Chronic pain and quality of life are inextricably linked.
Clients experiencing intractable pain endure substantial losses. They bear worry and stress about their health, ability to work and family responsibilities. They may be juggling doctors and hospital visits and contending with unpleasant side effects from medications or procedures.
Chronic pain often produces poor quality sleep, anxiety and depression, and diminishes quality of life.
Clients may be grieving a loss of vigor, comfort, independence, control, body image, friends and even identity. Under the weight of such burdens, coping skills can become overtaxed and ineffective.
Although counseling is not in any massage therapist’s scope of practice, there are many ways we can interact with and encourage clients, in conjunction with our hands-on work, that have a helpful effect on clients’ experience of pain. The path from helplessness to hope intersects chronic pain and quality of life, and encompasses deep listening, goal-setting, meaningful activities, and other strategies that plant seeds of hope.
Unrelenting pain signals without control over volume, duration, or frequency burn in a hard message of helplessness. Lack of positive experiences sap the capacity for hope. Each setback erodes expectations of feeling better. Massage therapists need understanding and clear strategies to help clients under these challenging circumstances.
A client who lacks hope may display such distorted thinking as catastrophizing, all-or-nothing thinking or blaming, and may make self–sabotaging decisions.
Do not get overwhelmed in your response. One well-placed question or statement of fact by the massage therapist can put a crack in biased thinking.
The phenomenon of learned helplessness was coined by researchers Seligman and Maier1,2 to describe the debilitating passivity and fear that follow an uncontrollable adverse event.
Behavioral studies in dogs and rats showed the animals abandoning efforts to escape a shock or even drowning when efforts were continually foiled. However, when rats learned to jump as an escape prior to the adverse circumstances (electric shock) they did not become passively accepting, unlike the group that had not learned an alternative response.
When animals learned they had control, their brain response to hostile events changed2,3. Just so, humans can learn to take positive steps despite a discouraging history. An invested, aware massage therapist can tangibly help renew clients’ agency.
Concrete actions that massage therapists can take include listening, identifying meaningful activities, providing evidence of progress, setting SMART goals, choosing appropriate benchmarks, and acknowledging positive changes that occur over treatment.
In order to hope, clients require vision, or a sense of possibility. In order to expect, they need evidence. Bring your client’s attention to positive and negative shifts in their pain level, range of motion or postural symmetry, however small. Strengthen the evidence of change by setting reasonable benchmarks and noting milestone achievements with your client.
It is easy to disregard impermanent or incomplete recovery. A client may arrive complaining of a headache and notice only that pain remains after session. In after-session debriefing, you can help your client realize the headache has now become mild, intermittent, and more localized. Documenting and commenting on small paybacks remind your client that progress is real.
Listen to Your Client’s Story
Hope can be fostered starting with the intake process. When clients come in, they have a story to tell. They need time to share their story, in their own way, even if they have already recounted it to other providers.
Open questions invite the full account. Listen and receive. When your client reaches a point of story saturation, you may hear a sigh or exhale as they let go.
Strategically interject such questions as “When did the pain start?” or “What are you taking medications for?” to unearth details about onset, duration, frequency, and intensity, and what makes your client feel better or worse.
It is a mistake to rush through intakes for maximum table time to “fix” conditions. Clients report greater satisfaction and confidence in providers when they sense their therapist is listening4. Confidence in you as a provider will jump-start their capacity to hope.
Use postural analysis and range of motion assessments. Test what you see, hear or touch or sense. Check postural anomalies with a ROM assessment on nearby joints. Relate postural analysis and ROM back to such functions as activities of daily living.
On the massage table, integrate tactile curiosity into massage strokes and manipulations; for example, when moving a limb, assess passive range of motion or when compressing soft tissue, note resistance and reactivity to identify hypertonicity, adhesions, spasms, trigger points or tender points.
Goal-Setting Can Encourage Hope
When providers promise quick fixes or miracle cures without delivering, clients lose confidence. Establishing specific, measurable, attainable, relevant and time bound (SMART) goals helps avoid client disappointment and loss of confidence in your treatment.
Identifying important activities that enhance your client’s life will motivate them to “get better.” To determine what “better” is, use a quality-of-life survey, a functionality questionnaire, or just ask.
Your patient may define “better” as stamina to play chess for four hours. That definition may not hold meaning for you but it is important for your client.
SMART goals channel functional limitations and attendant hopelessness into action treatments focused on desires and expectations, and attendant hope. S = Specific, M= Measurable, A=Attainable, R=Relevant and T= Time Bound.
S = Specific. When clients pinpoint a specific activity they would like to do but cannot, there is strong motivation to resolve the limitation. “I get a twinge in my low back when I pick up my grandbaby. I care for him every day and need to lift him to change his diaper.”
M = Measurable. Chart notes typically show numerical values, like 4 out of 10 on a pain scale, hours without pain, or degrees the knee can bend, before and after treatment. Measurable variables could also be designated mild, moderate, or severe. “His severe headache reduced to moderate after 15 minutes of neck effleurage.”
A = Attainable To inspire hope, goals should have a likelihood of fulfillment. When years of cumulative stress and injury manifest in a condition, complete recovery within one hour is not reasonable. A more realistic goal for a first session might be to decrease pain level from 5 to 3 out of 10.
R = Relevant Goals should match client needs. Goals that address important activities your client has identified best reflect their personal desires and expectations for feeling better.
T = Time-bound. Goals need to be reachable within a reasonable amount of time. “Soon” or “in a while” are not reassuring or explicit enough. Specify time frames in terms of sessions as opposed to time passed. Clients may double up on appointments one week or go for a month without receiving massage. Err on the conservative side for expected shifts, to not fall short and disappoint.
Goals are not set in stone. Review targets with the client each session, not only to see if they have been met but also if they are still relevant. If the original goals are not leading to improved quality of life, you can change them. Together, craft new goals that more accurately reflect your client’s priorities.
If you achieve a goal early, it is a success. When a short-term goal is reached, move toward the long-term goal. When both short term and long-term goals are met, create new goals using the SMART formula.
Meaningful Activities are a Bridge to Hope
You can also reference meaningful activities during assessment, feedback, self-care recommendations and professional communications. During assessment, ask your client to show the position that makes her knee feel weak when she dances, an activity she loves.
Assessment becomes fun and feels less like a waste of time. Your client becomes more willing to participate in tests for posture or gait when they pertain to what they value.
Now, when you ask about pressure or discomfort during a stroke, the client realizes you are asking how your touch is affecting that important activity.
Meaningful activities link self-care recommendations, such as icing, stretching, or increasing water intake to feeling better. No longer are you suggesting boring stretches or pointless hydrotherapy procedures. Your client sees that self-care makes them feel better.
Reference these activities in communications with insurance companies and other health care providers. Charting, case notes, and conversations with physical therapists, chiropractors, naturopaths and claim handlers can orient the entire team to a client-centered vision of health and hope.
Other Strategies that Evoke Hope
Additional tactics may help clients who are trapped in helpless feelings and unable to move beyond them. Include such specific strategies as providing choices, encouraging pain-free movement, and reframing scary metaphors about pain (outside attacker) as more comforting images (journey, path, garden) in your bodywork sessions.
Plant the seeds of hope by finding out what is important to your client and focusing on it. Water the seeds of hope by establishing meaningful, achievable goals and anchor in recognition of tangible progress.
Be persistent and patient, and institute these simple but powerful approaches to move clients out of hopelessness and toward hope.
An empowered client is more likely to engage in collaborative healing. The more involved the client, the more successful the massage, with better and more long-lasting results.
1. Seligman, ME, Maier, SF. (1967). Failure to escape traumatic shock. Journal of Experimental Psychology, 74(1), 1–9. https://doi.org/10.1037/h0024514
2. Maier SF, Seligman ME. Learned helplessness at fifty: Insights from neuroscience. Psychol Rev. 2016 Jul;123(4):349-67. doi: 10.1037/rev0000033. PMID: 27337390; PMCID: PMC4920136.
3. Baratta MV, Seligman MEP, Maier SF. From helplessness to controllability: toward a neuroscience of resilience. Front Psychiatry. 2023 May 3;14:1170417. doi: 10.3389/fpsyt.2023.1170417. PMID: 37229393; PMCID: PMC10205144.
4. Kinese, Thomas K. Personal communication – Kaiser Permanente NW Center for Health Research, in-house study, 2000.
About the Author
Marian Wolfe Dixon, LMT (OR #3902), is an NCTMB Approved CE Provider (#769). She completed master’s degrees in psychology and health education and a post-doctoral research fellowship with the National Institutes of Health. Working professionally as a licensed massage therapist and health educator since 1992, she is the author of “Myofascial Massage,” “Body Mechanics and Self-Care Manual” and “Bodylessons.”