The "A" in SOAP: Charting Goals for Client Progress

In my opinion, the "A" in SOAP charting is the most difficult section to address. As massage practitioners, we generally use this section for client goals, particularly when an insurance claim is involved. Goals are supposed to be SMART (specific, measurable, attainable, relevant, and time-bound); they should be based on ADLs (activities of daily living); and there should be two types of goals, short term goals (STGs) and long term goals (LTGs).

The problem I most run into is setting goals that are both SMART and based on ADLs. Why? Because many of my clients claim not to be restricted in activities of daily living: they are simply working on through the pain, and they claim there is nothing they really cannot do. In Hands Heal, Diana Thompson suggests asking the client about sleep patterns because even if they are not seeing restrictions in ADLs, people in pain are often suffering sleep problems/deficiencies. So, when a client does have a sleep problem, this can become the foundation of the goals if nothing else can be pinpointed. However, many clients have pain, but no trouble sleeping, so this option is out for them.

It is extremely tempting, then, to fall back on pain levels as the basis of the goals. For example, “The client will have no more than 4/10 pain after six massages.” I was taught, however, that this is a no-no because pain levels are subjective and hence not truly specific or measurable, and therefore not SMART (ACK!) It’s frustrating, though, because if there is one thing the client is sure of, it’s how much pain he is in at any one time.

I know that all of us want to handle SOAP goals professionally, particularly in cases where client care depends on the insurance company continuing to pay for services. What I would like readers to do is share successful methods of forming SMART goals for massage clients. I know that many of us would be eternally grateful for any tips and advice on this issue!

The Other F-Word

As I was leaving a massage room the other day, I almost literally ran into one of my favorite coworkers who had stopped short in the middle of the hallway. She looked both startled and confused. “What’s the matter?” I asked, concerned. She blinked at me, then burst out: “I farted! Should I say something?” Then she giggled . . . a little madly, I thought. “Uh, well,” I said, realizing she was expecting an answer, “as you know, in the South, ladies don’t . . . do that. Or at least they pretend they don’t. So if they do, they act like they didn’t and basically don’t call attention to it at all. Does that make sense?” She thought about that. “Okay,” she said, and went on her way.

A few days later, the same therapist and I were in a workshop. The teacher asked if anyone had any general questions before we began. My friend held her hand up. “Yes?” the teacher asked. “What do you do if someone farts?” my friend asked. The teacher looked at her blankly, and I put my head in my hands. “I’m not sure I understood the question,” the teacher replied. “If you mean, what would I say, I guess it would depend on the client. I might ignore it, or I might say ‘that was a good release.’ In any case, it’s a natural thing.” “I know,” my friend replied. “I just want to know what to do.”

I’ve been thinking about this question, and it causes me to realize just how fastidious I am in some ways. I can’t really even say “fart,” and I can barely even write the word down. In spite of the fact that ladies like my mother didn’t fart (of course) she still taught me to say “pass gas” so that I could have words to describe something that lesser humans might do. And no matter how many times they told us in massage school to expect lots of farting, I can face it, but I can’t say it. I may be a professional, but I almost feel that if I acknowledged a fart and used the f-word to describe it, 2700 miles away, my poor mother would faint. So I guess I’ll let my friend be the brave one for now . . . and keep on being lady-like!*

*(meaning, in this case, graciously and concertedly clueless).

Stand Up Straight!

Although my grandmother loved me very much, it didn’t stop her from terrorizing me about my posture. Perhaps concern for me drove her to use fear as a means of encouragement. “Stand up straight!” she’d screech, appearing out of nowhere and smacking me between the shoulder blades. “Be proud you’re tall.” And then she’d suck up straight herself to demonstrate to me how I should do it. Problem was, I wasn’t proud, I was mortified. I was not happy about being about a foot taller than the other kids (and ALL of the boys) and having red hair to boot. I did not want to stand out, and so I slumped. Slumping became a habit, and to this day, I still have to consciously self-correct my posture. And while pride/shame are no longer issues, the fact that I am no longer just tall, but busty as well, has made me paranoid that if I drop my shoulders back and put my chest out, someone might inadvertently lose an eye . . . sigh. So when it comes to my posture, I just do the best I can and call it a day.

I have many clients who are horribly self-critical about their posture. They deride themselves constantly, calling themselves “lazy” and indicating that they are “failures.” I like to point out to them that there are multiple reasons for “poor posture,” some of which are difficult to control (unreleased pecs pulling the body forward, gravity like a huge hand on the back of the head). What most concerns me is that I believe the body listens and absorbs negative self-talk. I would much rather have them say, “Wow, body, you had a terribly stressful day, and yes, you got slumpy, but now let’s take care of you with a massage and a good meal to help you stand up a little straighter.” I would rather have them explore dance, or massage, or chiropractic adjustment to improve their structural health rather than have them slumping further forward in a bad-posture-is-ugly-and-immoral funk.

My grandmother, who has suffered from osteoporosis for many years, is now shrunken and bent. It makes me sad to hear her criticize this “failing” and watch her try to suck herself up into a position she can no longer even remotely achieve. We weren’t born with books balanced on our heads, and we won’t die that way either. So while “good” posture and structural health are important, I tend to lean toward a “do the best you can” view rather than having people give up on their health or having them hate themselves for not matching the illustrations for optimal bodies in anatomy books.

The Massage Store

The store, which had been a gathering place for massage therapists, was going out and under. The shelves were half-bare and the phone had been cut off for a week. No more job board, no more bumping into friends, trying out CD's or talking shop. The Orange County Bodywork Emporium in Costa Mesa would soon be no more.

They never carried any oils I liked, but I had bought the odd emergency bottle of oil there. They had been there for emergency chair rentals, quick re-stocks of linens or replacing broken face cradles. I enjoyed looking at the odd and curious collections of self-massage items that would come and go.

In this age, we have a good half-dozen online massage supply stores and lots of ways to connect with emails and Facebook and tweets. Yet I still like the smell of oils and the feel of sheets. I’d picked up my second and third and fourth tables there, after carefully examining the workmanship and warranties. I liked the manager's way of announcing "And the Governor’s share" when he added on the tax. The store sponsored ads in our little newsletters, sponsored Touch Foundation volunteer and public service programs. The managers even went out to classes to show people how to lift a packed table without developing lumbago.

But all this is a remembrance of things past. The stores we order from today are online warehouse-style places 20 states away. Even with shipping the prices are great and if you know what you are ordering, the experience is easy. No doubt the online thing, just like this blog, is a far more efficient way to communicate and educate.

Still, I miss the little store on Newport Ave., with its block-letter sign dwarfed by the furniture place next store "Gen X" and the sandals place on the other side.

A sign of the times, eh? It's not like massage folks will hang out at a bar somewhere – well, maybe a juice shop. I’ll have a wheat-grass. Straight up.

Beautifully Useless

Sometimes we find that our brains just won’t stop working, particularly during times of stress. Images of things we wished we had or hadn’t done and images of all the things we have to get done keep playing and re-playing in our heads: many times accompanied by distracting and disturbing emotions. Sometimes this even happens when preparing to give a massage or even during a session. And it can be hard to clear our minds and return our very necessary good, healing intentions to the task at hand.

I read a wonderful book by Lois McMaster Bujold once, called The Sharing Knife. In one of my favorite scenes, a character named Dag is consoling the much younger runaway Fawn just after she suffers a sudden miscarriage and is trying to process a staggering kind of emotional loss previously unknown to her. “Think of something beautifully useless,” he tells her, recounting his own story of floating on a lake staring at water lilies when he was young. “There are a lot of senseless things in the world, but not all of them are sorrows. Sometimes—I find—it helps to remember the other kind.” When Dag finishes his story, he adds, “Later, in some very dry places, the memory of that hour was enough to go on with.”

I love the whole idea of something beautifully useless. I have my own versions of Dag’s water lilies. A pink rose in a blue vase, for instance. As a tiny child, there was a single rose bush growing in the courtyard of our rented house. And my mother would let me take the scissors and cut just one pink rose to put in a blue glass bud-vase left to her by her grandmother. The memory for me is pure joy. I was too young to attach any more emotion to it than that: just the appreciation of a perfect pink rose in a glowing blue glass vase. When I call such an image to mind, even if I can only hold it and nothing else for a few minutes, I find myself more relaxed, more rested, more centered, and I can return to my massage or other tasks with renewed presence.

The Dandelion: Magical, Messy Weed and Novel Nutritious Green

The dandelion is undoubtedly one of childhood’s favorite flowers; probably because it both incredibly magical and terribly messy. I still fondly remember warm weather spent crumbling mimosa pods and blowing dandelion fluff with my mother shrieking “STOP SEEDING THE LAWN!” in the background.

As an adult, the dandelion has continued to fascinate me with it’s perfect round sphere of little seed-wishes, each with a set of soft wings. The average gardener, though, is rarely so captivated. That’s easy to understand given that dandelion is very prolific and has absolutely no sense of boundaries—it will grow most anyplace, anytime, whether you’d like it to or not. This spring, in Seattle, I saw some truly amazing specimens, some between one and two feet tall. The rare dry heat of Summer 2009 seems to have curbed the crop a little, but dandelions are still cheerfully blooming up from every crack and crevice and over-run lawn. So I thought I’d blog a bit about some of the more universally useful qualities of this faery-like weed.

First, it’s long been used as medicine. Even those who don’t typically dabble in herbs much have seen a box of dandelion tea while shopping at Whole Foods or Super Supplements. According to Balch’s well-known Prescription for Natural Healing, all parts of the plant can be used, and it is an amazing composition of everything from biotin and calcium to phosphorus and zinc. It tends to appear in tea form often because it is a strong detoxifier and diuretic. It not only cleanses the liver and bloodstream and improves kidney and other organ function, but it has also been used to treat “abscesses, anemia, boils, breast tumors, cirrhosis of the liver, fluid retention, hepatitis, jaundice, rheumatism, and the prevention of age spots and breast cancer” (69).

Second, the greens are edible and plentiful. As someone who used to arrive home from playing outside carrying tube socks full of wild blackberries (Mom was really unhappy about that too), I just love the idea of eating straight out of Mother Nature’s lap (as long as her lap hasn’t been sprayed with pesticides). Mark Bittman’s Leafy Greens is an excellent resource for learning how to harvest and prepare dandelions. A few of his tips include:

• The smaller the better. Leaves longer than six inches are most likely too bitter to eat.
• Leaves can be sandy, so wash them well.
• Use young greens in a salad with olive oil and salt, adding a little extra vinegar or lemon juice to counteract the natural bitterness.
• If you can hide the plants from the sun (loosely covering them with boards, etc.) when they are about three-quarters grown, they will turn white and be less bitter.
• Older greens taste better steamed or sautéed like spinach. (23-24)

Bittman also remarks that dandelions “are so loaded with beta carotene that one half expects them to be regulated by the Food and Drug Administration” (23). If Mom had known that, maybe she would have been happier about us “seeding the lawn” . . . or maybe not :-)