Fulfilling need in a community-based primary care setting
Odette Wood (Dip TM, NZCM)
Massage may be considered to be a treatment accessible mainly to those with a reasonable level of disposable income. Recent research indicates that the most common charge for massage treatment in New Zealand is $60 per hour (Smith, Sullivan & Baxter, 2011). For those who are beneficiaries or on low incomes, cost can be prohibitive to seeking massage treatment. However, those who face high levels of financial strain often have higher levels of mental stress and physical health problems (Evans & English, 2002; Tobias & Cheung, 2003) and could benefit greatly from massage therapy.
Massage therapy has been shown to decrease blood pressure, state anxiety, depression and pain levels and to enhance immune function and sleep (Field, Diego, & Hernandez-Reif, 2007; Moyer, Rounds, & Hannum, 2004). New Zealand research has indicated that GPs recognise that massage therapy is helpful for some patient conditions and illnesses, with most GP referrals for massage therapy being for musculoskeletal conditions, followed by stress, pain and relaxation (Lawler & Cameron, 2004). A recent survey of GPs in rural and regional New South Wales, Australia, has shown high levels of support for massage therapies among Australian GPs, relative to other CAM professions, with low levels of opposition to the incorporation of these therapies in patient care (Wardle, Sibbritt & Adams, 2013).
In 2006, New Zealand College of Massage (NZCM) Wellington campus tutor Joanna Tennent approached community health service about the possibility of arranging community placements for year one Diploma in Therapeutic Massage students. The aims of the placement were to provide students with exposure to working with different cultures and populations, to be of service to the community, and to provide massage where it may not normally be accessible.
NUHS is a community health service providing comprehensive primary health services for around 6,700 low income, beneficiary and union members in the south Wellington area. The service has been in existence since the late 1980s and was developed as a result of the political and socioeconomic reforms that happened in New Zealand at that time, which led to a widening gap between rich and poor. NUHS has an integrated, holistic approach to meeting the health needs of its patients, delivering a range of services including clinical care, health promotion and early intervention, health screening, mental health, child and maternal health, refugee health, and social work (Well Health Trust PHO, 2013). It predominantly serves people living in high socio-economic deprivation with around 63% being in quintile 4 and 5. It also serves an ethnically diverse population, many of whom are refugee (Newtown Union Health Service, 2010), and a substantial number of people with mental health conditions.
NUHS was supportive of the community placement proposal and saw it as a win-win situation – patients would have access to a therapy that they would otherwise would likely not be able to access easily, and students would gain valuable experience treating clients and conditions that they may not routinely come across. The service has a history of participating in placement programs for nursing, GP and midwifery students, and providing allied health services such as social work and dietetics, so the placement opportunity fitted within that model. The massage clinic was based in a spare GP clinic room at the health service during the week. GPs provided written referrals which enabled the students to get relevant information so that they could safely work within scope of practice. Sessions were 30 minutes and provided free. The placement ran for about 2 years and during that time, many students found it to be an invaluable experience – learning to deal with the challenges of language barriers, getting to grips with cultural differences, being adaptable with having to work in a small space around existing equipment, and feeling good about providing a service for the community.
In early 2008 NUHS no longer had a spare clinic room available during the week for the community placement. However, for two students who had recently graduated - Sabine Cowan and Roberta Collingbourne, the placement experience had instilled a love to continue providing massage therapy at the specialised service, so they took on running the massage clinic themselves on Saturdays, for a koha.
Six years later, the massage clinic is still running on Saturdays at NUHS and it is possibly one of the only primary health-based massage clinics of its kind, within such a community setting in New Zealand. It continues to be well supported by NUHS GPs who refer their patients for massage treatment. GP Vivienne Coppell, believes that massage is a good treatment option for a proportion of her patients with muscular pain or impaired function. She comments that physical therapies rather than medical therapies seem to work for some people like this, with some of the Assyrian women in particular, responding quite well. She says that having the therapy available at NUHS premises and at a significantly subsidised cost, means that it is more accessible for their patients, which is part of the NUHS model. This is a benefit for NUHS patients. Dr Coppell says that for some of her patients, massage is a curative therapy – they have one or two treatments and are better. However, for the majority of her referrals, it is about ongoing management. Massage helps them live with their ongoing pain, providing an alternative to prescribing tablets all the time.
The massage clinic remains popular with NUHS patients. Liz Brown has been coming for massage on a weekly or fortnightly basis for 4-5 years. She says that were the massage clinic not available at NUHS, she would not be able to afford regular massage at normal industry prices. Liz says that massage helps by improving her movement, bringing healing and relief and helping her to manage her existing long-term musculoskeletal conditions. She also says that she feels reassured that the massage therapists at the NUHS clinic are researching her conditions in their own time so that they become better informed and develop their knowledge. Liz feels she is being treated by a professional who understands the body, not just from a medical sense.
Another patient, an Ethiopian woman who has been coming for two months after having an accident, says that massage is very important. She used to think massage was a waste of money but has changed her view after seeing the results that it has had for her. She says it is like medicine and has noticed changes in her body since she has been coming regularly. It helps her feel more relaxed, have less pain, and improved sleep. She says it is not easy financially, but she goes without buying some things to afford her regular massage. She also likes the friendliness of the therapists and recommends massage to her friends.
Eric McLeod talks of the massage enabling him to be a good father and keep his family together. He was first introduced to the massage therapy clinic in 2008 by his GP, Dr Pauline Horrill, to help find relief for his sore muscles that resulted from a fractured hip. He says he has received many therapeutic massages regularly and recommends anyone take up the amazing healing experience, as he has found it truly beneficial.
Sabine discusses cases that she has worked with for over 6 years. An Assyrian woman who has been coming fortnightly for six years to try and maintain her health. She has many stresses - family pressure, her home cleaning duties, isolation, financial struggles, having family back in Iraq and worrying for their lives. Or it could be the Indian woman who was working and studying fulltime to try and keep some sanity and feel included in New Zealand society. She suffered with depression as she was an outcast in her own society due to having married below her caste. Most women have cleaning jobs, which builds up more muscle tension. Years of stress can be seen in the patient’s tissues, reflecting their histories and life experiences. For many, this has included trauma, especially for those who have come to New Zealand as refugees and have had to endure physical, mental and emotional pain associated with leaving their once-safe home. The massage is an intervention trying to break a cycle, it’s really hard to try and work with bodies of steel – they really have such tough muscle tension and skin texture that feels stuck. Shoulders and forearms are some of the main areas being treated. These areas manifest a lot of pain, particularly among those who do cleaning jobs. Ongoing headache symptoms are also very common. Sometimes they don’t turn up on their first treatment session because they don’t know what to expect, or are really worried, as most do not speak English. But once they realise the therapists are willing to help them to understand what is required, they don’t miss many more sessions. They say the massage gives them a place to relax that is just for them – where they can talk to someone who is not involved. So while it may not be seen to always improve the chronic muscle dysfunction, it certainly improves the mental state of mind. For the therapists involved, it is humbling being part of that.
Having a flexible approach is critical to the role as a massage therapist working at such a place as NUHS, as is building good trust and rapport. The therapists also have to work quickly, having only half an hour for treatment. Although they have a referral to go by, the session time has to be maximised so the client can get the time on the table. Often the client changes quickly behind a curtain or the therapist holds up a sheet up for them. Non-verbal cues are watched for as they are an essential part of communication - sounds, muscle tensing, breathing patterns, facial expressions. These women strive to not show the amount of pain in their bodies, they prefer to suffer rather than let the therapist know, so it can be difficult to read these cues.
How do the therapists cope? Sabine says that it is never threatening and she always feels the solid support of Dr Coppell and all the other GPs at NUHS, who really foster the need for massage for the patients. It is always a warm atmosphere says Sabine. After four years of working for koha, patients now pay $20 per half hour and really value the opportunity for a complete therapy session. However, people work here to help, rather than to make money. There are now two therapists who work on Saturdays under Sabine’s knowledgeable supervision. Neriza Era is originally from the Philippines and understands what it is like to have English as a second language and move to another country. Having developing a passion for healing work since caring for and massaging her father after he had a stroke. She was drawn to massage therapy and decided to train in the field. Odette Wood was Operations Manager at NUHS, responsible for the day-to-day running of the service and involved in setting up the community placement with NZCM eight years ago. Through that link and her own experiences with massage, she decided to retrain as a massage therapist and see patients from the other side. This has been a very satisfying change for her. Both Neriza and Odette are about to graduate this year with the Diploma in Therapeutic Massage.
Working in the clinic is a great learning experience for therapists, encouraging them to think outside the box and bravely give new things a go, helping to prepare them for a long and successful care in massage. Most importantly however, the massage clinic provides a high needs community with a therapeutic approach that helps, not just physically but in a biopsychosocial sense as well.
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The author would like to acknowledge the support of Newtown Union Health Service for providing permission to write this article and to the patients who kindly shared their stories.