Transference is one of the most important concepts to understand for a massage therapist but the least understood and talked about. It is usually covered in a few hour workshop in massage school. Transference is a very complex phenomenon that comes from the psychology profession. The reason that it is so important to understand is the fact that the process of transference is actually what can lead a person to becoming more aware of their thoughts and issues. Transference is what heals.
Ben Benjamin author of the book “The Ethics of Touch” defines transference as this:
Clients defer to the practitioner’s judgment because they desire to be helped by an authority figure that possesses greater knowledge, healing ability and, therefore, power.
Since a power differential exists in any health care relationship, the client may be inclined to respond to the practitioner as he or she would other authority figures, and in doing so, may recreate elements of similar past relationships. This situation is known as transference, a normal, unconscious phenomenon that appears during a therapeutic process. Professional helping relationships usually have a strong transference element in which the parent-child relationship is unconsciously re-established. In transference, unresolved needs, feelings and issues from childhood are transferred onto the helper.
Elliott Greene author of the book “The Psychology of the Body” writes this:
Transference is the displacement or transfer of feeling, thoughts, and behaviors originally related to a significant person, such as a parent, onto someone else, such as the massage therapist. It is a common reaction of clients to their therapists. A bit of transference happens in most relationships in which there is feeling present. Usually, transference-related feelings were formed in the past, so it could be said that these feelings transfer from the past to the present. In transference then, the client relates to the therapist and present moment as if the therapist were the significant person. In this sense, transference is a projection of the internal drama of the client, and the therapist is assigned a particularly important role and script.”
Nina McIntosh in her book “The Educated Heart” says this about Transference.
“Transference may sound complex and unusual, but it’s actually part of our everyday life even outside of our offices. It’s normal for any of us to bring the past into our present relationship. In fact it happens all the time. They are magnified ina manual therapy session because of the intimacy of the setting, the clients altered state and the way that the practitioner/client roles mimic those of the parent/child.”"Transference isn’t a rational process.
Terrie Yardly-Nohr in her book “Ethics for Massage Therapists” says this:
“The very nature of the therapeutic relationship allows transference to happen easily. Bodywork can trigger a variety of emotions from clients such as anger, frustration, sadness, fear, or joy. These feelings are generally the result of some emotion the client felt in the past towards another person.”
Cidalia Paiva in her book “Keeping the Professional Promise” says this:
“Transference refers to those situations where the patient projects onto the therapist old feelings or attitudes they had about significant people in their past, often parental figures. Transference is often referred to as ‘the unreal relationship in therapy’. The roots of transference are most often found in early childhood, and it constitutes a repetition of past conflicts with significant people in our lives.
So what is transference then?
Simply put, transference happens when there is difference in authority that resembles the parent-child relationship. The client who comes to a massage therapist receives the nurturing that they never received as a child and puts the massage therapist on a pedestal. The nurturing touch brings out the old feelings and emotions that were repressed or suppressed in early childhood. The client unconsciously begins to see the massage therapist as the nurturing parent and it can bring up feelings of attachment that were not resolved growing up. It is when the client unconsciously thinks that the massage therapist is their mother or father or other significant caretaker. Note the word - UNCONSCIOUS.
Attachment is what happens between a mother and child that allows the child to grow and build self esteem. The infant knows learns about themselves through touch. There are various stages of attachment that occur in child development where the infant feels like they are one with the mother. (And of course they once were in eutero.) As a child grows they learn that they are separate from the mother. This is where things often go astray. If a secure attachment is not formed in their early part of life, they will have life long challenges that result from that.
Massage and nurturing touch re-enacts the process of development. I actually think this is also why spa treatments are so popular with the use of healing waters and body wraps. Getting regular massage and developing a relationship with a massage therapist in which the client feels nurtured and cared for as if they were receiving it from their mothers can help heal the grief of not ever getting those early childhood needs met.
Transference is really important yet difficult to understand. The best way to understand it is to experience it. You may or may not have had some of these feelings arise when you were getting a massage from someone:
Feeling like you don’t want the massage to ever end
Not wanting to leave the office
Seeing the massage therapist outside of the office and wanting to follow them where ever they go.
Or from the other aspect seeing it in your clients:
bringing you flowers or special gifts
hearing about people’s personal problems
being asked to make exceptions in scheduling and payment options.
inviting you out socially as a friend
asking you out on a date or making other advances on you.
Or if you ever worked with a psychologist or mental health professional in therapy, you can come to learn more about transference from seeing your own. Becoming aware of your projections in a therapy setting can be a painful experience. It is a matter of getting a look at your unconscious thoughts through relationship. It can be a very eye-opening process and really lasts a lifetime.
While some of these things may just seem like normal things, it is difficult to know the difference. You probably won’t know the difference.
What you can do is create a code of ethics and a set of policies and procedures for your practice that will help you make proper decisions in any situation. It is having boundaries that teach people when they are in transference that you are separate from them is what will allow the person to heal and build self esteem.
The other thing about transference is that it not only occurs in these helping types of relationships but almost all relationships. Friendships, significant others, family members and the person who checks you out at the grocery store who seems to ‘look just like your mother”.
Reading and learning everything you can about transference can also help. These are some of my favorite books:
“A New Earth” is Eckhart Tolle’s book that is now being promoted by Oprah. They are teamed up and offering a free online class that starts on Monday, March 3rd.
When I read “A New Earth” a few years ago when it first came out, I couldn’t put the book down and it became an inspiration for me to continue writing about such things despite many massage therapists not quite getting it that they can build a massage practice using similar principles of becoming more authentic by being present.
So many massage therapists are caught up in knowing more, learning more and doing more and the client usually gets caught in the middle. Part of the problem is how we are trained to ‘fix’ in massage school and our new role with the medical profession requires us to do it even more by reporting on improvements and having treatment stopped when function returns rather than when pain is resolved.
I was at a spa a few weeks ago and overheard a massage therapist in the hallway talking to someone who had just come out of the massage room and telling her how stressed the client was and how much more work the person needed. I could feel the tension in the air. The person who had just gotten a massage was being berated for how much stress they had rather than being honored for who they are. Now I am sure I am reading into things because I don’t know the whole story but it is examples like these or other stories of massage therapists saying things like “I just need to fix their pain” or ‘it is my duty to tell people about mercury poisoning and other possibilities that could be causing their health issues or I don’t feel like I am doing my job.
What “A New Earth” talks about is our roles that we take on to protect ourselves and our egos from suffering and how that creates more. But it is suffering that can free us from our pain and unhappy lives.
The ego is not something that is bad or that we need to get rid of. He says “It isn’t wrong, it is just unconscious” We are alive today because our egos are invested in ourselves. Tolle says that ‘Our egos are just are false self. It is the unconscious part of ourself.” The way to become more conscious is to become more present and aware of our egos.
But awakening from being unconscious is a little like thawing out from having frost bite - it is painful as we start to regain feeling.
A common thing that I often hear from massage therapist that I work with is about how they don’t feel like they know enough to help people. Tolle says this is actually the best place to be. When you can admit you don’t know enough you can realize that you are enough just as you are.
Another way to become aware of your ego is to become aware of what you are feeling in your body. As massage therapists we have the unique opportunity to help people feel their bodies more. ( I actually think this is more important than any specific massage technique or method.) Tolle says “Body awareness not only anchors you in the present moment, it is a doorway out of the prison that is the ego. It also strengthens the immune system and the body’s ability to heal.”
I also so often see massage therapists who become their role thinking that they are the only ones that can help someone and that massage is the end all answer to the worlds problems. I used to think like that when I first started out saying things like ‘if everyone got a massage once a week there would be world peace” (well there might be!) I also hear them complaining about things like working for chiropractors who take advantage of them or not having enough clients because of the economy or whatever the complaint is at the moment. Tolle says that “Complaining is one of the ego’s favorite ways of strengthening itself”. It makes us feel better to complain. And clients come into us complaining about this or that, this work situation or family situation and they come in with their pain and their attachment to their pain.
He talks about roles and how we take on roles to get the needs of the ego met.
How can we as massage therapists learn to become aware of our roles and learn to just be as a massage therapist?
How can we learn to serve and become more present with ourselves and with our clients to help make “A New Earth?”
One common issue that I always get emails about or see comments on my Yahoo Group or other groups is about massage therapists working for chiropractors. I actually have already started to address this issue in another post but another thing keeps popping up - that of billing insurance companies and what the massage therapist gets paid by the chiropractor.
When a chiropractor (or even a massage therapist) bills an insurance company for massage services, one of the common practices you will see is one of overbilling the insurance company - the person coming in and paying cash will be charged something like $60 and if the insurance company will be charged $220 or something above and beyond the charges for the person paying cash. The thing about this is there is some concern over whether it is actually legal or not to do that and it may vary state to state but as far as I know after attending a workshop put on by two attorneys for AMTA- WA last year, it is illegal to charge more for your services when you bill an insurance company. You can bill a fee that would be equal to what you have to pay a billing person to actually do the paperwork and collections which I would think a normal fee would not be much more than $20 and that is guess high. The thing is that insurance companies will and do pay the higher fees and also do not really have a system for catching such discrepancies.
Here in WA there was actually a law passed awhile ago that limited the amount a chiropractor could charge to the insurance companies. ( I think this is it but am not 100% sure so let me know.)
So then you have a chiropractor charging high rates to clients like $200 or more for a massage and the client is left paying a high copay if it based on a percentage of the fee and the massage therapist is usually paid between $25-$50 an hour. Where does all the money go? To billing? I don’t think so. The chiropractors are getting rich off of the massage therapists work.
On the other hand you also have to take into consideration that the chiropractor is probably doing all of the marketing and work to get that client. That is worth something I think - but is it worth $150 a session or more?
The other thing that seems to be going on is that chiropractors think that they need to be the boss and tell the massage therapist what to do and how to do it. Well that is fine if they are an employee - you can tell an employee what to do but it is different if that person is a sub-contractor. Chiropractors also are only trained in chiropractic methods and some are not informed of what massage can do. They also can seem to be overly protective of clients and not refer freely to massage for various reasons -like I had a client who had so much inflammation going on the chiropractor thought it would be best to wait when massage is one of the best things to deal with inflammation.
The thing is that there are chiropractors out there who are mainly interested in their patients health and will hire a massage therapist to participate in that healing process.
Part of the problem is also that massage therapists are not informed when they take a position with a chiropractor and end up complaining about something that they unknowingly agreed to.
Some things to ask a chiropractor when interviewing for a job at a chiropractors office are:
How much do you bill the insurance company for the massage I will be doing?
How long are the sessions I will be doing with a client?
Will I have time between sessions for self care and client follow up?
Is it OK to tell clients to stretch and so other self care things?
Is it OK to tell clients about other therapies that might work better?
Do you give clients the option of paying cash and receiving a receipt so that they can bill their insurance company later and be reimbursed?
What is your philosophy on healing and chiropractic?
How do you see massage fitting into your practice?
So often massage therapists are so excited about the possibility of getting a job at a chiropractors office they forget to stop and figure out what it is that they really want and find out if the chiropractor is somewhere where they can fulfill their dreams. The best way to actually know about a chiropractor is to get treated by them first as a client. If you wouldn’t go to that chiropractor or send your mother to them why would you want to work for them?
When you make an uniformed decision you often end up complaining and blaming the chiropractor. If you get stuck working in one of these offices, while you can try to voice your needs and work with that chiropractor if they are open for it. If not just learn more about what you do want and learn to focus on what you do want rather than focusing on what you don’t want by staying in a bad situation.
While it is always easier said than done - better now than later.
It is possible to find a good job that pays you well and has a respectable chiropractor as the owner who is willing to work for you.
And what about someday having massage clinics that hire chiropractors???
One of the big issues in the massage profession has to do with the number of hours of education that one needs to become a professional, licensed massage therapist. While many states have adopted 500 hours of training as the basic amount of hours of massage school, there doesn’t seem to be any proof of what is really needed.
There seems to be two schools and probably many in between but the two basic versions are:
100 hours of basic massage training focusing on giving massage
500+ hours of extensive training in anatomy, physiology, orthopedic massage or some advanced systems of massage
When I went to massage school back in 1987, the basic requirements in WA State were 250 hours of massage school which did include anatomy, physiology, pathology and treatment massage for working with various basic conditions such as sprains/strains, headaches and common conditions. I was in the last group that was let in under those requirements of 250 hours. The number of hours of training that was required was going up to 500 hour of massage school where it stands now. I was very glad to be in the last class at 250 hours because I didn’t want to spend the extra time and money. The reasons for the increase in the number of hours of training was just an arbitrary thing that the state board seemed to come up with at the time. The massage schools were actually requesting it for no other reason than that they could make more money by getting students to stay longer. Keith Grant in his white paper on “Issues in Massage Governance” which he wrote in 2002 described this situation exactly. I have spoken about it here and really recommend that anyone who is interested in the future of the massage profession read it. It is quite lengthy and I have summarized this before on the blog.
Basically what he says is the same thing - that 100 hours of massage school is enough training to do massage and become a massage therapist.
People who think differently seem to have such an extreme reaction to this statement but don’t seem to have any proof or references to back themselves up other than statements like:
People can’t do medical massage with only 100 hours of training
People can’t give a good massage with only 100 hours of training
People need much more anatomy and physiology than could be fit into a 100 hour training class
There is a whole other controversy over the issue of medical massage. Does medical massage require extra training or is it just the ability to be able to bill an insurance company for massage services which only requires knowing what paperwork is needed and how to show improvement in a massage session. Anyone who can do basic massage and can create a change in a muscle can show improvement in a condition.
I guess I must have my own personal definition of medical massage because I have been doing it since 1989 when I started my practice with 250 hours of massage school. From the very beginning I was able to bill insurance companies and be paid and was also very successful in working with clients. That doesn’t mean I didn’t get more training through the 20 years of being a massage therapist.
I am not saying that having more training is not good and that all of those years and thousands of dollars that are spent are not worthwhile. I am not saying that more education can improve your chances of being successful.
What I am saying that anyone can be taught to do a basic massage in 100 hours of training. How successful they will be depends on them, just as it does with someone with 1000 hours of training. There are so many massage therapists that do have training and still are not successful. ABMP reports that about 50,000 massage therapists leave the field each year and though they don’t say why, I would guess that most are due to being unable to make a living whether that involves getting injured or sick or what.
The thing is that we really don’t know what is required as far as education in creating a massage therapist who can be effective and successful. As a profession we have not created any studies that show that 100 hours or that 1000 hours is the best.
I don’t really know what the answer is to the issue but am really open to hearing about solutions such as studies that could help create more successful massage therapists. Keith Grant’s solution is apprenticeship programs which seem to be put on the wayside to make room for the big massage school conglomerates such as Cortiva, Corinthian Colleges and the like. And with the increase in massage franchises that only pay massage therapists $15 an hour, I just have to wonder what exactly is going on.
Since many have not been exposed much to peer supervision or peer supervision groups, I am going to be writing as much as I can about them. There are many forms of peer supervision. You can work one on one with an experienced therapist who is trained in peer supervision or you can work in a group setting with the peer supervisor as the facilitator. This type of sessions that meet with a individual peer supervisor includes a fee for service.
Once you understand the concepts of peer supervision and how to work in a peer supervision group, you can start your own group by inviting your fellow massage therapists in your neighborhood or just others that you know. You don’t have to pay for this kind of regular meeting unless there is a fee for the meeting room. You can hire a peer supervisor to come in for specific things like learning to bill for insurance or to look more deeply at your helping issues or whatever is needed by the group.
The basic things to understand are things like this isn’t therapy. It isn’t one person telling another what to do. It is learning to listen and provide empathy in order for others to grow on their own in a supportive group. It is basically what happens on your massage table with clients when you remain present with them and learn to become aware of when you are fixing others on a grander scale. I have written a few pages on my website www.massagepracticebuilder.com, about how to set up and participate in a peer supervision group that you can read yourself, but to really learn how to work in a peer group it is necessary to work with an experienced massage peer supervisor who has at least 5 years experience in doing massage and preferably the same amount of time participating in peer supervision themselves.
One of my basic rules which I have actually adopted from Parker Palmer’s groups which he calls ‘circles of trust’ is “No fixing, no saving, no setting each other straight.” When I inform a new group member of this they often are left wondering what they are going to say or do in a peer supervision group.
A peer supervision group topics is really determined by the participants and their needs. The first few minutes of the group are spent checking in with each person to see how much time they would like to have to speak in that session. While there may not be enough time for everyone to speak, the others often learn just as much if not more from the person sharing their issue or story. ( an in person peer group size is usually from 3-8 people.)
After starting and running my own unofficial and free of charge online peer supervision group (massage_practice_builder at Yahoo Groups ) in the form of an online discussion group (which I started in about 2000 and used for sending out my newsletter and now is open discussions ), I have realized that there are so many lurkers and the group is dominated by a few people who like to speak out that so many are missing out that I have decided to start a private online peer supervision group where participation will be mandatory (well to a certain extent.) The other thing I am seeing from getting regular requests for email consultations is that there are many massage therapists out there who are in rural areas and don’t have a network of support so again the online peer supervision group will fill that need. Having a smaller group will allow participants to get to know each other better and be able to talk about the deeper issues that surround their practice. I will be facilitating the group and also writing a regular newsletter to stimulate conversation. I will be charging a small fee for my time and 20 years experience as a massage therapist and 5 years in peer supervision. To find out more and apply to join please see my website www.massagepracticebuilder.com .
