The art of listening: How to take a professional case history for massage therapists by Rachel Fairweather

“A good listener is not only popular everywhere, but after a while she knows something” – Wilson Mizner

Taking a case history is often the first real contact you have with your client. This is the point where you can really start to hear your client’s story, make a connection with them as a human being, and start your detective journey gathering clues as to their physical, emotional and spiritual make up. It is also the point where your client will start to make judgements about you; your level of skills and professionalism, and ultimately whether they will come back for further treatment. Taking time to do a thorough case history is an investment not only in your client’s welfare but also an investment in your business. Your job at this point is to draw out the information that you require to make an assessment of your client’s needs and, most importantly, what outcome they would like to see from this treatment or series of treatments. It is your task as a professional to figure out how you can achieve this outcome and realistically how many sessions this may take.

You can start your assessment the minute your client walks through your door. Getting a sense of how your clients move and present themselves can help you to build up an overall picture of how to make a connection and give the best treatment. Think of both structural and emotional considerations:

• Structural: Are they able to walk, sit etc easily. Do they struggle taking their coat off or getting up the stairs?
• Emotional: What are your first impressions? Is your client presenting as confident, nervous or frightened. Are they taking ownership of their mind-bodies or are they looking for someone to fix them?
• Make these observations while keeping an “open mind set” and be prepared to be proved wrong about your initial assumptions once you have found out more about your client. Don’t make judgements about what your client needs or the source of their issues – the burly body-builder doesn’t necessarily need a sporty massage with loads of stretching while the medical doctor might love some energy work.

Listening skills in assessment: The principles of Metta and Unconditional positive regard

Listening skills are a vital part of the professional massage therapist’s tool kit yet this is an area that is often overlooked in initial training. Most people in pain need to feel heard. This is your big opportunity to make a lasting connection with your client; a meaningful relationship is the real reason why someone comes back to you. Remember to keep an open mind and look for “the face behind the face”- people may have an outward show of defensiveness or cheerfulness but what lies behind that? What is it in this person that helps you to understand and accept them fully? One of the principles of our own practice is the belief in the power of “unconditional positive regard” – a term coined by humanistic psychologist Carl Rogers to denote the basic acceptance and support of a person regardless of what the person says or does. This fantastic quote illustrates Roger’s approach beautifully:

“Years ago, I was invited to a seminar given by Carl Rogers. I had never read his work, but I knew that the seminar, attended by a group of therapists, was about ‘unconditional positive regard’. At the time I was highly sceptical about this idea, but I attended the seminar anyway. I left it transformed.
Roger’s theories arose out of his practice, and his practice was intuitive and natural to him. In the seminar, he tried to analyse what he was doing for us as he did it. He wanted to give a demonstration of unconditional positive regard in a therapeutic session. One of the therapists volunteered to serve as the subject. As Rogers turned to the volunteer and was about to start the session, he suddenly pulled himself up, turned back to us, and said, ‘I realise there’s something I do before I start a session. I let myself know that I am enough. Not perfect. Perfect wouldn’t be enough. But I am human, and that is enough. There is nothing this man can say or do that I can’t feel in myself. I can be with him. I am enough’.

I was stunned by this. It felt as if some old wound in me, some fear of not being good enough, had come to an end. I knew, inside myself, that what he had said was absolutely true: I am not perfect, but I am enough” – (Remen, 1989)

Unconditional positive regard is similar to the Buddhist principle of Metta (loving kindness) – a benevolence toward all beings, without discrimination, that is free of selfish attachment. It is a strong, sincere wish for the happiness of all beings. It is worth remembering that loving kindness lies at the very basis of massage practices. Traditional Eastern massage bodywork such as Thai massage are essentially spiritual in nature and considered to be a meditative application of Metta.

Key points of Effective Listening skills

Effective listening skills rely on both good verbal and non verbal communication and several key elements are involved (Mind Tools) :

1) Pay Attention: This may seem obvious but you need to give the client your undivided attention, and let them know they are being fully heard. Give warm and accepting eye contact and have an open body posture – don’t sit behind a desk or fold your arms which instantly creates a non verbal barrier to opening up. Develop the ability of forming a connection with your client while jotting down relevant information; you may wish to use key words that you can flesh out after the session. Your client’s perception of you will be greatly influenced by your body language during the intake; you are likely to gain more information if you are not glued to your note taking during this process.

2) Show That You’re Listening: Use your own body language and gestures to convey your attention. Nods, smiles, and small encouraging verbal comments like “yes” and “uh huh” help the speaker to open up and give you the full story as they feel that you are genuinely interested.

3) Reflecting back: mirroring and paraphrasing: The skills of mirroring and paraphrasing are useful communication skills to help fully draw out your clients story. Mirroring involves repeating back key words or phrases to show you have understood and encourage them to continue. For example:

Client: My back has been hurting for such a long time I can’t even remember when it started
Massage Therapist (nodding sympathetically) : It’s been a long time, hasn’t it?

Mirroring can feel a little awkward at first but is an effective tool; it should be short and simple, repeating back the last few words or key words that the client has said. Be careful not to over mirror which can be extremely irritating. Anyone who has been on an introductory counselling course will be familiar with the hilarious parody of students head bobbing, uh -huh ing and mirroring simple requests such as “Shall I close the window” (Response: I hear you saying you want to close the window). As with all good skills, moderation is key!
Paraphrasing involves reflecting back what the speaker has said using different words, showing that you are really trying to understand the meaning of what is said. Sometimes this involves taking in a large amount of information and summarising the meaning. For example:
Client has been talking for 15 minutes about the history of the back pain, the times when it has been really bad, the medics and therapists she has seen etc.

Massage Therapist: So it seems like this has been an issue for a really long time and the pain tends to get worse at stressful times of your life when you are feeling overwhelmed and unsupported. And that the lack of a clear diagnosis of why it hurts so much has been really frustrating for you.
Client: Yes that’s right actually – I never really thought about the fact that it gets worse when I’m stressed

4) Asking questions: In general you should be listening more than talking; don’t interrupt, correct the speaker or start talking about your own experiences. Use questions wisely to get the information you need. There are 2 main types of question that are useful in the assessment process -open and closed questions:

i. Open questions: These are ones that require more than one word answers. They are great for drawing people out and getting them to expand on what they were saying. Examples of open questions are:

a) What does the pain feel like when your back hurts?
b) Is there a pattern to when you get the headaches?
c) Was there anything else going on for you when you first started to get the IBS symptoms?
d) Tell me exactly what happened in the accident when you hurt your knee.

ii. Closed questions: These require only a yes or no answer. These are useful if you are starting to bring the assessment to a close, narrow down on specific information or make sense out of rambling client story! Examples are:
a) So the pain started last June?
b) The pain is worse at night – is that right?
c) So although you said you didn’t do much exercise, you do cycle to work every day?

Areas to cover in your case history

A consultation form is useful to help you remember what areas to cover in the assessment. There are many different types of consultation form; we generally recommend you design your own as this will suit your needs best. Remember a form is only as good as the way it is used. We are not fans of using tick-box forms for clients to fill in themselves (unless you are going to explore this in detail later). People do not fit into tick-box forms and want to know that you have heard them. Leave plenty of room for comments on your paperwork.

Talk to your client, using the form as a guide rather than firing questions at them. Much like your massage, the assessment should feel like a flowing dance of true communication. If your client has a tendency to talk a lot about irrelevant matters try and gently draw them back to the relevant topics without being abrupt. Open questions can help to draw out more minimalist clients whereas closed questions can help to narrow things down with those who tend to ramble!

When taking your case history there are several main areas you should aim to cover:

1) The current pain condition itself
If your client is presenting with some kind of pain problem you will need to focus in with your questioning to give you the information you need to treat effectively. Use the mnemonic OPQRS to help:

• Origin of the pain: When did the pain begin? Was there a precipitating factor – accident, fall, emotional trauma? Has it been going on for weeks, months or years? If clients describe a physical cause (e.g. falling off a horse) it is also helpful to ask “Was anything else going on for you at that time?” to evaluate whether stress or emotional factors were also involved. Time after time I find that the horse fall coincided with parental divorce, bereavement or childhood abuse. Remember it is far easier for clients to point to physical rather than emotional factors as being causative in their pain.
• Provocation: Does anything make the pain worse? i.e.: cold, movement, getting stressed. Conversely does anything make the pain better? Ie: warm bath, moving around etc.
• Quality of the pain: This can help you identify the source of the problem. Nerve pain tends to be tingling or electric. Chronic soft tissue pain can be dull and achy whereas more recent acute muscle pain can be sharp and stabbing. Pain of a muscular origin is often aggravated or relieved by movement. Beware of pain that is deep and unrelenting, even in sleep, and make sure that other causes have been ruled out. This type of pain can often be a sign of a more serious medical issue.
• Radiate: Does the pain stay in one place or does it radiate to different parts of the body? Referred pain can indicate either the presence of trigger points or nerve pain if it is more electrical in nature.
• Site: Where is the pain exactly? Get your client to point to the body area to avoid misunderstanding. You would be amazed at the difference between a client’s perception of where their “hip” or “back” is! It can also be helpful to have a picture of a body on your case history form where the client can draw in the areas of pain.

Also find out if the client has been given a diagnosis for their pain state, by whom and if they understand what it means. People can be notorious for self diagnosing (“it’s arthritis, my mother had it”). Unfortunately medics and other practitioners can also be prone to handing out unhelpful or confusing diagnoses that often have no basis or relevance to what might be going on.

2) Past or concurrent pain conditions or medical factors
Make sure you also ask about other pain conditions that may be current or have occurred in the past. Clients often also forget to mention other conditions you may be able to help them with such as digestive problems or headaches. A good checklist includes asking about:

• Headaches
• Menstrual pain
• Digestive issues: Any constipation/diaorrhoea or IBS type symptoms
• Any other episodes of the current pain or other pain problems. Find out how it was treated and how long it took to resolve
• Any accidents or operations: Make sure you enquire about any scar tissue as this can also be contributing to the pain issue
• Red flags – Red flags are warning signs to the practitioner that factors other than musculo-skeletal issues may be at work. For example these would include signs such as the pain being unrelenting even at night, accompanying systemic unwellness, unexplained weight loss or a recent accident. Presence of one or more red flags in musculoskeletal pain conditions may be indicative of a mores serious pathology and in these cases the client should be referred back to a medical practitioner to have this checked out. Massage therapy may still be appropriate but the primary cause of the complaint should be identified first.

3) The role of stress, emotions and other psychosocial factors

Manual therapists often minimise the effects of psychological and social factors in pain conditions seeing them as secondary to structural or soft tissue factors. Yet it is now well known that these aspects play a significant part in chronic musculoskeletal pain conditions . Although we are not counsellors, massage therapists need to develop the ability to ask sensitively about these areas to assess their likely influence in the presentation of pain. A good question is to say “Where would you put your stress levels at the moment on a scale of 1-10”. Then use this as a springboard for some open questions about the role of stress or emotions in the client’s life. Helpful follow up questions for example could include:

• Is it home or work factors that are most stressful for you at the moment?
• Sounds like you have a lot going on at work? Do you feel like you are getting any support around those issues?
• Do you have any strategies for helping manage your stress levels?
• Sounds like you have been feeling pretty anxious since your road accident? Have you had a chance to talk that through with anyone like a supportive friend or counsellor?

4) Functional limitations

Find out how the pain is affecting the client’s daily life – in other words what is the client not able to do that they would like to do. This might be sporting activities (running, cycling) or less immediately obvious things such as being able to pick up their child without pain or reach the top shelf of the kitchen cupboard without wincing.

5) Physical activity

Assessing how much your client moves during the day and in what way can be very revealing. Inactivity is one of the biggest causes of chronic pain conditions. Does your client exercise? What type and how often? Do they enjoy it or does it feel like a chore? How does exercise make them feel afterwards? How do they get around during the day? Walk? Cycle? Drive? Even moderate levels of physical activity can impact positively on pain. Rather than asking “How often do you exercise?” which can lead to an immediate feeling of inadequacy for the non sporty you may find questions such as “How do you spend your day” more helpful and have a greater likelihood of eliciting an honest answer!

In conclusion
Taking time to develop your listening skills will pay off a hundred fold in helping you to achieve positive results with clients and gain a wealth of repeat business

I will leave you with the wise words of therapist Carl Rogers, one of the true great masters of the noble art of listening

“When I have been listened to and when I have been heard, I am able to re-perceive my world in a new way and to go on. It is astonishing how elements that seem insoluble become soluble when someone listens, how confusions that seem irremediable turn into relatively clear flowing streams when one is heard. I have deeply appreciated the times that I have experienced this sensitive, empathic, concentrated listening.” – Carl Rogers

References

Mindtools.com, (n.d.). Active Listening: Hear What People are Really Saying. [online] Available at: http://www.mindtools.com/CommSkll/ActiveListening.htm
Remen R.N (1989), The Search for Healing in Carlson, R. and Shield, B. (1989). Healers on healing. 1st ed. Los Angeles: J.P. Tarcher. p.93

The Art of Listening by Rachel Fairweather – Massage World

About Rachel Fairweather and Jing Advanced Massage