Ep 141 – Mindful Awareness in Body-Oriented Therapy with Dr. Cynthia Price

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0:02:07.8 Darren Buford: Welcome to The ABMP Podcast. My name is Darren Buford, and I'm Editor-in-Chief of Massage & Bodywork Magazine and Senior Director of Communications for ABMP.

0:02:15.9 Kristin Coverly: And I'm Kristin Coverly, licensed massage therapist and ABMPs Director of Professional Education.

0:02:21.1 DB: Our guest today is Dr. Cynthia Price. Dr. Price is a research professor at the University of Washington School of Nursing in Seattle, and the Director of the Non-Profit Center for Mindful Body Awareness. She developed mindful awareness and body-oriented therapy, MABT, a body therapy approach designed to facilitate interoceptive awareness and related skills for self-care and emotional regulation. Dr. Price's research is aimed at the study of MABT within community care, particularly for those in recovery from trauma, chemical dependency, chronic pain, and other life stressors. Dr. Price is committed to increasing access to integrative and complementary healthcare for underserved populations through her research, teaching, and service. For more information, visit cmbaware.org. Hello, Dr. Price and hello, Kristin.

0:03:17.9 Dr. Cynthia Price: Hi, good morning.

0:03:19.4 KC: Hello and welcome to The ABMP Podcast. We're excited to have you here. We're very excited to learn more about MABT, but let's start by learning a little bit more about you. So, tell us about your background. How did you get started in massage therapy, and then what led you to diving into and becoming involved in bodywork research?

0:03:37.3 DP: Well, I trained as a massage therapist in 1981. I was a junior in college and decided to take a semester off and do that, and that kind of was... That was because I was getting increasingly interested in women's health and also alternative therapies and traditional medical approaches through both some of the activism I was doing, as well as studying anthropology. So, it was kind of this mix of things that I was like, "Well, what's [0:04:13.9] ____ successful to me around the corner," and massage therapy was. So, I went to California, I'd never been there, and that seemed like the right place to go to study massage. [laughter] And it was. I had a wonderful experience at Heartwood Holistic Health Center studying massage therapy there for a semester, and I thought I would never do anything with it. I thought I was just taking a break from college and trying this thing out.

0:04:40.2 DP: But I loved it, and I surprised myself, I have to be honest, with deciding to increasingly make it part of what I was doing career-wise after I finish college. So, I had a part-time practice and I worked in other... And other arenas part-time, and then it became what I did full-time. So, I was in practice for 20 years, and toward the end of that period, I felt more and more drawn to thinking about how this work that I was doing, which was increasingly focused on body awareness, increasingly, my patient population or the clientele that I was serving were women in trauma recovery. And I was really committed to moving this work, so it was more accessible to more people. And I couldn't figure out how else to do that other than doing research. And that was partly because at the time, we're talking the late 90s, I was living in Boston... In the Boston area, and it was really challenging to bring an alternative therapy more mainstream. There wasn't... I felt like I tried and I talked to people, how could I do this? How could we set up a program, how could we bring this more into sort of traditional mental healthcare? 'Cause I was really, really focused mostly on trauma recovery.

0:06:17.6 DP: And it's like hitting your head against a wall. I just couldn't... I didn't have a PhD, I wasn't known as... I just had my little private practice.

0:06:31.1 DP: So everything kind of pointed in that direction for me for some reason, and I'd done a little research in some other jobs, and I liked it. I tried doing... My first research project I did within the context of my practice, I had a Boston massage school set up an IRB for me, and I published that in the end, but it became really clear that you don't know what you don't know, and how much there is to know about research. And so all things kind of started pointing in one direction, and there was the Center for Women's Health Research that was at the University of Washington, and I came out to... For Women's Health Research, it was the only funded center for women health research. I didn't totally realize when I came out that it was in the School of Nursing. And I had this experience of meeting all these faculty members going, "Oh, my gosh. I could do my research here." They would support me doing touch-based research here, and I like these people, and I would be getting a very rigorous PhD program. I hadn't thought I wanted to do a PhD, but everything culminated to my going, "Okay, let me apply." And so that's how I ended up where I did.

0:07:46.6 DB: Dr Price, what led you to develop mindful awareness in body-oriented therapy?

0:07:51.9 DP: So as part of my PhD program, I came in very, very clear that I was there to study the work I had been doing. And so I wanted to do a touch-based dissertation intervention study. And nursing practice... In the old days, massage therapy was part of nursing practice. And nurses are pretty comfortable with touch in general, so nobody looked at me cross-eyed. They were like, "Okay, you're in a different discipline, we know that, but we'll support you." So my mentor and the chairperson who ended up chairing my doctoral committee, she said, "Okay, well you need to have a protocol if you're gonna do a dissertation involving intervention study." I didn't even know what a protocol was. There was so much for me to look at. And she said, "You need to... If you're wanting to study the kind of work you were doing, you need to think through what were the core components that you were doing in your practice, and write up this protocol and I'll help you." And at first, I think I looked at her probably like, "You've gotta be kidding." I didn't think about what I was doing in a protocolized fashion because it wasn't.

0:09:07.1 DP: And I was unsure whether I could really do it. And so my initial responses were why... There's lots of other people doing stuff similar to this, let's just find somebody else's protocol that's similar enough, and we'll use that. But that didn't fly. People who have... There's a lot of protective orientation around folks who have developed their certain approach. So even though there are other approaches that are very similar to what I was doing, I did reach out to people and there was absolutely no willingness or interest in having me research what they were doing. So I was in a position where I had no choice. I had to design this protocol just as I had been instructed to do, and that ended up being quite a job for me, and I did get excellent help, and then that ended up being the protocol that was used in my dissertation study and that we still use today.

0:10:04.4 KC: I'm so curious, how long is the protocol, how many minutes?

0:10:08.5 DP: We do an eight-week intervention, and it's 75 to 90-minute sessions over those eight weeks. So some studies, most studies, they've been 90-minute sessions once a week for eight weeks. The current study, they're 75-minute sessions.

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0:11:04.2 DB: Now, let's get back to the podcast.

0:11:06.7 KC: So when you were developing this protocol, I'm so curious to know what are the core principles and components of MABT, what did you settle on when you were thinking about how do I really develop a protocol and a practice to research what you were looking to research?

0:11:23.1 DP: The actual process was so long ago now that I don't remember for my personal process with that, [chuckle] but what we did end up with was a protocol that's designed to incrementally introduce people to body awareness and then to teach them to move more deeply into the experience of moving their attention into their bodies in a mindful way. So, so many of the people that I had been working with in practice were pretty disconnected from their bodies, mostly because so many of them had severe trauma histories. So they needed to feel safe bringing their attention into their body, and they needed to have a way in which they grew their capacity to do that. So the intervention is designed accordingly. The first couple sessions are focused on what we call massage with body literacy, which is simply finding words to describe... To identify and describe how you feel.

0:12:32.4 DP: So we're staying more on the external level of awareness to the body in response to touch, through massage, where the practitioner is pausing at certain places on the body that often might be a tight knot or something like that, and just saying, "What do you notice here? How would you describe it?" So we're starting there, and then the next two sessions are focused on helping people to gain some capacity for accessing awareness internally. So instead of having their attention more externally on a tight muscle, it's bringing their attention more to the experience of the sensation of breath, for example, which is very, very typical in mindfulness-based approaches, following me, for the sensation of...

0:13:28.4 DP: Inhaling and exhaling is a very classic way that you introduce the concept of interoception in mindfulness-based meditation. We're doing that kind of thing, a little different than that but that kind of thing, in the next couple of sessions, just to help people bring their attention more internally.

0:13:49.9 DP: And then the last four sessions of this eight-week intervention, the primary focus is on learning to sustain attention in a very specific region of the body. So let's say someone says, when they're... One of the things that they're working on in their lives that's really hard for them is that they get really anxious in certain kinds of situations, and they notice that in their bellies. So what we're gonna be eventually focusing on is can they bring their attention into that region of their belly where they feel that? If you know anything about mindfulness interventions, there is this term called "Mind-wandering," which we all do. You bring your attention inside, and the next minute, you're thinking about the grocery list. And it's like the work is not... That's normal. The work is to say, "Okay, we've noticed that," and bring your attention back inside.

0:14:46.8 DP: So the therapist is working with a client to both normalise that, but also to help them return. And that's why we use touch, and touch is so extremely important because it gives the client a place to help them know where they're returning their attention to. So the therapist's hands could be there sometimes, they then go home and practise this, and they put their own hands there to do the same practice. The touch is extremely helpful for teaching, it's extremely helpful for practice, and what the therapist is then doing in that process is helping the person to pay attention to what they notice internally, whether it's how comfortable or uncomfortable it is, whether it's some information that's more kinaesthetic to sensory awareness in the body, that's more physical, whether it's other things that might come up for them that, "Oh, yeah, I really feel anxious now," to, "Oh, my anxiety level is really reducing and I'm feeling really relaxed right now." And then talking about that experience and reviewing it.

0:16:06.5 DP: So those are the primary components on the table. Every session starts seated, ends seated, with talking to both help guide how the session is gonna go at the beginning, and then to integrate the work that happened on the table at the end, and to come up with a related home practice. So in some ways, it's five components, 'cause I think that introduction and that session review that we call it, or the intake and the session review, are as important and certainly take up as much time in the total session experience.

0:16:40.8 DB: Dr. Price, would you describe the hands-on component as Swedish massage or typical relaxation massage or deep tissue, or can that fluctuate?

0:16:50.3 DP: The first two sessions, when we're doing... We're kind of doing a full body massage, but pausing wherever there are places in the body that it seems like it would be a good place to ask this question, for someone to tune in and really describe what they feel. If it's some place where there's not much going on, you're not gonna stop there, but it gives the therapist an enormous amount of information, so this is as much for the therapist as it is for the client. The therapist then gets a real sense of the person's body, where they're tight, where they're not tight, how well they can describe what they feel, where they can't. And that's enormously helpful information that can then guide the therapist, too, in what they will do next and how they're gonna do what they do next. But we're really focused on those verbal interactions that happen consistently throughout the time that they're on the table.

0:17:46.6 KC: The phrase "Interoceptive awareness" may be new for a lot of listeners. Can you tell us a little bit more about that?

0:17:52.4 DP: Sure. It was new for me, too, actually 10 years ago, I would say, and it's a term that really was not used clinically at all at that time, but then started to be used mostly because of the mindfulness meditation research that was happening, where as it was explaining this focus, for example, on the inhale and exhale of the breath, that is [0:18:22.9] ____ and attaches to internal sensation, which is interoceptive. Proprioception is the sense of your body moving through space. Interoception is sensations that can be experienced internally, many of which are not conscious. So the term "Interoception" was used more traditionally to actually refer to often unconscious processes that are about how sensation is... Sensory pathways in the brain are bringing information to us all the time, but we don't always... We're not always aware of that.

0:19:04.0 S1: And as clinicians got more involved in the concept through this research of what's happening through the mindfulness world because neuroscientists were getting involved in that research, so the term kind of came through this kind of process, and then people like myself, who were clinical researchers were going, "Well, that's exactly what we do. We're paying attention to interoceptive awareness all the time, we just didn't know the term and we weren't using that term." I was using the term "body awareness" which is a perfectly fine term, but it's more broad. It can include any kind of awareness, proprioception included. So a bunch of us actually got involved in scale development and conversations, white papers that really help to bring this term into the work we were doing, whether we were mindfulness meditation researchers or, in my case, a bodywork researcher. And so that kind of happened around that time, around 10 years ago, and so now we're using the term a lot.

0:20:13.0 DB: Dr. Price, because MABT has this verbal component to it, do you ever get asked questions about scope of practice?

0:20:20.2 DP: I get asked that question all the time. Yeah, and I think with massage therapists, I get asked that question all the time. There's often that initial concern, "Does... Will this... If I learn this work, will I be taken out of my scope of practice, if I'm doing this much verbal interaction?" And you know, there's some people who I think would feel uncomfortable, you know, who might say, "I don't want to... I wouldn't wanna go that direction 'cause that's not where I wanna focus how I work with patients," and that's totally fine, but for many people who are massage therapists who are more interested, I think in really focusing and integrating body awareness and maybe focus more on emotional well-being and the ways... See themselves as the educators around sort of this broad well-being realm that we often find ourselves in, I think that this work very much fits into the scope of practice of massage therapists because we're really focusing on sensation and staying in present moment awareness.

0:21:26.1 DP: So we're not asking about someone's past history, and their psychological stories. I mean, this is about present moment awareness, not about the past. This is about what's going on right now. And that doesn't mean that you won't have a client who might have a memory, or might have a story that they bring into practice, I think massage therapists experience that often, regardless of whether this is the focus of the work, because we have a lot of people who talk a lot, we have people who are bringing in their life stories, they're bringing in their stressors, they're bringing in their goals for themselves that have to do with their daily lives and the struggles that they have. And so some massage therapists are gonna hear more about that anyway, right? And so, it's we all have to find a way that we manage that, and that's a skill in and of itself.

0:22:22.6 KC: I'm curious, we've been talking a lot about the protocol in terms of an eight-week protocol, that people can learn and follow, and that makes a lot of sense for a research study, where everyone needs to be doing the same thing for the same amount of time, but I'm curious about how private practice therapists who learn MABT take it back into their own practice? Do you recommend that they follow the eight-week protocol or that they take pieces of the tools and incorporate them into their practice in different ways?

0:22:50.0 DP: You know, we are teaching the protocol to therapists because it's structured, and so it's an easy way to present the material, but we're not necessarily suggesting even that people in private practice follow an eight-week protocol. Now that doesn't mean that someone might not choose to do it that way in their practice, that's up to them. The idea is that they have a new set of skills in their tool box, just like anything else that they would go to study for advanced practice, and they're gonna integrate these skills as much or as little and when and wherefore, that they feel is appropriate. Now, when I was using this kind of work in my private practice, there was not an eight-week protocol.

0:23:33.9 DP: So that mindful body awareness piece was something I might do with someone every session for a component of this session for two years, because you can go very, very deep with it, very deep with it therapeutically. So, there's the learning process of it, of really exposing people to all of these skills, and that's what the eight weeks is about, but you could have somebody who's like, "Oh, [0:24:04.4] ____ paying it, describing what I feel for sensation, I know how to do that." You assess that very quickly, you know what I mean, but you never do it again, right? So then you're kind of moving into, "Well let's learn these other ways of bringing your attention to the body, maybe somebody needs a lot of time with that to get really comfortable with it, and maybe somebody doesn't. So how much of this you use when you use it and for how long is so individual and when you're in private practice, you can do it that way. I do wanna emphasize that we don't get to do this in any program. We don't get to continue to use these skills in a way that deepens someone's therapeutic work, and in private practice, you can.

0:24:47.7 DP: And I think, I don't know how the people we train who are not working at our research studies do what they do. We'd have to have a practice-based research study in order to find that out.

0:24:57.7 DB: Dr. Price, the mission of the Non-profit Center For Mindful Body Awareness is to increase access to mindful body awareness strategies. How does the center work to fulfill that mission?

0:25:08.8 DP: In terms of increasing access for people who may not otherwise be able to learn these skills. So if we've got practitioners who trained with us who are in private practice, who are still mostly serving probably middle to upper class income folks, but we see quite a lot of folks who also are volunteering, they're working with homeless populations, they're working in other kinds of situations where they have access to folks who don't have access to these kind of services from a self-pay or an insurance pay kind of situation. But we're also working to kind of bring this work into systems, and I'm still growing that part of what I'd like to see happen, which is to really help have more of this work available in clinic situations like we're doing our research, where it's integrated into either a treatment protocol, or an inpatient or outpatient recovery kind of situation for people who are in substance use, but honestly, this work is really helpful for people who are managing other kinds of health conditions, and I just haven't done research in this realm, but say you've got diabetes, or say you've got another kind of condition where learning to focus on your physical cues to kind of help you manage that.

0:26:39.5 DP: So whether it's a physical health condition, or a mental health condition, or just your stress at home, finding ways that this work can get integrated more in this system because more therapists know how to do it, not just bodyworkers, but other kinds of disciplines as well, is huge, and that's the research end of it, as well as just hopefully finding clinics that get it. You have to have the leadership understand the importance of this kind of work and value it enough in order to think about how you can actually make it an integral part of what you offer, whether... Regardless of which discipline you have on your staff to do it. Whether it's a physical therapist, whether it's a nurse, whether they're a massage therapist, or whether you're hiring people in order to do this work. So we've got a brand new implementation study we're doing at a pain clinic at Vanderbilt University. It's called the Osher Clinic, it's part of the Osher Clinic system of which there are seven in the world. But anyway, their massage therapists are on staff and they've trained in this approach, and they're really integrating it into practice. And so that kind of grew out of the center.

0:28:00.3 DP: We've now got some small grant opportunities to help us do research, but... 'Cause we're doing this little implementation study to look at how is this happening on a systems level? Are the various providers that are involved at this clinic referring to these massage therapists in order to get this MABT approach? How many people are coming? Do they stay in? Do they ask for more than eight sessions? Those are the kinds of questions that we're asking on a systems level, and we need more of that, we need more of that. So the center, well, from my perspective is, got all these different branches. The primary work we do right now is offer these classes to individual practitioners, but I would like to see us have more opportunities to really move this work into these bigger domains as well.

0:28:50.8 DB: I wanna thank our guest today, Dr. Cynthia Price. Listeners, find out more information about Dr. Price and her work at cmbaware.org. Thanks, Dr. Price, and thanks, Kristin.

0:29:04.0 KC: Thank you so much for being with us and for this wonderful work that you do and for telling us all more about it so we can start to explore ways we can bring that into our own practices.

0:29:12.9 DP: My pleasure. Thank you.

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