what more I needed to prove. Clearly he had some issues with committing to this course of treatment, but I wasn’t getting all the information from him.

The second set of sessions went much more smoothly. Dr. P. still seemed anxious about falling but I was getting the sense that he was beginning to trust that I would not let that happen. He also showed a marked change in affect at the end of his sessions: he came off the table looking relaxed and content, instead of tired and anxious as he had seemed when I arrived. While session six was taking place, his son, J, came into the apartment. At the end of the session J told me how glad he was that his dad was having these massages, and that he would lobby Dr. P. to continue them.

When it was time to discuss the future of his massage treatments, Dr. P. asked J to leave the room. He then told me that he had decided to suspend his massages. “I don’t think it’s good for me psychologically to continue.” I paused and tried to digest that information. After all, the main purpose of the massages, from a treatment standpoint, had been to relieve his psychological symptoms. At the end of each session he seemed like he was feeling better. What was going on?

Dr. P. reassured me that I’d done a great job, but he reiterated that he didn’t feel like it was good for him, psychologically, to continue. He admitted that he had some issues that were getting in the way, but he declined to elaborate. He promised to keep in touch should his circumstances change. I thanked him for giving massage a thorough trial, shook his hand, and said goodbye.

As I left the building it occurred to me that massage therapy might have been too intimate an experience for an elderly widower who had never received touch from any woman other than his wife. The nurturing touch I provided might have triggered his grief on a deeper level. Or he may have become sexually attracted to me, and that may have been uncomfortable for him. Without a detailed explanation I can only guess, but his care manager seemed to agree with my interpretation.

Until meeting Dr. P. I’d always thought that I would want to have massages at the later stages of my life. Even though massage is familiar and comfortable for me, I wonder how it would feel to be grieving the loss of my spouse and to have someone else touching me. I can honestly say now I don’t know the answer, but that maybe, when one is faced with such a profound loss, massage might become a trigger for grief rather than a comfort.

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Just before my first session with Liz, Teresa, her home health aide, warned me that she could be a bit “moody.” I wasn’t sure what that meant exactly but I had known my share of moody patients. One day they might swear at me, another day tell me that they loved me. I was trying to be ready for anything Liz might throw at me.

We entered her room and she was in bed, with her eyes closed. “Liz,” said Teresa, “This is Eva. She’s here to give you a massage.”

Liz opened her eyes slightly, glanced at me, and closed them again. “Do whatever you want with me.” Not exactly an enthusiastic endorsement of the therapy she was about to receive, but I took it as consent nonetheless.

She spent the next 20 minutes pretending to be asleep while I massaged her legs and feet.¬†Finally, as I was massaging her shoulder, I decided to try to end her game of possum. “Liz, how does this feel?”

She opened her eyes and stared into mine. “You’re so pretty,” she exclaimed. She closed her eyes again and kept them closed for the rest of the session, but I understood that, by complimenting me, she was trying to say that she was enjoying her massage.

The next week, when I went to see her again, I got some more context for her behavior. It turns out Liz is not merely “moody,” but she suffers from bipolar disorder. Although she is being treated with medication, her moods still vary widely.

During our session she started out resentful, then she began to trust me and relax. When her massage was over, I asked her if I could come back the next week. “Definitely,” she said. My challenge will be to arrive at the next session free of any expectations and prepared to have to earn her trust again.

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