The Thinking Practitioner Podcast:
Episode 66: Beyond "It Depends" Oncology Massage (with Janet Penny, Rebecca Sturgeon, and Loretta Luchau) 

Til Luchau:

Hi. This is Til, and The Thinking Practitioner podcast is supported by ABMP, Associated Body Work, and Massage Professionals. ABMP membership gives professional practitioners, like you, a package, including individual liability insurance, free continuing education, quick reference apps, legislative advocacy, and much more. ABMP's CE courses, podcast, and Massage and Body Work Magazine always feature expert voices and new perspectives in the profession, including Whitney Lowe, my cohost, who is not here today, and myself, Til Luchau. Thinking Practitioner listeners can save by joining ABMP at abmp.com/thinking.

Today's episode has a very personal dimension for me. About nine years ago, when Loretta Carridan Luchau, my wife and partner of 38 years, was diagnosed with breast cancer, it was really a shock for both of us, obviously, and that journey of being with her through her cancer journey has catalyzed a lot of learning in a lot of ways for me professionally and personally.

One of those was that as her live-in body worker, I had to really retool the way that I did my hands-on work with her. I really had to learn how to work with her differently in the different types of treatment she was going through. Nine years later, she's been through three surgeries, two rounds of radiation. She's just finishing her second round of chemotherapy and about to start a third round of radiation. She's also an accomplished body worker herself, and I've been lucky enough to have her as my live-in body worker when the time is right for that, and I'm lucky enough to have her along with some other guests on today's podcast as a guest.

Hello, Loretta. Thanks for joining us today.

Loretta Carridan:

Yeah.

Til Luchau:

Thanks for being here. I really wanted you in this conversation because as I had to do the retooling that I mentioned having to recalibrate what I was doing as a body worker with you, your input was so crucial to be able to have your guidance. Then in this most recent round of treatments you've been going through, I realized at some point I'm just such a learner, a beginner at this that I really want some more input, more ideas, more help, and I'd done some research and reading early on, but went back, hit the books again and came up with oncology massage and integrative approach to cancer care or at the book, it came, and I realized it's published by Handspring Publishing, whom I also published a book for. So I didn't even realize that. So I thought, "Wow, why don't I talk to the authors, Janet Penny and Rebecca Sturgeon, about this whole journey that I'm on and see if there's anything useful for other people as well.

So Janet Penny and Rebecca Sturgeon, welcome very much. Janet, let's start with you if we could. You are a registered massage therapist. Thanks for being here today. Anything else you can tell us about yourself?

Janet Penny:

Absolutely. I've been a registered massage therapist in Ottawa, Canada for about 15 years. It took me an excruciating seven or eight years to complete the training, which is usually two or three years here in Ontario, but a mix of children being born and parents dying, it took up a lot of time. So it took me forever to complete the program, and when I finally did, I didn't even have a clue if I still liked massage or not.

So there I was newly registered and started working and, fortunately, found that I absolutely love it, and I have never tired of it. About seven or eight years ago, I got the opportunity to work at an integrated cancer center here in Ottawa, which was really one of its kind at the time. There, I got embedded in integrative cancer care and really started to understand not only what massage therapists could bring to people living with cancer, but what naturopath and traditional Chinese medicine practitioners, acupuncture, yoga therapy, on and on and on together could help really support the health and the healing of people living with cancer. A few years into working there, I got the opportunity to work on the book with Rebecca, Oncology Massage, and the rest is history at this point.

Til Luchau:

I'm so pleased that you accepted my invitation and can talk me through these things.

Janet Penny:

I should be here.

Til Luchau:

Yeah. Rebecca, I first met you through your work with Healwell as their Education Director. You're also a massage therapist, huh?

Rebecca Sturgeon:

Yes.

Til Luchau:

What else do you want us to know about you?

Rebecca Sturgeon:

Well, as you said, I'm the Education Director for Healwell, and also the producer of Healwell's podcast. So it's nice to have this podcast trade with you today. I started oncology massage as an escape from my spa job. We were given the opportunity to take the training and work somewhere that was not the spa, which I thought was amazing because I'm not suited for spa work. Never thought that it would be the thing that I ended up loving the most, and through a various circuitous journey, started teaching oncology massage, continuing education first for an organization called Greet The Day, which is based in California, and then for Healwell, and eventually became Healwell's Education Director, and through that, got the opportunity to work with Janet on this book and to just come in when the book proposal had already been written and help with this project. So in addition to my work with Healwell, I'm also a writer in other genres and I'm very grateful to be here today.

Til Luchau:

Grateful that you're with us. You're both educators, you're both writers, and probably this idea for me came from a moment where I'm just thinking, "Okay. I could just really use some help and support here in figuring this out." So it came from a personal place, but then as I start to expand it and think, "How can we have this conversation here in this format and ask?" Really, the main question is, what do massage or manual therapists need to know about working with people with cancer and cancer treatment?

As we lead into that, I just want to acknowledge that you, as educators, I don't know if you feel this way about it, but when people ask me that kind of question about things that I teach, I always have to pause for a moment because the answer is always, "Well, get some training, of course, and get a lot of training," and to think that maybe in an hour podcast we could even do something that was useful, important, and responsible is maybe a tall order.

Yet, nonetheless, I want to try with the full acknowledgement of that, that there's a lot, this is such a big field and I appreciate that the more I look into it, that I really understand that, and I imagine that a lot of the answers are going to be lead ends to much bigger conversations.

Rebecca Sturgeon:

Well, yeah, of course. I mean, we have a joke at Healwell, but it's actually true that the answer to every question is it depends.

Til Luchau:

Yeah.

Rebecca Sturgeon:

So the answer to that question is, "It depends."

Til Luchau:

You're right. It depends. Well, depend or not, still my hope is to, again, come away with some pearls for myself but also just help the listeners with some ideas or tools or awarenesses that will help them when they have someone come to them that's living with cancer and cancer treatment.

Rebecca Sturgeon:

Yeah.

Til Luchau:

What would you say? What are some of the essential things that we need to know as practitioners?

Rebecca Sturgeon:

You need to know what you don't know personally.

Til Luchau:

You need to know what you don't know. Yeah.

Rebecca Sturgeon:

Yeah, and hold what you don't know. You need to know how and when to ask questions. I mean, obviously, there's information, and as you acknowledged, Til, it's more than we can cover in an hour conversation, but we've said before, and I know I said this to Janet so many times, she probably wanted to punch me through Skype, but our book is really about critical thinking, and oncology massage is really about critical thinking, more than almost anything else. What would you add, Janet?

Janet Penny:

Critical thinking, for sure, and when I'm offering short webinars on this subject, I always want to give people a strong foundation because when a client comes in, they can come in with emotional complexity and very complex signs and symptoms. So how do we take all that information in a short period of time and give a treatment that's at least safe, if not safe, and effective for what they're bringing in and hoping to have worked on.

So we use critical thinking, but we also want to have a fairly broad knowledge of biomedical cancer treatments and how they impact the body, especially the soft tissues, which is what we work with. We want to really look at the basic oncology massage principles of pressure adaptation, the site that you work on, the duration of the treatment, and the duration of time you spend on a given area of the body, as well as positioning.

We want to always think three-dimensionally because cancer treatments have an impact throughout the entire body. If you think of radiation treatment, it not only has its entry point, but its exit point as well, and it impacts everything in between. So we need to be thinking beyond just the skin and the muscles that we're feeling under our hands and think about the blood vessels and the lymphatic vessels and the organs that are underneath that and how they might have been impacted by the radiation and how that might impact some of the signs and symptoms that the person's bringing in.

Finally, we can use the stages of healing as a guide for our treatment. So if somebody's just had surgery and it's a few weeks after the surgery, that stage of healing, it's too early to work directly on the area that's had the incision. So we want to make sure that we're always respecting and supporting the body as it heals.

Til Luchau:

Okay. That's a great outline, and that's a good framework for a discussion. So where do you want to start? What's the most important thing to unpack there?

Janet Penny:

Oh, tough question. So something I came across recently, I get a research sent to me routinely and this was a research study called Manual Therapy for Patients with Radiation-Associated Trismus After Head and Neck Cancer.

Til Luchau:

Trismus?

Janet Penny:

Yeah, so the difficulty opening the jaw, which is often impacted by the radiation treatment to the head and the neck. I didn't want to pay the whatever amount to read the article. So I contacted one of the lead authors and asked if she would send it to me. So we started a dialogue and she, her name is Holly McMillan, and she's given me permission to use her name when I talk about this. She's a speech language pathologist and a certified lymphedema therapist at MD Anderson Cancer Center.

This is what she wrote to me in one of her emails. She said that after all of her education, she went back to school to obtain her massage license because she thinks it plays a critical role in cancer recovery, and she can't remember how to treat a patient without some sort of massage therapy intervention.

So I love this interchange for a whole bunch of reasons. One is the incredible work and the detail that was in the study in terms of supporting manual therapy dealing with radiation trismus after head and neck cancer treatment, but also the fact that as a researcher and a speech language pathologist, she's truly is integrative for us, and she brings a perspective that we can't have as massage therapists. So yeah, I guess-

Til Luchau:

You're saying a couple of things. You're saying, one, we got to be humble. We got to realize even when we looked at everything, there's still more to know.

Janet Penny:

Yes.

Til Luchau:

You're also saying there's a role for massage or manual therapy in all kinds of treatment or all kinds of recovery processes from these treatments.

Janet Penny:

Very much. She was very affirming of that.

Til Luchau:

Yeah. That's great. Okay. So how about pressure? What about pressure? You listed it as one of the things that were important to talk about.

Rebecca Sturgeon:

Absolutely.

Til Luchau:

You mentioned Tracy Walton's pressure scale.

Rebecca Sturgeon:

Yes.

Til Luchau:

What can you tell us about that is important for us to know?

Rebecca Sturgeon:

Well, it's so vitally important, and we're so grateful, eternally grateful to Tracy Walton for allowing us to use her pressure scale because it is, unlike other ways that manual therapists describe the pressure they're using, it is an objective reproducible scale that is based on which tissues you are touching and how your body is approaching your client or patient's body.

It is one of, I think, the most vitally important adaptations is to be able to modulate and accurately and consistently modulate the pressure on someone's tissue, someone's body because of the effects of cancer treatment that even local treatments can have systemic effects, and even treatments that happened months or years ago can continue to have effects on the tissues of the body.

So Janet was talking about thinking of the body three-dimensionally. I would say you also think about not just, as Janet was saying, working with the soft tissues, but really the nervous system as being one of the most important systems that we affect, and the way that you modulate pressure definitely affects the nervous system and affects the body systemically. So that's, I think, one of the most important hands-on adaptations to oncology massage.

Til Luchau:

Is to understand the role of pressure. Is it as simple as the lighter the better?

Rebecca Sturgeon:

No, no. It is absolutely not that simple. Yeah. Loretta, I would love to hear your thoughts on this as well as someone who has received-

Til Luchau:

Loretta, you're even shaking your head no, so yeah.

Loretta Carridan:

Right. Well, it's like, I think, Rebecca, you said earlier, it really depends, right?

Rebecca Sturgeon:

Yes.

Loretta Carridan:

On what part of the body we're touching. Is it the site? It depends on where I'm at in the treatment in terms of pressure, too. Yeah.

Rebecca Sturgeon:

Exactly. Exactly, and it depends on things like how you, your individual body is responding to treatment, right?

Loretta Carridan:

Yeah.

Til Luchau:

I'm going to name this episode It Depends, I think.

Rebecca Sturgeon:

Please do.

Til Luchau:

In that, let's take it another level because that can be a conversation stopper, too. That can stop us from really going into the it depends on what.

Rebecca Sturgeon:

Well, it depends.

Til Luchau:

So what does pressure depend on?

Rebecca Sturgeon:

Pressure depends on how someone's body is responding to treatment. So we talk in the book also about using the "medical model" as a way to inform critical thinking, and that includes things like asking questions about people's activity levels, and have they modified their activity levels. So for example, the way you modify pressure for someone who is used to running 20 miles a day, who in treatment is only running 10 miles a day might be different than the way you modify pressure for the person who is used to walking a mile a day and now is in bed most of the day, right?

Til Luchau:

You turn it down a lot more for that second person.

Rebecca Sturgeon:

Right, right. So you are always, as with any body work, I think we would all agree you are informed by the population, but you're looking at the individual, and you are working with this individual human as they are right now, so things like current activity level, things like the type of treatment and where in treatment someone is, are they in the middle of treatment or in what we call active treatment, was their treatment done a month ago, done a year ago, done 17 years ago. We also look at things like what is-

Til Luchau:

Sorry, from time since treatment being an indicator of how experimental I might be with pressure, say I spend longer than I can be a little more experimental you're saying or what?

Rebecca Sturgeon:

Well, say it with me, Til, it depends.

Til Luchau:

It depends, but yeah, it depends on what?

Rebecca Sturgeon:

On the types of treatment and how it's affecting their body. So for example, there are things like having lymph nodes removed during the field of radiation that are permanent changes to the body and to the way the lymphatic system works. It's, in fact, one of the most important adaptations for oncology massage. There are things like surgical interventions that might affect range of motion or the way that someone operates inside their body for a long time.

Til Luchau:

Absolutely.

Rebecca Sturgeon:

Janet always gives the amazing example about reconstructive surgery for breast cancer and how that scar formation can affect shoulder range of motion. Also things like if someone is receiving a chemotherapy or an immunotherapy, a "drug therapy", what is it, what was the purpose of it, and how can it affect the body. So for example, typical chemotherapy, antineoplastic chemotherapy is designed to target fast-dividing cells. So the side effects of that can be different than a therapy that is a targeted immunotherapy. So it's things like that. It's also things like if someone is receiving radiation. Is it external or internal radiation? Where on the body? Like Janet said, what are the other organs, tissues, systems that can be touched by the radiation? What else, Janet?

Janet Penny:

Yeah. One thing that comes to mind with the amount of pressure we use is what our clients expect and what they think is realistic. Often, people will say, "No pain, no gain." They want a very deep treatment, which might be appropriate. I'm not even convinced it is, but maybe it is if you have tight hamstrings after running, but it's probably not appropriate and it might even be dangerous if you're dealing with the tissue density after radiation. So one of the things we have to do is once we're convinced that we have to moderate the pressure, we also have to educate our clients on what's actually going on in the tissues in their body and why a certain amount of pressure is safe or unsafe for them.

Til Luchau:

So how might you do that with the person that wanted more pressure on their hamstring. Say how might you talk to them or what might you say.

Rebecca Sturgeon:

Go ahead.

Janet Penny:

Well, if they're still running, like Rebecca says, 10 miles a day, then they might have a very deep treatment on those hamstrings, but on the area that's received radiation it would be much softer. It's a tough one because does the customer know best or do we know best? I see it as an opportunity to educate people. Occasionally, I've had people who are really not satisfied with a lighter pressure and they don't come back, and I often have a discussion with them as they leave that they have to find the best massage therapist for them at that time, but that they want to make sure that the person they're seeing understands the impact of cancer treatments and what that can do and how we have to moderate our treatment. Some people will get it and some people won't.

Til Luchau:

So it sounds like you have your own limit for how much you're comfortable using and you find ways to talk about that. So I'm just wondering about the education process, how you help someone understand why you have the limits you do in a way that doesn't predispose them to feel like they're messed up, damaged or flawed.

Janet Penny:

Yeah.

Rebecca Sturgeon:

Yeah. This is challenging. One of my favorite phrases that I use when I'm in that situation of speaking with a client is, "Your body is busy right now, and your body is very busy doing something that's important and vital, and I don't want to interrupt that," but you're right, Til, it's a delicate balance that requires a lot of inner understanding on the part as a therapist, as well as open presence in the treatment room.

One of the things that I think also helps is I tell students all the time in our continuing education classes that, "You are not taking things away from people when you're adapting for their cancer treatment or their experience with cancer treatment. What you're doing is adding your knowledge, your increased knowledge that you have spent time and money to get, and you're giving this to people, even though," because I think framing, if we go in thinking, "I am taking away this deep pressure. I'm taking away this particular thing," then it's harder to have a conversation with the person in front of you and think of them as someone who is lacking or missing out. If we arrive in our wholeness, then we can also allow our clients and patients to arrive in their wholeness, whatever that looks like today.

Til Luchau:

I'm just thinking back, again with my experiences with you, Loretta, how I don't really know. For me, we had habitual ways of working before you started treatment that we had to adjust, but it really became a process of just really getting you to guide me in terms of the pressure you needed and taking it very cautiously, especially with the radiation phase or all of it, honestly, but just to see how you responded because, yeah, I'm aware of the fact that a lot of situations that how it feels in the moment isn't the only guide either. We have to see how you are later. What would you-

Janet Penny:

That's part of the conversation with the clients as well to really stay in touch with them throughout the treatment, but also to stay in touch with them after the treatment. I usually email people a few days after treatment to see how they feel, and I ask them for any and all feedback because it will guide further treatments. I always tell them that we work cautiously at first, but then we can work less cautiously, but still carefully as we work together over a period of time and I get to know their body and they get to know what massage does to their body as they go through cancer treatments because that is the unknown.

Til Luchau:

I hope, Loretta, I hope you got my little autoresponder follow ups with you to see how you're doing after our massages there. Do you have any-

Rebecca Sturgeon:

Over morning coffee?

Til Luchau:

That's right. Do you have any thoughts about this question we're unpacking here, Loretta? How do we modulate the pressure?

Loretta Carridan:

Yeah. Yeah. I mean, definitely. I mean, I like what you're all saying and, yeah, I'm fortunate that I have an in-house body worker because I can say a few hours later and even a day or two later like, "Wow, this is what I'm experiencing," and we can know that and work with that. So that's fortunate for me, but yeah, I mean, it depends on what's going on physiologically at the site or other parts of my body in terms of depth and kinds of work. There's different kinds of work that I've chosen to do at different times, whether it's lymph node work, acupuncture or body work, deeper light or whatever.

I think, Rebecca, you said something about open presence, and I think that's really important, and I think maybe I'm assuming what you meant by that, but open presence, when you mentioned it, and correct me if I'm wrong, but there's something about that contact with the client or therapist with me that allows me to inhabit my body in a way to in the moment know what I'm feeling physiologically because it's a new territory for me, too, right?

So the therapist can really help me by being in that open presence in terms of finding what I need because it depends on our personality typologies, too. We might just say, "Oh, go, do whatever. You're the expert," and hand over my power, but really, I think to empower the client is one of the most important things because this is a journey. Cancer is a journey with a message, I think, and it can be so easily missed if we're not being attended to with that kind of presence, if you follow me.

Rebecca Sturgeon:

Yeah.

Til Luchau:

I love it. Yeah.

Loretta Carridan:

So physiologically, there's all this stuff going on, but emotionally, too, will affect the kind of touch that I'm needing that day. I might have deep work one day, but the next day, I'm in this dark, unmotivated emotional place, and I can only have hands laid.

Til Luchau:

I'm picturing, yeah, I'm picturing it. We have this five level pressure scale from Tracy Walton. I'm picturing a present scale from Loretta, like pounds of presence or something like that that we need to amp up in inverse proportion to whatever's going on there. So it's true, Loretta. That's my biggest takeaway in my memories of having to do that calibration process in the beginning. Had to pay a lot closer attention in a way, and it really was a process of me paying attention and then inviting you to pay attention too, and having that dialogue in the moment that made it educational for me, made it work in a way.

Loretta Carridan:

It could be very empowering for the client because cancer is, and it might help a client realize cancer is part of my journey, my spiritual journey, and who am I, and in that moment, can I really feel into who I am, what I need, and express that. That can happen in a session. That's a big emotional piece. Oftentimes, and I have experienced this, a client can feel missed emotionally and, therefore, not get the physical attendance they need maybe.

Til Luchau:

Yeah. Do you have examples or ideas about how we could miss or how you've been missed maybe?

Loretta Carridan:

Oh, yeah. So I mean, an example would be, for me, I'm showing up at the office of the massage therapist who's busy and moving fast. I'm having treatment, I'm slow, I'm unmotivated, things are dying inside of me. I'm in a totally altered space, and I'm met with a pace that doesn't match me, and I either feel like I can withdraw or I feel like I have to meet that. So I have to come out of myself to meet that, and that's not really therapeutic, actually. That's not helpful. That's not me as a client making the time and spending the money and hoping for a connection, and then to show up and not be met in terms of emotion, well, it moves into the emotional realm and even physical because maybe they're touching me too fast or telling me about my experience versus really coming in with the presence that I think Rebecca's talking about open presence and feeling into what I need versus what they think I need or just not being present.

That's one of the biggest things because I can end up leaving a session really feeling missed and more emotional and almost like just missed and not seen and not part of the world of the living, which you really feel when you're in treatment. You are removed from the world, in a way. So I think I'm getting more into the emotional piece there, but it's a big piece. It was a big piece for me, how am I being received, held, met not only physiologically, but emotionally, and maybe not physiologically if they're moving too fast and telling me what I need.

I mean, I had somebody telling me to lay on my stomach and I had a port in and I didn't want to, "Oh, it's okay. Everybody does it. We can put the donut." I'm like, "I really don't want to lay on my stomach." "Find a way to work with that." I got a little bit triggered by that. So I don't want my client to get triggered emotionally in session because they're already saying what they need and I'm telling them, "It's okay to do it a different way," when I'm specifically saying, "I don't want to lay on my stomach." Do you know what I mean?

Til Luchau:

I do. That's like your-

Loretta Carridan:

Little things like that can just turn a person.

Til Luchau:

Well, there's all these tangible examples like that. I think this is part of your position factoring in your model, Janet and Rebecca, but all these are, in a way, metaphors or ways to talk about this process of meeting our clients. For me, as a therapist, putting my agenda on hold enough to really sense where my client or partner or the person on the table is, and to see what they need and to join them in some ways in that very unique, interesting universe they're in in that process.

Janet Penny:

I'm really curious how we can instruct massage therapists in that and still stay very safely within our scope of practice because I think what you're talking about is the magic of massage. I think that's where the extraordinary work really happens, but it's nowhere in my scope of practice, any of that.

Til Luchau:

Really? What do you mean?

Janet Penny:

Our scope of practice is very much focused on the physical intervention of massage therapy, but I do think that what, yeah, Rebecca and Loretta, you're talking about is really massage therapy. I think that's where the extraordinary work happens, and how do we talk about technique and the safety of oncology massage and bring that other stuff into the awareness and still have the practitioner able to maintain a really clear therapeutic boundary so that they don't feel like they're the counselor, and so that they don't go home exhausted at the end of the day. I think it takes a lot of finesse to do that, but I think it's critical.

Rebecca Sturgeon:

Well, it's interesting, isn't?

Loretta Carridan:

I think you're talking about bedside manner. I would even like to see that in the medical profession, just simple bedside manner.

Til Luchau:

Well, that's another story, but Janet, I want to maybe just push back a little bit on what you said about scope of practice because we're not talking, I don't think, I don't, Loretta, I heard her saying, "Ask about their spiritual path and figure out what their emotional life is." I didn't hear her say that. I heard her talking about how we do the physical. If your scope of practice is the physical, doesn't that include how we do it, and things like pacing, and things like the choices we make, and the tone of voice use, those sort of things? Aren't those part of scope of practice?

Janet Penny:

They are. I haven't read my scope of practice in a little while, but I think it's probably not the written part of the scope of practice, but it is, I think, integral to how we're trained to do our work. When I was being trained, I don't remember too much of that. Yet, I very easily brought that with me to the work, but I mean, I go for massages with different people all the time, and they're not bringing that presence. They're not bringing in awareness of me on the table in that moment. So I do think there's something missing in terms of how we are taught and how the entirety of massage is explained to us as we learn the trade.

Rebecca Sturgeon:

Right. Well, I think that's exactly right. The way our scope of practice is written is all about, well, you can use these tissues and these parts of your body to work with these tissues and you don't open up any tissues, but we know in actual practice and in actual interactions with human beings you cannot touch someone's tissues without also touching their spiritual, emotional, psychological being. Whether we're trained in that or not is part of what we really need to work with, and it's part of the challenge of just being human.

Janet Penny:

I agree. Yeah.

Loretta Carridan:

I'll just interject a little bit. I'm not suggesting that anybody try to counsel, but I think I don't know if it was Rebecca or Janet who mentioned we have the tools and the skills for the work, the hands-on work, but there's some awareness of client's state and what might be going on that we can be present to without even entering that with them, without questioning it, without trying to take them anywhere, but just a knowledge that, "Wow, there's a lot going on for this person."

I mean, we would think that if we ran into somebody in the grocery store and they said they were going chemo, "Wow, your world is different than mine." So just to hold that awareness of the client's state, and like you said, not knowing. There's a lot we don't know, but how do we just stay present with that.

Til Luchau:

I'm just remembering, too, that, I'm remembering my first client early in my practice, first client I had who told me she got a cancer diagnosis and what an impact it had on me. I was seeing her regularly, but the impact on me as the therapist, too, was it really sent me for a loop. I was upset. I didn't know how to relate to her. It did bring up all my associations with, "Does that mean she's dying? Does that mean ... What do I say? Do I say my condolences? Do I say I hope for the best?" I really didn't even know how to deal with all the feelings that brought up in me. What guidance do you give people around that Janet or Rebecca?

Rebecca Sturgeon:

Oh, Til, that is so hard. It's hard, right? As many years as we've been doing this work and working with people who are going through cancer treatment or other chronic illness, it doesn't get any easier, first of all. That's the first thing that I would say to people, Let's be realistic.

Til Luchau:

I know. Okay. So it's difficult, it depends, it's hard, and?

Rebecca Sturgeon:

Then what do you do, right? So let's get practical. I hear it in your voice. One of the things that I try to guide people to do is to be aware, and this is something that we talk about a lot in Healwell, too, is to be aware of the stories that you are telling yourself. For example, your client that you talked about, Til, the first person that you interacted with that you knew of, who had a cancer diagnosis, to just take a step back and acknowledge, "Okay. So now I am telling myself the story of how this client's going to ... This is going to happen to them, and this is what the progression is going to be like," and recognize that for what it is. It's a story, and to interrupt that process of storytelling because our brains will take us all kinds of places that are not useful in the moment.

To be able to interrupt that in ourselves and be like, "Okay. So that's a story. This is now," and to come to that blank space, for lack of a better term, and it's not something that can be taught in a three-day workshop or a six-day workshop. It is something that is a lifelong practice. So we encourage people to have, "Do you have a contemplative practice?" whatever that means to you, whatever speaks to you or practice that really where you are really sitting with and examining and understanding the workings of your mind.

Til Luchau:

Talking about a contemplative practice that gives you a place to reflect or to maybe understand that my feelings are my story, a perspective on that.

Rebecca Sturgeon:

Right, and gives you practice in doing that because you can practice that on your own in whatever framework is meaningful to you so that it's available to you more easily, the same way that we practice, for example, the physical techniques of our work so that they're available to us when we have an actual client or person. I don't know. What do you think, Janet?

Janet Penny:

It's such a complex part of our work. What I always try to do and guide people in doing is to stay with where the client is. So not go on the ups and downs with them, but stay where they are so that we're not bringing our own stuff into it because we can bring our own fears. If a client has just had a new diagnosis, we can be quite frightened, like you were saying, Til, or we can be very emotional if it's someone we've worked with for a long time, but we really want to stay with them because it's their experience, and we don't want to bring our own stuff into it because that can be an incredible burden to them.

Til Luchau:

That's such an important point. I mean, I experienced that myself in various health conditions that I had in the past, but I watched that happen all the time with you, Loretta, where all the expressions of caring you get have a different impact, depending on their content, where they're coming from, and so many of them, sitting back in this place, are so well meaning and yet have so much need for the sender in them. It's actually more of a request than an offering in a sense.

Rebecca Sturgeon:

Very much so.

Til Luchau:

"How are you doing?" being a really complicated question or, "What's going on with your treatment? or just the innocent, unawareness of how big a question that is in a way.

Janet Penny:

So actually, I'm curious for you, Loretta, how or if you can tell when someone is approaching you from a place of support and openness versus approaching you from a place of, "I'm scared about what you're going through and I need things."

Loretta Carridan:

Yeah. I want to say something more than the energetic that I feel, but it is about, "Are they just being with me or are they doing something?" Do you know what I'm saying? So if I'm with somebody and it's how they're looking at me, it's their energy, are they moving fast, are they just being with me, are they feeling like they need to do something to give something to me or are they just being with me. I think it has to do with being versus doing and just who I am. It's just an energetic thing. I feel like I'm not answering the question very-

Til Luchau:

I got it.

Loretta Carridan:

... scientifically. Maybe you could translate, Til.

Til Luchau:

Well, yeah. I think it's back to the presence thing, at least what I'm understanding. You're saying, do you feel someone's being in them? Are they reading the text or are they speaking from between the lines? Is there a spaciousness? Is there a matching your pace? Is there receptivity on that side or is it just all one way content coming at you?

Loretta Carridan:

Right, and can they look at me and be with me and feel me or do they feel like they need to do something with me?

Til Luchau:

Oh.

Loretta Carridan:

Maybe that-

Rebecca Sturgeon:

I've often thought that humans should be called human doings not human beings because we spend so little time being.

Loretta Carridan:

Right. Well, and it makes me just think about our culture and how we're trained, and how fast we're moving. In my treatment world, I'm way slowed down. So it's really clear to me when somebody is trying to do something versus just sitting with me and feeling where I'm at.

Til Luchau:

Yeah. It's been a challenge and a gift for me to be with you through that because I'm not in treatment, but I'm with you and still podcasting and doing all this stuff. Yet, going home and having to-

Loretta Carridan:

Downshift.

Til Luchau:

Downshift, recalibrate, go, "Okay. A different state of mind, different state of being here," it's been a great practice, but I can see that being so important for a therapist, too, to understand that every one of our clients is in a different state of being, and that there's lots of selections on our gear shift, and we might have to downshift at that moment to meet theirs.

Loretta Carridan:

Right.

Til Luchau:

All right. Couple other ... Thanks, by the way, Rebecca and Janet, for joining Loretta and I for our conversation about this. This is really nice to have this chance to catch up with Loretta, too. What's realistic to expect from massage, let's say? What are some of the clear benefits that we can think of or that we can help our client's reality check on what they're going to get out of massage in treatment?

Rebecca Sturgeon:

Yeah. I'm not going to say it depends even though I want to because there are some things, and I want to plug again, and I hope Janet will talk more about this. One of the chapters that Janet wrote in the book is a wonderful research chapter, which has some really specific types of inquiry around massage and cancer treatment, but there are some effects, experiences that are somewhat universal or very common no matter what your treatment is, pain, anxiety, nausea, depression, fatigue.

Massage therapy can benefit all of those. I should say adequately trained, appropriately delivered massage therapy can benefit all of those, and these are things that no matter what the specific treatment someone is receiving, they will probably have an experience of at least one, possibly more than one of these.

Til Luchau:

Give us that list again, Rebecca, if you don't mind.

Rebecca Sturgeon:

Pain, anxiety, nausea, depression, and fatigue. The more esoteric thing that I don't necessarily have research on, but I feel this is true thing, at least for traditional Western cancer treatments, there is necessarily a lot of approaching the body in pieces and parts. This is not an indictment of Western cancer treatment because approaching the body in pieces and parts has been responsible for a lot of remissions, and a lot of people who are living today, who may not have been decades ago, but where massage can step in is that we can be a respite and sanctuary where your body gets to be whole and your body, as it is right now with whatever is going on, is, well, to borrow from Sonya Renee Taylor, is not an apology. Your body is what it is and what it is is it's been successful in getting to your massage appointment. It's been successful in living you through this day. So we get to acknowledge that wholeness, which is a little bit harder to codify, but it feels deeply important to me.

Til Luchau:

You're talking about just celebrating or acknowledging or being with the physicality that we are just being in your body with someone else and having them attend to your physical being.

Rebecca Sturgeon:

Right. Yeah, and just having a space where there's a person, your massage therapist, your body worker, whose entire reason for existing is to be sweet to you, to be sweet to your body, to be kind and loving and attentive to your wholeness, your whole body is really powerful. No matter what is happening in your life, it's incredibly powerful.

Loretta Carridan:

I can just interject a little bit there. All the things that you mentioned, the pain and discomforts of treatment can make you feel in touch, can not only make you feel whole and transcend that discomfort state, but also, it's like something feels good in the midst of feeling not good because of the treatment. The touch can actually, it's a respite, but it also feels good. It's great to have something feel good when you're not feeling good.

Til Luchau:

Let's underline that because that does tend to get missed I think in our discussions of effects, that feeling good is not a small thing, especially if that's not available to other ways. It's like feeling good is plenty good. I'll take it. Great. Okay. I got so many questions. What's the hardest thing that you've seen already trained therapists like me to get as they start to work with people in cancer treatment or what would you say?

Janet Penny:

I think the intake portion is really tough because a client can come in with so many symptoms and to figure out what might be causing them, for instance, a neuropathy could be from chemotherapy, it could be from radiation, it could be because they also have diabetes. There's a very complex medical treatment, cancer treatment on top of a complex body, which is what we all have, and to figure out what the client's bringing to us and what we can realistically help them with and what we can't, and knowing that clarity within ourselves, but also helping them to understand what the power of massage is, but also the limitations, which is where we can really help them to connect with other people, the integrative approach, to find someone who can help them with things that they might not be able to dress themselves or that we can't help them with.

Til Luchau:

In some ways, it's coming back to those benefits. That's what I'm picturing. It's like my client comes in with a list of physical maladies that perhaps in other circumstances massage or body work might be an indication for. In this special circumstance, though, it's a bit more complex. Yet, for me, coming back to the fact that, "Well, if I can't necessarily help Loretta's neuropathy be diminished in one session there, at least I can find some way to help that be an easier experience overall."

Janet Penny:

Absolutely. Yeah.

Til Luchau:

Okay. Anything you have to say, Rebecca, about that, the hardest thing for already trained therapists to get?

Rebecca Sturgeon:

Well, I'm so glad that Janet talked about intake, but the other thing that we see, which seems like it would be the easiest thing, but it's the modulating of the pressure, not necessarily learning how to do it, but owning it, for lack of a better term.

Til Luchau:

Breaking the habits that might not go along with that, in my case, yeah.

Rebecca Sturgeon:

Exactly, and and owning that you can touch someone what we call lightly and still have an effect that is profound. That's a hard sell in some workshops and we have many experiences and many stories about the person who came in who was, sorry, Til, I'm going to say a welfare or who was used to heavy, heavy hands, and for them to understand that they can work with someone with their hands being more gentle and sensitive in that way at a one, for example, on Tracy Walton's pressure scale versus a four or a five on Tracy Walton's pressure scale, and still the person will still feel benefit and feel better after the treatment. That's often very challenging for people to accept.

Til Luchau:

That is, yeah, in this realm and in others. I mean, that's a theme in our trainings, for sure, that it's often the case that people come in used to working a certain way and used to using a certain level of pressure to feel the results to let them know that they're having an effect. So it is a recalibrating whether or not you're working with someone with cancer or living with cancer to really understand. You said something, Rebecca, about tissues. We're not changing tissue.

It's a big discussion in the field the last decade or whatever, and maybe a theme on the podcast here, but I would say we are at least, especially maybe brain tissue or heart tissue or all of the different perceptive organs that are tissue-based. For sure, we're impacting that tissue, and that's been a helpful model for me to realize that I can actually influence the experience someone's having in their brain and their heart and their being, and it isn't related to the amount of physical pounds of pressure that I use. It's more the pounds of presence or something.

Rebecca Sturgeon:

Well, I would agree with that.

Til Luchau:

All right. So thank you.

Loretta Carridan:

I mean, pounds of presence and also changing their focus with all the pain work that you've done, Til, working with people with pain. So you're working with the brain and it's like if somebody comes in and they have a focus on what's going on in their body, you can actually help them change their focus by appealing to what they're focusing on, basically.

Til Luchau:

Okay. So anything else you want to underline around when we should refer? We've talked about that a few times along the way, but just anything else you want to make sure we say that when they should seek more training, when we should seek more training for ourselves? What do you think?

Janet Penny:

Always is the answer. The more we know, the more people we're exposed to, the more styles, the better practitioners we can be, I believe.

Til Luchau:

Always seek more training. When do we refer?

Janet Penny:

Well, first of all, medical emergencies. Sometimes people come in and they might have signs of blood clots and they might not know, so we need to know that so we can tell them that it's something they should have checked out before their massage happens. Infections, poor tissue healing, again, not everybody is really aware of what's going on in their body and what it signifies. So if we know a few of those indications, then we can really help people to get the help they need if there's a medical emergency. Also, if something's outside of either our scope of practice or our comfort, which I do all the time, if there's something I'm not really that comfortable working with or I don't feel knowledgeable enough, then I refer all the time. Rebecca?

Rebecca Sturgeon:

You said it so well. I mean, really, yeah. I have no notes.

Janet Penny:

No notes? I guess signs and symptoms of lymphedema as well. That's something that we should all know as massage therapists and body workers so that if somebody has any indication that they might be developing lymphedema that we can refer them to someone who can do an assessment of that. The earlier they get help with that, the less they might be impacted by it. So that's a really important one as well.

Til Luchau:

That's great. What thoughts do you want to leave us with?

Janet Penny:

This is the most satisfying type of work to do as a massage therapist in my experience because we have such an impact on people's physicality and their sense of wellbeing and their ability then to go out and do more of what they have to do to get well, more treatments, more this, more that. I think we really offer a place for people to restore some of their energy, and I absolutely love the work.

Til Luchau:

Nice.

Rebecca Sturgeon:

Growing from that, I would agree with that that it's very satisfying on a heart and soul level for me work, and it's not necessarily for everyone, and that doesn't mean that there's anything wrong with you. I think it is important for all body workers to at least have a basic understanding of oncology massage because of the prevalence of folks who are in or been through cancer treatment if only to know that this is not work that you want to do and you need to prefer that out. So to just really seek out an understanding of this kind of work and if it doesn't appeal to you, then know that and act on it.

Til Luchau:

That's great, to acknowledge that what we are comfortable with, what we're not and have that be okay, but then you mentioned prevalence. What is the prevalence? I think, I mean, just from memory, isn't it one in four women deals with breast cancer, specifically?

Rebecca Sturgeon:

Yeah. Oh, shoot.

Til Luchau:

One in five men deal with prostate cancer?

Rebecca Sturgeon:

Right. It's in the book, but-

Til Luchau:

It's in the book. Okay.

Rebecca Sturgeon:

Really, we can say, I think, with pretty high confidence that if you are a body worker for more than a year, you will, absolutely 100% will have someone come into your office who has a history of cancer treatment, whether you know it or not.

Til Luchau:

Yeah. That's right. Okay. Loretta, anything you want to leave us with?

Loretta Carridan:

No, I really like what Janet and Rebecca are saying about scope of practice and referral and all that. I just think as a practitioner and as someone on the receiving end, it can just open up worlds if we are aware in terms of the skills that we need, but also, it just can open up worlds of how to just really be present and have it affect our lives and our clients' lives.

Til Luchau:

Well said. Okay. Well, what would you put in part two?

Rebecca Sturgeon:

Of this?

Til Luchau:

If there was a part two?

Rebecca Sturgeon:

Oh, my goodness.

Til Luchau:

What didn't you have time for that was important or what do you want to expand some more?

Rebecca Sturgeon:

There's so much. Yeah. I don't think we didn't really talk that much, we got to it a little bit at the end, but that much about the prevalence of cancer treatment. I would love to drill down more into intake, like Janet mentioned, because it's so important. You can only work with what you know, right?

Loretta Carridan:

Right. The scope is important.

Rebecca Sturgeon:

Yeah. Yeah, and actually, I would love to, now that you asked, I have a hundred things. The emotional impact of this kind of work on the practitioner and the real potential for burnout and emotional burnout and how to manage that, which I don't know if I know how to manage that. Ask me if I'm still practicing in five years then I'll ... Maybe I do, but I think it's always a conversation worth having.

Janet Penny:

I think it's something we have to relearn daily, it seems.

Rebecca Sturgeon:

Yeah, yeah.

Janet Penny:

I'd be interested in talking a little bit more about the practical applications. I work with so many people who, for instance, if a woman has had breast surgery and she needs to increase her range of motion in order to receive the radiation. I've worked with so many women where manual therapy of some sort, whether it's physio massage, helps them to be able to get their body working well enough to receive the treatment they need to get rid of the cancer.

Til Luchau:

That's great. That's great.

Janet Penny:

Very practical things, and again, just radiation, but people have to assume all kinds of physical positions. You think of head and neck cancer and having the mask on and what that does to a person's emotions and psyche. So some of that very practical stuff I find is very interesting for massage therapists. I know that both Rebecca and I feel really strongly that there should be some oncology massage awareness in entry level massage training, irregardless of how long that training is.

Rebecca Sturgeon:

Exactly.

Janet Penny:

Just because of the prevalence of the cancer rates, but also survivorship, there's so many people who survive cancer now, and yet, they still come in for massage and we need to know a little bit about that.

Til Luchau:

Absolutely. Right. Well, thank you, Loretta. Thank you, Janet. Thank you, Rebecca. Rebecca and Janet, if people want to find out more about each of your work, where would they go? Janet, let's start with you if we could.

Janet Penny:

Yeah. I have a website, focusmassagetherapy.ca. That's in Ottawa, and I answer all emails,

Til Luchau:

Focusmassagetherapy.ca. We'll put that in the show notes.

Janet Penny:

Thank you.

Til Luchau:

Rebecca?

Rebecca Sturgeon:

Well, you can always check out Healwell at healwell.org. Again, I also answer all emails. We have online classes and an online community. There are all links from there that you can connect with folks who are doing this and other kinds of work.

Til Luchau:

Wonderful. Thank you all for being with me today. Thanks very much.

Janet Penny:

Thank you. Lovely. Thank you, Loretta.

Rebecca Sturgeon:

Thank you so much.

Loretta Carridan:

Thank you. It's so nice to be with you both, Rebecca and Janet. Yeah. Thank you.

Til Luchau:

On the way out, I want to thank Handspring because when I was looking for a publisher for a book I wanted to write, I was fortunate enough to end up with two offers, one from a large international media conglomerate and the other from Handspring, which at the time was a small publisher in Scotland run by just four people who have a love of great books and of our field. To this day, I'm glad I chose to go with Handspring. It's not only did they help me make the books, I want to share with you the Advanced Myofascial Techniques Series, but their catalog has emerged as one of the leading collections of professional level books written especially for body workers, movement teachers, and all professionals who use movement or touch to help patients achieve wellness.

Handspring was recently acquired by Jessica Kingsley Publishers, where it joins their integrative health publishing under the Singing Dragon imprint and their amazing impact continues there today. Head on over to their website at handspringpublishing.com to check their list of titles, including Janet and Rebecca's book, Oncology Massage and Integrative Approach to Cancer Care. Be sure to use the code TTP, The Thinking Practitioner at checkout for a discount. Thanks, Handspring.

Thanks to all of our sponsors. Stop by the sites, my site or Whitney's site for show notes. Whitney's site is academyofclinicalmassage.com. My site, advanced-trainings.com. If there are questions or things you want to hear us talk about, email us at info@thethinkingpractictioner.com or look for us on social media under our names. Rate us on Apple podcasts. Look for us on Spotify, Stitcher, Google podcast, wherever else you listen, and please do share the word and tell a friend. Thanks, everybody.

Rebecca Sturgeon:

Oh, no. I went a whole hour without cussing. I'm going to go with that.

Til Luchau:

Wow! You cut your leg.

Rebecca Sturgeon:

Quite a fucking bit.

Janet Penny:

Oh, God! I love it. Shit.