This is based on an article I wrote for a massage therapy trade publication. I’ve adapted it for a lay audience.
How can predictive coding help bridge the gap between bodywork professionals and other health and wellness practitioners?
When I was first introduced into the massage world twenty years ago, I found that massage therapists tended to see their work either primarily as a physical endeavor or as a spiritual one. The first group thought of the body primarily as a system of muscles, bones, tendons, and ligaments where their job was to push and pull on these parts in order to make their clients feel better. They saw their work as a specific set of skills where inputs and outputs can be clearly defined and linked to one another with the intention of guiding their clients toward clear ideals of posture and movement. The second group saw themselves as a continuation of traditional medicine practitioners from around the world and would comfortably define themselves as healers. Where the former saw their client’s discomfort as an engineering problem, the latter were addressing pain on an esoteric, spiritual level. This second group used a language of energy, saw their role as promoting the movement of this energy, and viewed therapeutic success in terms of energetic shift and flow.
These two archetypes have more in common than it appears at first glance, but they’ve been hampered for as long as they’ve each existed by a lack of common language. The more physically-oriented massage therapists tended to use mechanical language that resonated with their clients and allowed them to better integrate with other Western healthcare and fitness professionals (chiropractors, doctors, personal trainers etc.). The healers’ language found its home with clients and professionals who also shared their language, like yogis, acupuncturists, and practitioners of other traditional healing modalities.
In my work, I’ve found that these languages each have a lot to offer while still feeling unfortunately limited. I’d like to propose a framework that integrates both our conceptual and our linguistic background. This framework honors the history of bodywork, which has led us to where we are today and offers us an opportunity to integrate our varied linguistic and conceptual histories with current neuroscience.
By taking advantage of this framework, we can achieve three specific benefits. First, we will better understand the nature of our work and will gain the ability to speak clearly to our peers about it. Second, by putting this framework into practice, we can improve client outcomes with less time and effort – with the added benefit of staving off practitioner injury and burnout. Third, by shifting our language, we can help our clients to feel empowered in their own therapeutic journey.
What is Predictive Coding?
This framework is based on predictive coding theory. Popularized by Northeastern University neuroscientist, Lisa Feldman Barrett, in her book How Emotions Are Made, predictive coding exists in opposition to the classic triune brain model (where we have a “lizard brain” with layers on top of it that serve to regulate our basic instincts). Predictive coding is a relatively new approach in the world of neuroscience, which posits that our lived experience in the world – including our sense of wellbeing, our perception of pain, even our muscle tone are based on what our brain – via our nervous system – deems safe. Using this model, physical symptoms such as chronic pain or muscle tightness, as well as mental and emotional symptoms such as anxiety and depression, can be understood as mismatches between the brain’s prediction and correction processes. For instance, in the absence of a physical symptom, when the brain predicts physical discomfort and there’s no corrective feedback to tell the brain “Hey, nothing wrong here,” then that person may experience chronic pain. On the other hand, if there’s relatively little input coming from the body to the brain while the brain is constantly trying to make corrections, that could manifest as anxiety. There’s lots more to learn about this, but the key takeaway is that the difference between the accuracy (or lack thereof) between the brain’s prediction and the stimulus causes our lived and felt experience.
“We don’t know what we don’t know, yet once we know it, it’s known in the muscle,” says Edward Ulm, LMT, SEP, an Austin, Texas-based massage therapist and founder of the Science of Touch continuing education program. “There’s an ancient Papua New Guinean proverb that goes ‘knowledge is not known until it’s in the muscle.’ When we talk about predictive coding, we’re talking about how we interact with the world on a subconscious level. We don’t generally walk into a room and say ‘I am in danger.’ Our bodies default toward a protective response through a motor pattern. When we update that motor pattern, that can be profound. It could literally be life-changing for someone.”
This was a revelation to many, myself included. Based on previous assumptions, it seemed unbelievable that simply pushing on muscles or fascia caused the tissue to change as though they were made of clay, which negated the mechanical style of massage therapy. The energetic style was even more unbelievable because — despite having great experiences both as a client and therapist, I felt like theories of “unblocking qi” or “releasing stuck energy” were inauthentic to my experience.
A predictive coding framework
Using a predictive coding framework, the technique works like this:
- Novel stimuli are introduced to the client (primarily through the hands however, wait until the next section!) and are sent to the brain via the nervous system.
- The brain then compares the stimuli to the predicted sensation.
- If the brain perceives an error in its prediction, then (in the best case scenario) it assimilates this new information and provides feedback through the nervous system.
- That feedback is perceived by the client as relief. As practitioners, we perceive it as a change in muscle tone (from a mechanical standpoint), or a release (from an energetic standpoint).
By assuming the language of predictive coding, what we do as practitioners is much more akin to having a physical “conversation” with our client.
Putting Theory into Practice
Personally speaking, it was exciting to put a language together that helped me wrap my head around why manual therapy works. This framework allows us to better relate to clients who may themselves be more mechanically minded, or whose experience in their body is deeply rooted in their perception of energy. We are often advised to “meet people where they are;” this framework helps us to do just that while staying authentic to ourselves.
Here’s where things get really fun because get this – the top two reasons that massage therapists let their licenses lapse are injury and burnout. Neither of these need to be the case.
Preventing injury and burnout
Let’s talk about injuries first. There’s ongoing study into job-related injuries and it feels reasonable to say that a major cause of injury to a therapist is working much too hard in session. Nearly every massage practice talks about “deep tissue” work. If we think of our work as a conversation, deep tissue work is like yelling. If you want to get someone to change their behavior, you wouldn’t start off by yelling at them, would you? Then why would we start in with deep tissue work on our clients’ bodies? Using the predictive coding framework, we can think critically about what we’re trying to achieve and we can start to search for other solutions to reach those outcomes. If our objective is to introduce an error into their model of prediction, we can exchange some of our intense techniques with techniques that are easier on both the client and the practitioner. For instance, providing some physical feedback through ranges of motion may help our client find greater freedom of movement without pain. Helping a client reach a state of deep relaxation through light touch and breathwork can elicit a drop in overall nervous system tone. This also likely achieves a reduction in overall muscle tone with a much lower intensity of technique. There’s a time and place for just about every technique and it’s important for us to have a variety of diverse techniques and to develop critical thinking skills in order to use the right tool at the right time.
The second reason people abandon our profession is burnout. While this is a really complicated issue with as many unique situations as there are expired massage licenses, many of our peers feel isolated in their work. In a traditional setting, massage therapy can demand an intense one-sided physical, mental, and emotional focus. We put the onus on ourselves to bring the energy, to be the healer, or to act as a receptacle for someone’s physical and/or mental pain. After a long day of this type of one-way energy, we feel drained. The last thing we want to do is recharge our batteries in the company of others – this is a formula for constantly draining our reserves!
The antidote to this is two-fold. The first is outside the purview of this article, but is worth mentioning anyway: we need to orient our business around our own self-care. That means setting strong boundaries around working hours, number of sessions per day, per week, or per month, and then setting the rates we charge based on that capacity.
The second is to shift the dynamic with the client from one-directional to bidirectional. Since the objective of each session is oriented around the client, it makes sense to have the client be an active participant in communication, to ensure that we are moving in the right direction. This approach has a foundation in predictive coding as well. If we are able to help a client form a story that integrates their physical experiences with actions that help change what they perceive to be happening in their body, they can intellectually make sense of the experience. This introduces error into their prediction and response loop. Making sense of a situation changes the situation.
“If someone doesn’t know what they can feel and they feel it, that’s the work we need to be doing,” explained Ulm. “Touch is such an omnipresent sense, that’s the medium we need to be working in. One of the things that’s most important is the surprise – harming and healing happen in the same mechanism, and that’s the surprise.
If we surprise the body into harm, we predict harm. If we surprise the body into healing, we predict healing.”
Build a culture of client empowerment
Promote client engagement from the room into the rest of their life.
When a client is an engaged and active participant in their treatment, outcomes improve. There are two reasons for this. First, we can check our work and ensure that we’re moving in the right direction. Second, a consultation with a massage practitioner may be the only place where a health and wellness professional takes the time to really listen to their complaint, to enable them to pay attention to what’s happening in their body, and take their feedback and adjust their treatment accordingly. In short, our practice may be the only place where our client feels empowered.
Empowerment matters…a lot.
The word empowerment means something very specific. First and foremost, empowerment isn’t something that can be bestowed on someone. Empowerment is a sense of self-sufficiency gained through personal discovery. To this end, a client who develops a greater range of vocabulary to describe their experience in their body or discovers “shades of gray” in their experience of pain (whereas previously it was black and white, i.e. pain or nothing) is a client who is empowered. A client who can fearlessly return to an activity they’ve avoided knowing that even if something goes wrong, they’ve got someone in their corner, is an empowered client.
As professionals, we are allied with empowered clients. As allies, we have a real opportunity to serve a vital and often missing role in someone’s journey of healing. We can become our client’s sounding board as they make sense of the work they’ve already done with several practitioners. This may be thorny ground for some based on the specifics of our expertise, our working environments, and our scope of practice – so your results may vary. Many clients leave appointments with other health professionals with either uncertainty or with guidance that doesn’t feel terribly useful to them. Using the same principles outlined above, we can help a client make sense of the exercises recommended by a physical therapist or the program prescribed by a trainer.
A recent client of mine was also going to physical therapy for lower back and knee pain and had become frustrated by a perceived lack of progress. Her program was pretty straightforward and included exercises like clamshells and glute bridges. By vaguely asking “How are you feeling about the program?” she began to unpack feelings of frustration and discouragement. It felt like torture to do three sets of twelve clamshells. It was mindless and boring, so she was inconsistent about doing the work, which she felt guilty about. Worst of all, it hadn’t made any difference to her pain. To this client, each set looked like a mountain where the only way to get through was to shut her brain off and finish it. It makes sense, then, that she was caught in a self-reinforcing cycle of feeling like a failure.
Once her dilemma was clear, we were able to blend together her expertise in her body and my understanding of the PT’s objective (to build neuromuscular connection and stimulate some muscle growth). She knew that she enjoyed movement when it felt intentional and she also knew that she had never really enjoyed “gym-type” movements. We tried slowing the movement down to see if she could maintain a mental connection to the movement throughout the range of motion. We found that by making a minor tweak to the angle of motion and using a significantly slower pace, she was able to feel the muscle through the full movement and also as though she’d done some real work. As a matter of fact, she felt like she’d done more work with three mindful reps than she ever felt after three sets of twelve reps.
We followed this similar line of thought throughout each movement in the home program and discovered ways for her to achieve her objective. She left that session with a strong understanding of why her PT had recommended these exercises, a grasp on how she could better perform them to achieve the objectives, and the questions to ask the next time her PT introduced a new exercise to her routine. Incidentally, we did no traditional hands-on work in that session, and she left without feeling any discomfort in either her back or her knee. Four weeks later, she’s maintaining the same program and remains pain-free.
Your future role
The scientific world’s understanding of the body, brain, and their interaction has evolved dramatically over the past twenty years, yet so much of the work we do as massage therapists remains focused on finding the right hands-on techniques – as though there was a “magic bullet.” The concept of predictive coding is an entryway into the rapidly evolving world of neuroscience that can immediately have a significant impact on the lives of our clients. By recasting ourselves from the role of healer and into the role of helper, we can build a transformative culture of client empowerment while also improving our own quality of life and the longevity of our practices.