read the article and fill out the attached Word Doc
Creating integrative work: A qualitative study of how massage therapists work with existing clients Journal of Bodywork & Movement Therapies (2015) 19, 25e34 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier .com/jbmt QUALITATIVE STUDY Creating integrative work: A qualitative study of how massage therapists work with existing clients Luann Drolc Fortune, PhD, MA, LMT, NCBTMB a,b,*, Glenn M. Hymel, EdD, LMT c a School of Mind-Body Medicine, Saybrook University, San Francisco, CA, USA b Fellow, Institute of Social Innovation, Fielding University, Santa Barbara, CA, USA c Department of Psychology, Loyal University, New Orleans, LA, USA Received 19 December 2013; received in revised form 15 January 2014; accepted 29 January 2014 KEYWORDS Bodywork; Complementary and alternative medicine (CAM); Client-centered; Clinical reasoning; Health care; Holistic; Integrative healthcare; Manual therapy; Qualitative research; Somatic awareness; Therapeutic relationship; Wellness * Corresponding author. 5305 Broad E-mail address: lfortune@saybrook 1360-8592/$ - see front matter ª 201 http://dx.doi.org/10.1016/j.jbmt.201 Summary Introduction: As one of the most often used complementary treatments, massage is increasingly positioned as an essential component of integrative medicine. Recent studies evaluate the clinical efficacy of massage therapy, but few studies explore how massage therapists (MTs) execute their work and exercise clinical reasoning in natural settings. Purpose: To gain foundational knowledge about clinical reasoning and applied knowledge, this study examined how 10 MTs executed an entire session with established clients. Results support translational research design and inform educators. Methods: Ethnomethodology and phenomenology informed the qualitative design. Data were collected by videotaping actual sessions and interviewing the participants immedi- ately afterward while viewing the videos. Computer-aided analysis identified data patterns for thematic interpretation. Results: The MTs shared tacit knowledge that directed their work: a) maintaining a primarily biomechanical focus, b) prerequisite safe touch, c) multitasking not allowed, d) MTs assume physical risk, and e) the work affects multiple bodily systems. The MTs sensed effectiveness experientially by adopting common tactics: a) visualizing the manual engagement points, b) assuming the client controlled the physiological release, and c) educating the client. Within these commonalities, they operationalized their work in complex and singular ways, with the particular client relationship critical to structuring the session and evaluating the outcome. Branch Rd NW, Washington, DC 20015, USA. Tel.:/fax: þ1 202 244 2420. .edu (L.D. Fortune). 4 Elsevier Ltd. All rights reserved. 4.01.005 mailto:
[email protected] http://crossmark.crossref.org/dialog/?doi=10.1016/j.jbmt.2014.01.005&domain=pdf http://dx.doi.org/10.1016/j.jbmt.2014.01.005 www.sciencedirect.com/science/journal/13608592 http://www.elsevier.com/jbmt http://dx.doi.org/10.1016/j.jbmt.2014.01.005 http://dx.doi.org/10.1016/j.jbmt.2014.01.005 26 L.D. Fortune, G.M. Hymel Conclusion: MTs viewed their work primarily as a biomechanical intervention, but under- stood therapeutic massage as serving multiple functions. Process-oriented clinical reasoning mirrored models found in psychotherapy and was informed by experience, intuition, and training, which resulted in an intentionally holistic approach. ª 2014 Elsevier Ltd. All rights reserved. 1 Ranges from 52 to 88%, based on how the survey defines private practitioner. Introduction Massage therapy is used by over 38% of adults in the U.S. (Barnes et al., 2008) and estimated to be a $10 to $11 billion annual industry (American Massage Therapy Association [AMTA] 2012). As one of the most often used complemen- tary treatments, massage is increasingly positioned as an essential component of integrative medicine (Horrigan et al., 2012). Healthcare providers and consumers consider massage therapy an adjunct medical service, resulting in demands for assessments of clinical efficacy (Eisenberg et al., 2002; Walkley, 2004). Consistent with standards in conducting medical science research, clinical trials aim to isolate variables and quantify outcomes (Menard, 2002). Some massage research demonstrates positive effects under specific circumstances, while other studies are deemed flawed and inconsistent (Moyer et al., 2004). There is a dearth of scholarship on clinical reasoning and practice fundamentals, particularly in-depth qualitative studies (LeMoon, 2008). However, research is impacting clinical patterns through market-practice dynamics and increased professionalization (Kahn, 2002; Turner and Hodge, 1970). Massage therapists are increasingly encouraged to adopt evidence-based practices to keep pace with expectations from both consumers and adjunct health care providers. Exploratory investigations could inject practical wisdom into translational research (Hymel, 2010) and support further integration of massage into conventional healthcare. Purpose This article presents original findings that depict the experi- ence of 10massage therapists (MTs) working with established clients. Data were collected by videotaping massage therapy sessions. Immediately afterward, therapist-client dyads viewed the videos to stimulate recall (O’Brien, 1993) during open-ended interviews that elicited the participants’ understanding ofwhat transpired. Thematic analysis, applied here as systematic searches across data sets to identify repeated patterns of meaning (Bentz and Rehorick, 2008; Braun and Clark, 2006), rendered findings that were inter- pretedbasedonpsychology and social science constructs that relate to work (Garfinkel, 1986), therapeutic relationship (Rogers, 1951; Rosenzweig, 1936), and empathetic resonance (Silverberg, 1988) (defined here as an experience of deep empathy that incorporates somatic awareness, emotional transference, and often a transpersonal connection). Methods This qualitative research design was informed by principles from hermeneutic phenomenology (Bentz and Rehorick, 2008) and ethnomethodology (EM) (Gubrium and Holstein, 1997). Phenomenology identifies essential characteristics of lived experience and is appropriate for topics new to empirical inquiry and to fields in transition (Bentz and Shapiro, 1998; van Manen, 1990). In hermeneutic method- ology, the researcher integrates data from multiple sources (Creswell, 2014; van Manen, 1990) and explicitly contrib- utes their perspective to the analysis (Bentz and Rehorick, 2008). EM identifies foundational structure and meaning in social interactions, particularly among workers who share a common vocation (Garfinkel, 1986; Gubrium and Holstein, 1997). This study relied upon EM principlesdabout tacit understandings and commonsense knowledge, for exam- pledthat assume members of a group share fundamental knowledge about how to conduct work (Gubrium and Holstein, 1997). The primary researcher, a practicing massage therapist, collected data and performed the analysis. The secondary investigator, also a massage therapist and industry expert, served as an advisor. The study was approved and supervised by the primary researcher’s Institutional Review Board. All subjects gave written informed consent and are identified by an alias. Everyone recruited completed the study. Convenience sample Ten MTs volunteered based on email recruitment and telephone screening calls. All worked in a metropolitan area in the U. S. Mid-Alantic that mandates MT licensing. Selection criteria required that MTs were: a) actively engaged in private practice, b) licensed in their domain, and c) able to recruit an “established client,” defined as one treated a minimum of 6 times for at least 6 months. Each MT recruited a client for a total of 20 participants (Creswell, 2014). All MTs completed a minimum of 500 hr basic training and passed a national certifying examination, per local licensing requirements (U. S. Bureau of Labor, (2010)). The study compensated MTs at their standard rate; participants received the massage at no cost. The sample size conforms to phenomenological guide- lines stating that 6 to 12 interviews produce data saturation (Guest et al., 2006). In the U.S., the majority1 of MTs work in private practice (AMTA, 2010; American Bodywork and Massage Practitioners [ABMP] 2009; Webb, 2011), thus each MT in this study was self-employed and unsupervised. No other selection criteria were used, nor were the MTs instructed to use any specific style or modality of thera- peutic massage for data collection. Research results are not generalizable (Creswell, 2014) but rather intended to offer insights to practitioners, educators, association leaders and regulators, as well as inform subsequent research. Figure 1 Flow chart of study. Creating integrative work: massage therapists and existing clients 27 Data collection Data collection occurred between December of 2010 and May of 2011 (Fig. 1). All sessions occurred in the typical work setting for each MT, including 5 home-based work- spaces, 4 commercial, 1 client home, and 1 private class- room.2 MTs were instructed to conduct the sessions according to their typical practice. The videotaped therapy sessions ranged from 50 min to 2 h beginning when the client entered the MT’s office until they would normally leave. In addition to table time, all included intake and closure segments per their usual practice. Immediately after the therapy session, the primary researcher, the MT, and the client watched the video. Interviews ranged from 44 min to 1 h 43 min and were conducted using an open-ended format (Creswell, 2014). Participants described the activities as they viewed, pausing the action as needed to align the narration with the video action, and fast-forwarding through repetitive segments or places where participants had no comments. The interviews were audiotaped and transcribed. Analysis Data analysis occurred in two separate processes. The first was adeductive analysis informedbyEMconstructs (Gubrium and Holstein, 1997). The second was hermeneutic and inductive according to phenomenological stages (Moustakas, 1994; Schutz, 1967). The two analyses plus the external re- views served to triangulate the results. Reliability in this study, consistent with established qualitative research methods, is achieved through consistency (Creswell, 2014). A single investigator executed thedata collections andanalysis in a completely transparent framework, contributing to internal consistency. Validitywas achieved throughmember- checking the final report with participants, and the use of an external examiner. In addition, the two analyses produced consistent findings to further triangulate the results. EM based analysis The EM-informed analysis adhered strictly to participants’ empirically based statements. Interview transcripts were scrubbed to eliminate extraneous comments, separated into discrete words or phrases, electronically sorted, and coded line-by-line (La Pelle, 2004). Codes were determined deductively according to pertinent concepts and clustered into primary and secondary themes (Hymel, 2006). Frequency is reported as one criterion that supports the derivation of a theme (Hymel, 2006). Primary themes were then compared to 6 EM principles: tacit assumptions, commonsense knowledge, typifications and accountings, reflexivity, and indexicality (Harper, 2008). Typifications and accountings refer to the process of naming a condition and assessing its characteristics, similar to the medical practice of matching a diagnosis to a prescription. Reflexivity refers to reciprocal reactions between subject 2 The sessions totaled 11 because one pair also participated in the pilot study whose data were included for analysis. Nine of the 10 pairs contributed 1 session to the total data. and environment (Marcus, 1998). Indexicality connotes context or setting (Gubrium and Holstein, 1997). Phenomenological analysis The phenomenological analysis included the researcher’s explicit voice (Bentz and Rehorick, 2008). The researcher re-examined the videos, the audio recordings, field journal notes, and the interview text in its entirety, including researcher comments. In the phenomenological steps known as reduction and imaginative variation (Moustakas, 1994), phrases that revealed essential characteristics about the phenomenon were grouped by