A Profession-Wide Mental Health Crisis: Risk Factors

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Corey Rivera and Cal Cates address the alarming suicide rates among massage therapists by exploring underlying risk factors, including perfectionism, isolation, and occupational stress. By recognizing these nuances, the conversation encourages community engagement and accountability to promote better mental health outcomes.

• Discussing general risk factors for suicide 
• Understanding perfectionism and its types 
• Examining isolation within the massage therapy profession 
• Highlighting the economic instability faced by massage therapists 
• Analyzing the impact of ACEs on mental health 
• Exploring job demand and control dynamics 
• Reflecting on the effects of COVID-19 on the workforce 
• Emphasizing the need for community and support in the profession

Healwell Blog; Worst. Game. Ever.

CDC Article: Suicide Rates by Industry and Occupation
Healwell Class: Empowering Individuals to Navigate Crisis
Integrated Motivational Volitional Model of Suicidal Behavior

Chapters

• 4:39 General Risk Factors
• 11:02 Comfort with the idea of death
• 14:53 Sensitivity to Physical Pain
• 17:08 ACEs
• 20:25 Occupational Risks
• 26:34 Job Demand Control
• 31:16 Effort-Reward Imbalance
• 44:07 Isolation
• 46:51 Massage Therapist Risks
• 53:11 Pandemic Lockdowns

Transcript

Corey Rivera: 0:42

Welcome to the Rub a HealWell podcast about massage therapy. I'm your host, Kori Rivera, licensed massage therapist and information magpie, and today we're going to continue our conversation about the suicide rate for massage therapists by talking about risk factors. Before we get started, you should know that I got COVID a couple weeks before recording this episode and that means for some of this recording I sounded like well, like I had COVID. This episode is my re-recording of some of the information, with HealWell's Executive Director Cal Cates' comments dropped in. Sorry about the unevenness of this episode. You can join us on Tuesday, February 25th, at 7pm Eastern for an online processing session about this information. The event is free, but you will need to register at the link in the show notes. Also, we now have a phone number where you can leave a message for the podcast, which is also in the show notes. If you didn't listen to the last episode, I highly recommend going back and checking it out. The question that I sort of skated directly by in that episode was probably the first question on your mind, which is why why are massage therapist rates so high? And the reason we glossed over it is because we felt it was more important to give people information about what they might be dealing with in the present than it was about musing about why it might be so.

Corey Rivera: 2:11

Today, Cal Cates and I are going to talk about the first part of the integrated volitional model. We talked about parts two and three in the last episode, and now we're going to talk about the first one, which has to do with background and risk factors, which are reasons or past experiences that can increase the risk of suicidal behavior or things that make you vulnerable to entering the cycle of defeat, entrapment, suicidal ideation and suicidal action. There is no scoring system for risk factors. It is not one plus one equals two. It's not straightforward and it's not that if you have all of these traits, you're going to enter the cycle. So we can talk about risk factors that increase risk and we can talk about factors that decrease risk in groups of people, but that risk doesn't directly apply to a single person.

Corey Rivera: 2:57

In this episode we're going to talk about things that increase risk for everybody in general and things that increase risk that have to do with jobs and occupations, and then we're going to sort of ponder some ideas that might have to do with massage therapists specifically. The ideas that have to do with risk in general are quite well supported. There's a lot of studies that have been done. They have a lot of attention. There's a lot of money that has been put into these ideas to try and understand them. As for the things that have to do with massage therapists, we're guessing because we don't put money or effort into studying ourselves. We just don't, and you're going to hear me say that a lot and maybe for forever on this podcast, until we start doing it, because it's a thing that drives me absolutely batty. The Massage Therapy Foundation has very specific grants that it awards people with every year, and those grants are very, very specifically written and they exclude us from funding studies to study ourselves. As far as I understand, this was just an oversight. Building something like the Massage Therapy Foundation and launching an academic journal is a gigantic, enormous task that I am honestly constantly amazed was successful. So for now, just know that the conversations Kyle and I are going to have about massage therapy are things from our experience. They're from what we see and what we hear from people, which is certainly a valid form of gathering data, but it's not as comprehensive as we wish it was.

Corey Rivera: 4:20

Okay. General risk factors. I'm going to start right off the bat with guns. Owning a gun ups your risk for attempting suicide. It doesn't matter if you will use the gun in the suicidal act. Just owning one increases your risk, particularly if you're male. Men are more likely to successfully complete an act of suicide and women are more likely to attempt it, but men tend to complete the act more often, and partly that has to do with the use of firearms. As for race or ethnicity, Native Americans and Alaskan Natives are at the most risk. White people are actually second on the list and it turns out that Black women have the lowest rates, and no one is completely sure why. For family history, suicide is not genetic, but having a family member make an attempt or have ideation or an experience with it can increase your risk. The best predictor of a future attempt is a past attempt or past self-harm. That's something that we know absolutely for sure. We know that isolation is also a big factor. We know that mental health problems can contribute, although only about 70% of people who attempt have a diagnosed mental illness, which means about a third of people do not, and most people with a history of mental illness will never make any attempt at all. So those are basic demographic risk factors, there are also personality risk factors.

Corey Rivera: 5:52

There's a personality trait called perfectionism that I have some experience with. Perfectionism itself is a scale. It's not a binary. It's not that you are a perfectionist or you are not. Generally, most people are somewhere along the continuum and it's circumstantial, which means that something happens that makes it flare up. In one of the books I read, it says it acts up when provoked, which I thought was a very good description.

Corey Rivera: 6:13

There are three types of perfectionism. The first is self-oriented perfectionism, which is what we expect of ourselves. The second is socially prescribed perfectionism, which is what we think others expect of us. And the last is other-oriented perfectionism, which is what we expect of other people. The one that really gets you is the second one, socially prescribed what we think others expect of us, and this is really important, because it's not actually what others expect of us, it's what we think they expect of us. There's a scale that's used to measure this.

Corey Rivera: 6:50

With questions like I find it difficult to meet others' expectations of me, and people expect more from me than I am capable of giving. We tell ourselves stories all the time to make sense of the things around us, and all of our stories are always incomplete and you don't actually know what anybody else is thinking unless you act them directly. And even then they would have to know what they're thinking and tell you directly in order for you to get a whole picture. So it's really just this process of ongoing guessing. So this idea that you are thinking about what other people are thinking, which makes you think about yourself, is known as metacognition, or having thoughts about your thoughts, and it's hard because it feels like you're not in control. The thoughts are real, but the reality of those thoughts might not be. Here's Kel Cates.

Cal Cates: 7:39

I mean, you alluded to this very problematic thing that I think we tend to gloss over in daily life, which is that we don't typically have unfettered access to our own thoughts and that when we ask other people to tell us what they're thinking or what they're feeling, they're in the same boat, and so they they perhaps not even with intentional plans to obfuscate the truth. You're not. You're getting what they have access to, which, as you said, is always incomplete. And yeah, so I, we can't. I feel like you can't stress that enough, that we are living in a world of stories that haven't been fact-checked, and this is how we make the decisions in our lives and how we shape our view of what our world looks like, and it's very hard to notice that we're doing that and to fix it, even if we do notice it, like, how do you actually see what's true? I think that's a very hard thing.

Corey Rivera: 8:45

And in the final part of this re-recording I want to tell you that there's an interesting correlation in specific states Montana, wyoming, colorado, utah, nevada and New Mexico have about a 30% higher rate than the national average, and nobody knows completely why Nevada and New Mexico have about a 30% higher rate than the national average and nobody knows completely why. The first theory I read was about living at high altitudes, which I don't know. That I really believe the other reasons were that these states are very rural and they don't have a lot of mental health resources. They have high rates of gun ownership, which we talked about earlier, and high rates of population shift, which means that people sort of come and go in the communities and they don't necessarily stick around to build community ties. So they have weakened social bonds. That means their isolationism increases, their social connection decreases and that maybe results in higher rates. Here's Cal Gates again.

Cal Cates: 9:49

I have to support the idea that it's not about altitude, as there are lots of thriving here's Cal Gates again. And isolation people go oh well, I have lots of friends or I'm married or I have kids and the idea that if there are people around, that you're not isolated. And you know, I know that massage therapists will get into how isolating this sort of job is. But it's a people job, right? And I think that we have this story that if there are people around or I am quote unquote in a community, I'm not experiencing isolation. And I know we're going to unpack that. But that feels very important to me that it's not actually about being in a crowd or not in a crowd, or being a member of a family or not. It's. It's again about your perspective, about your level of connection about your level of connection.

Corey Rivera: 10:42

Yeah, we will get into more of that a little bit later, but for now I want to talk about this idea of comfort with the idea of death, and this is something that came up in the last podcast episode, but we didn't really talk about it very much, partly because I hadn't really thought too much about it in relation to massage therapists. It seemed more like a general idea and then the more I thought about it, the more. The more I thought about it, the more pertinent it seemed to become as far as being a massage therapist. So here's my theory, and then I'll ask Calcates to jump in here.

Corey Rivera: 11:20

So massage therapists have a huge role to play in death and dying, whether or not you work in a hospice situation, but probably especially if you work in a hospice situation.

Corey Rivera: 11:33

But the risk isn't about understanding or being introspective about death, isn't about understanding or being introspective about death Although if you're going to work in these situations, you should definitely get some education and HealWell has some really great stuff that you could check out to help you with that but the risk is inherent in the job itself, because you're dealing intimately with people's lives and people get sick and people die and family members get sick, lives and people get sick, and people die and family members get sick, and there's a lot of, just there's a lot of exposure and really direct exposure, I think, probably for any healthcare professional, but for us, we're next to it, but we're also in it with people and in order to do that job and to be there for people, you have to get more comfortable with the idea in order to take care of that person that you're working with.

Corey Rivera: 12:24

So I think of it as like the risk of getting burned when you're working in a kitchen, it's just always a risk because you're in a kitchen and things are hot and there's no way to get away from it, and that's just. That's just nature of the job itself, calcates. You have a very, very thoughtful expression.

Cal Cates: 12:43

I feel like yes, and because in my experience, even massage therapists who come through our end-of-life classes or our classes that are about mortality and such, are coming for other people.

Cal Cates: 12:59

They're not there to look at sort of their own mortality. And also I think that there is possibly and this is maybe part of what exacerbates the isolation that massage therapists experience is that what you've just said is absolutely true. What we are doing is working with human bodies, which, you know, in Buddhism, the five remembrances are I am of a nature to grow old, I am of a nature to die, I'm of nature to become sick, like this is what bodies do. And every time we see a person, maybe they're in the quote, prime of their life, right, and there aren't obvious signs of infirmity or sort of mortality. And yet I think there's a there's that metacognition, that that thoughts about thoughts, that while you're working with this person, you're pushing away this death piece, this sort of infirmity piece. And so it's there, but like wellness, big air bunnies, and like the health industry, et cetera, is deeply invested in not acknowledging that I was just thinking of, like what the commercial looks like.

Corey Rivera: 14:08

That's like you're going to die. Would you like to buy some soap?

Cal Cates: 14:13

Death stinks, but you don't have to.

Corey Rivera: 14:18

So, yeah, high comfort with the idea of death equals more risk. Just because you're less afraid of dying again, it does not mean none of this means that you are necessarily more at risk. It means it's a general sort of sense. The next one that came right after that that I also kind of glossed over in the last episode, was sensitivity to physical pain and I was like that's not really us, that's like, that's like firefighters and that's like, again, with the kitchens.

Corey Rivera: 14:46

My husband worked in the kitchen for a long time. So I have a lot of a lot of kitchen stories but like a lot of standing, a lot of like a lot of twisting and kitchens, a lot of lifting of heavy things. I was like it's more like that, that's not really us and more like that, that's not really us. And then and then I had a conversation with someone and they were like oh yeah, I think I just dislocated my pinky and it'll be fine and I'm going to go work on the three people that I still got today. And I was like, oh, maybe we do. I used to work with someone who had ganglion cysts in their wrists from being a gymnast and they just just bothered her all the time and she just came to work every day and worked on six people all the time and, you know, took some ibuprofen and got on with her job. So injury and physical pain and discomfort is 100% part of being a massage therapist.

Cal Cates: 15:34

Well, and I wonder. I mean, pain is so complicated and obviously we all have our biases and stories and judgments about it. But I wonder also about the that when you are, I'll say, in denial and that's maybe not a graceful way to say it, but in denial about your physical experience, it's another piece of isolation, right, it's another piece of disconnection that you're like just pressing on despite all evidence to the contrary, and it makes sense that that would be a risk factor and that it's not. I don't know. There's I think there's sort of some bragging that happens even.

Corey Rivera: 16:14

Oh, definitely.

Cal Cates: 16:15

Right About how you can work through anything and like you know pain don't hurt.

Corey Rivera: 16:19

Look how tough I am. Right About how you can work through anything and, like you know, pain don't hurt. Look how tough I am.

Cal Cates: 16:23

Right and culturally. I feel like there's a lot of support for the idea that you just suck it up and well yeah, being a good little productive member, look at you. Right, no, no wellness, it's not for me, it's for you.

Corey Rivera: 16:44

Yes, I'm a purveyor of wellness, not a consumer, not an actual practitioner. That's not not for me, right, yeah, yes, the last thing I want to talk about, that is sort of a generalized risk factor, are what are called ACEs, which stands for adverse childhood experiences. Aces are events that happen to people usually when they're under 18 years old. There's 10 items in this list and they include things like abuse of any kind, exposure to violence, parental divorce, having household members in prison, and, of this list, the more ACEs you have generally the worse your health outcomes are, kind of all the way around. So ACEs have gotten to be a metric that is used in most, I think, health measurement study situations is to compare how many ACEs people have to what the health outcomes ended up being.

Corey Rivera: 17:39

So multiple ACEs in this case means a greater risk of a suicide attempt, and it's exponential. So seven or more ACEs increase the chance of a suicide attempt for adolescents by 51 times and, as an adult, by 30 times. So it's big Things. To remember about ACEs is that the ACE count only counts bad experiences. It does not take into account good experiences or resiliency building experiences that might counteract the ACE experiences that happened. So it's an incomplete picture by any sense of the word. It's an incomplete picture, however you want to take it, but it is pretty reliable, sort of as a predictor and a scale that we now use in this time in our lives, slash history where, um, I feel like it is truly incumbent upon us to see each other fully aces feel have always felt really important.

Cal Cates: 18:39

But I feel like, if we, if we each just passed each other a card that had our aces on it when we met, you squared around your neck like a lanyard, like can you? I mean, can you imagine people be like, oh right, like every meetup would start with a hug, um, and then we'd all be like, oh okay, yeah, okay, yeah, no, how about if I don't harm you? Like, how about if we just try to, you know, stem the tide here, and that we just have so little awareness of how each of us has been shaped and the vulnerabilities that we sort of come to adult life with, or even adolescence? And so, as you said, the aces is not a complete picture, because, of course, for many of us there are plenty of aces.

Cal Cates: 19:24

But then also there was that basketball coach who sort of took you under their wing, or there was that, you know, all these other experiences that maybe mitigate or ameliorate the long term impact, but still that when you look at the list, there are a few of us that don't have some ACEs right, at least one, yeah, yeah. So an adverse childhood events is such a sanitized sort of way to say what's on that list, but it makes complete sense that it might add to a sense of hopelessness or a sense of a need to escape as you continue to live this human existence.

Corey Rivera: 20:07

So this is the general sorts of everyday population level risk factors, and now I want to talk about risks that are specific to occupation.

Corey Rivera: 20:17

So there have been since about the 70s and 80s, and then sort of increasing from there, studies about how jobs and work environments affect people and specifically how it affects their health, how it affects their happiness and because we are a capitalist society how it affects their productivity, because if you're making an argument to a company or a boss, they like the word productivity to be included and they get much more interested when you say productivity is lower, and then they perk up.

Corey Rivera: 20:52

So the CDC report that we got those statistics from has, it's just a list of like six to eight things that might contribute, and so I took the list of six to eight things and then went to look for all of them, because this is what I do in my job now. So there were a couple of things that were really really straightforward that contributed to suicide risk in an occupational manner. The first one was lower in absolute relative economic status, which means you're just poor and you might not be able to get out of it ever. So that one was pretty straightforward, made a lot of sense. The second one was lower educational attainment, and I couldn't find a really good explanation as to why lower educational attainment was on this list, and part of me feels that higher educational attainment also sort of goes with the idea of not having lower economic status.

Cal Cates: 21:48

It doesn't seem like a unique factor.

Corey Rivera: 21:52

It's sort of like representative of other life situations. Most people are pretty well aware now that getting a degree doesn't necessarily mean that much and what you got your degree in doesn't necessarily mean that much. So just having the degree being a thing that lowers your risk is like I don't know, I don't know, that's the piece of paper that did it. The third thing was lower skilled jobs. I don't really like the term lower skilled personally, because I think all jobs require skills. They just might not be as technical or require an eight year degree as other skills. That doesn't mean you were unskilled.

Corey Rivera: 22:30

But when I was discussing some of this with Dr Ambler-Kennedy, who ran a project called COPE during the COVID lockdowns that was assessing moral distress in healthcare workers, including massage therapists, she mentioned that a lot of the things that showed up at the top of this list for suicidal rates are occupations that do not have transferable skills. So like bartending is on this list, and if you're a bartender, you're a bartender. And if all the bars are closed, what do you do? You don't really have a place to go. And then I had a discussion with a nurse and she talked about how a lot of her friends just switched nursing jobs. So they maybe were working in a hospital with patients and then during COVID they were like, nope, can't do it, peace out, I'm going to go do paperwork. So their job skills are transferable or at least they have places to go. And as far as massage therapists go, we're massage therapists Like that's. We don't really have a paperwork job to slide into.

Cal Cates: 23:34

Well, I'm thinking oh well, we could be bartenders because there's a lot of similarity there, but not if there's no bars open, so never mind, that's true, that's true.

Corey Rivera: 23:44

So skills that don't shift well to a new job opportunity. So that sort of feeds into the entrapment idea that we discussed in the last episode. The next one was economic instability or variability. I think this one applies to us a lot.

Corey Rivera: 23:59

Massage therapists do not get paid time off. For most of us we don't get paid if we don't have clients booked. We don't get paid for time that isn't spent hands-on most of the time. Demand sort of waxes and wanes, everybody, all massage therapists know that Valentine's Day, if you like couples massage, it is the time for you, and if you hate couples massage, that's too bad for about three weeks Because you're going to have to set up both those tables and have that wife glare at you while you work on her husband, and that's just what's going to happen for a while.

Corey Rivera: 24:32

And then in summer, right, people just sort of go off and do summery things and maybe your schedule's not so full, so the variability is relatively high. And then even with booking your schedule, aside from that, clients cancel at last minute. We struggle with our no-show fees, so you don't get anything. If you're working for yourself, maybe your business this is one of my favorites is when the person that you work for is like well, do you want to enforce the no-show fee? Can I make you the bad person where you enforce the no-show fee?

Cal Cates: 25:13

where you enforce the no-show fee. Well, I was thinking that you know, when I had a really busy private practice that certainly there's the boundary issue right of enforcing the no-show fee. But another thing that points back to sort of the overwork et cetera is that when clients would cancel last minute, I would often just be relieved because I had time to either catch up on my notes or my laundry or right. It's like I don't feel right making you pay for time that I'm getting back, right, and so it's sort of a wash. But it's also not a wash Right, because no one is paying me for that hour when I support my business, right.

Corey Rivera: 25:42

So your relief is apparently enough for you not to enforce the no show fee and then also to assuage your guilt that you're not, that you're like kind of okay, yes, just got some quote free time, unquote, correct and maybe you can go home, you know, 40 minutes earlier because you were able to do the other thing. But when you look at it from a business standpoint, you just made zero dollars.

Cal Cates: 26:03

So zero dollars less than zero dollars. Right, Because you worked for free, really.

Corey Rivera: 26:09

Really yeah, yeah, Yep. So we are definitely. We definitely fit the economic instability and variability category. And then the next two concepts I want to talk about kind of together, but I want to explain them separately. So these are the things that kind of came out of the 70s and 80s. And if you start reading literature about occupational stress and like mood disorders, it comes up in every article. These things every, every single article cites both of these concepts.

Corey Rivera: 26:36

So the first concept is called job demand or low job control, and this is a structural issue. So job demand theory describes types of work in two dimensions. So, if you like, picture like a box plot sort of thing one of those dimensions is the difficulty of the job. So do you have a hard job or do you have an easy job? And the other dimension is how much control you have over the execution of the job. So do you have a lot of control and you get to make choices, or do you have very little control and you have to follow somebody else's rules? Whether or not those rules make sense, it doesn't, you know. And we've all had all kinds of jobs that have all of these traits.

Corey Rivera: 27:22

So if you put it in a box plot. It creates four kinds of jobs. Right, there's a high demand, high control job, which is something like a surgeon, where your job is really hard but you have a lot of control. You're the person in charge, you get to make those decisions. And then the other end, there's a low demand, low control job, which might be like a fast food worker Although I could also make an argument for that being high demand. But in this scenario low demand, low control you're doing the same thing all the time. It's extremely regulated and rigid and there's a lot of rules and a lot of routines that you have to follow. But you're not opening somebody's aorta either. So those are the two sort of spectrums.

Corey Rivera: 28:04

So the danger zone comes in when your job is high demand, when you have a lot of responsibility and you have low control over how you execute that responsibility, and this sounds a lot like the worst kind of franchise work that could ever exist. So you're taking care of a person and you're taking care of their body and their mind and you're comforting them and you're interacting at a really personal level no-transcript and self-reporting. So they have questionnaires that they give out to people to self-report and then they track whether or not, they have heart attacks later. The results are not great for people who are in high-demand, low-control jobs. So this is the experience of having lots of responsibility and being micromanaged.

Corey Rivera: 29:11

This is about structure, like I said before, so this is about power structures at work. This is about the division of labor at your work. This is about democracy how much say in what you do. So one study showed that low job control increases suicide rate by four times, which is quite a bit. It's very stressful, and if you are in a situation where you cannot change jobs and you don't have a prospect which we're going to talk about in a second and you're stuck there, that's a lot of stress to put on a human.

Cal Cates: 29:43

I wonder also.

Cal Cates: 29:44

I was talking in one of our classes, just actually we were talking with our palliative care program students yesterday. The conversation was about this, this ongoing tension of sort of the customer being right, and I feel like certainly we think about structural factors in terms of low control. And you know, if you work in an environment where someone else is setting your schedule, but that even in your treatment room, depending on your treatment setting, you are often being asked by the people who are your clients, customers, whatever word you use, you're being asked to do things that are against what you know is sort of safe or healthy or supportive, and that you sort of don't have the ability to say actually like, let's, you know, work a little bit differently, or I hear what you're saying and let's do this. That you really just are, you know. To go back to our robot episode, you're being expected to do what the customer wants, even if that goes against whatever boundaries you have internally or whatever you know about safety and technique, et cetera. So another aspect of low control yes, yeah.

Corey Rivera: 30:53

So it's not just your manager but it is also your clients, so it's from both directions. So the second idea that comes up in almost every piece of literature that I read is called effort, reward and balance, and this is both structural and personal. So effort, reward and balance is the idea that you work super hard and nobody cares, um, and even if they do care, and maybe they love you a lot and they'll give you an amazon gift card once in a while and they'll have a ceremony at work where they give you a trophy that you really could use the 30 they sent on spent on the trophy, but you know, thanks anyway. So it is constant effort rewarded with little or nothing. And high effort alone and low reward alone are not nearly as stressful as having both of them together, so they like compound each other. So if you work really hard and people kind of recognize it, then it's OK. And if you aren't rewarded a lot but you don't actually have to do a lot, then like that's not great but it's also okay.

Corey Rivera: 31:55

But high effort, low reward bad news bears. So this causes problems with your self-efficacy and your self-esteem and your sense of belonging, because you're being taken advantage of and you know it, and nobody cares, and obviously I mean massage therapist, right. So we're like it must be me, um, must be something about me, and we are constantly, I think, put in a position of subservience to most of the people that we work with, to our clients and our managers, so you don't have a lot that you feel like you can say about it. The other important piece about this and I think I laughed out loud when I first read it so reward in this context is considered money, esteem and career opportunities, and that includes job security and promotions. And we got none of them, not a one.

Cal Cates: 32:57

Well, and I feel like the esteem thing is particularly complicated because, you know, even when we talk about the rewards, the rewards Corey are internal rewards. The rewards Corey are internal. I am a loving, compassionate person. So the idea that I would even feel exploited, even if I don't say it out loud, as you said, means that I'm doing something wrong, because as a massage therapist, I am proud of my open hearted, giving nature, and if I'm feeling like there's an imbalance there, that's on me, and so it is that double whammy of you know, I better keep quiet about it which of course takes us back to isolation, which of course takes us to disconnection, and it is a really it's not even a single dog chasing its tail right. It's like a whole, like puppy mill Pack. Yeah.

Corey Rivera: 33:45

A puppy mill? Oh no. So this imbalance happens when there are a few job alternatives. So we talked about lack of mobility and lack of your skills transferring when your contracts are poorly defined. This is an interesting concept that I would like to pursue. So there's an idea called an incomplete contract. That is not, it's not a law idea, it's like a philosophical idea. So it means that nobody told you or something started to get assumed about your obligations and benefits of your job. So in an incomplete contract, it's like we did a handshake and an elbow rub and like you know what the job is like, it'll be fine, that's fine, and then the job just grows.

Corey Rivera: 34:40

Or you don't know how, like how you're being evaluated. You don't know who's evaluating you or why. You just don't have enough solid information to make decisions or even make suggestions about your job. So high effort, low reward often happens at the beginning of a work life because you think that if you put up with it for long enough, then you will get an opportunity later. This is internships. Internships are massively, massively in this high effort, low reward thing. So I'm not going to pay you. Or for massage therapists, it's exposure, right, I'm going to pay you an exposure. Just you'll get your name out there and you'll work for 10 hours at our job fair. Sure, that's going to work out. So we're much more willing to kind of compromise at the beginning. And also I think there's no one to tell you not to do it and I sort of quietly assumed that this is just how it always happens. Right, you always have to pay your dues, like that.

Cal Cates: 35:45

Well, and I would argue that, even the sort of incomplete contract with yourself that I have worked at a couple of places, at a massage therapist, but as a massage therapist, but I've largely worked for myself and I remember when I first began my practice that I set my hours right and then I was like, oh, I will see anyone anytime they can.

Cal Cates: 36:06

You don't say, no, right, you're building your practice and it's like, oh, but you're building your practice on poor boundaries and you don't know that until later. But we, I think we go into private practice with pretty incomplete contracts with ourselves, which also sets us up for these other risk factors.

Corey Rivera: 36:21

Yeah, and I'd say with self-employment too, you're like this is what the job is going to be, and then you're like, oh, it's and this, oh and this, oh and also this other thing that I didn't think about. Now I have to fight with the guy who delivers my sheets, like what is going on? Yep, high effort maybe, okay, reward, but, as we discussed, that is money, esteem and career opportunities, so not necessarily. The other thing that rolls into effort, reward and balance, which made me laugh in exactly the same manner as perfectionism did, is the over committed trait, which I have no experience in at all, just like perfectionism. Uh. So over committed is when you have a poor perception of two things. One is underestimating the work demands and overestimating your resources to deal with those demands, so it's not just taking on too many things, it's taking them on and having no way to manage any of it, and that just compounds the effort reward problem. This rolls into ideas about fairness A lot of fairness ideas here in the workplace and there's a lot of policy ideas that could be attached to sort of fixing an effort-reward imbalance that you feel at work. Those things are increasing your wages, job security and training people in social skills and development and leadership behavior so that if they do have that overcommitted sort of trait, you give them tools to manage that better.

Corey Rivera: 38:00

So I want to sort of talk about how this fits in with the job demand. So effort, reward and balance is the idea that you are doing a lot of work and no one is noticing. And job demand and control is that you do a really hard job and you either have control over how you do it or you do not. And I think the two things intertwine a lot into how you currently feel about your job and how much stress your job is causing you. So my job demand I would say I have a lot to do and I do it independently.

Corey Rivera: 38:41

I have high control over my job and I've been in jobs with low control and like that is just awful, that is. That is everyday torturous, I don't want to do this anymore feeling. But the effort, reward and balance if we're talking capitalism, then no, I'm not getting rewarded properly. But if we're talking actual satisfaction, then yes, I think I am. And if we're talking overcommitting, then like that's just life for me, that's just how I roll. So I we're talking over committing, then like that's just life for me, that's just how I roll, so I'm I'm relatively comfortable with that.

Cal Cates: 39:14

And I think this relativity piece is so interesting because you know, when we go back to like the conversation about perfectionism and how the the idea that I am trying to live up not to what other people actually expect of me, but to what I think they expect of me.

Cal Cates: 39:32

I feel like right, this is such a huge I am satisfied a because I get to work with amazing people and I get to do work that I feel like is important. And could I be paid more? Yes, and I want, like you said, I want this job. So I live my life in a way that I don't want to be. It doesn't feel like, oh, I wish I could do this thing, that if I made more money, I could do it's like I love not hating every moment that I'm at work and I've had those jobs also.

Cal Cates: 40:06

I have worked in cubicles and I have worked for bosses who don't understand my job and you know I have been treated like a robot. So it is relative in that you will give up some things for other things. I mean people say, oh well, yeah, you know I'm stressed or like when somebody cancels, I don't want to charge them for a no show, but I'm in my house, right, I didn't have to drive to an office today. I don't have to, you know. So I'm willing to deal because of these other bonuses. And, yeah, it makes it hard to. It makes it easy to rationalize being in an abusive relationship with yourself or with your work right.

Corey Rivera: 40:47

Yeah, it's so complicated, yeah. So then then, like, part of that question too, becomes what is it about this dynamic? Or could it be about this dynamic that would stress out massage therapists? So obviously people love their jobs, um, you wouldn't, god. I hope you're not doing this job if you hate it. Um, because you're not going to get anything else like money and promotion. Esteem not, but I think that I think that the job demand and not being able to have control over your choices in your job is probably pretty hefty for us, and I think that doing a job that does not have a promotional opportunity is really rough, because I think for massage therapy, sort of your only promotional direction to go is to manage other people, and a lot of people don't want to do that at all or are going to be bad at it, like. And then in that case, like, is it a promotion? Like, not, not really For anybody.

Cal Cates: 41:51

For anybody Right yeah?

Corey Rivera: 41:53

So not to like change the subject and change the subject just slightly right here. This is why we need some sort of tier system in what we do. It is not just because some people want to be better than other people, it's it's. It's not that. It is that if there's a ladder to climb and there's a thing like if there's steps to go with and recognition to be had that you have done hard work and somebody has noticed and you earned a thing, and now your clients notice because you have the thing that is respected, that demonstrates that you did the hard work.

Cal Cates: 42:28

Like psychologically, that is important and we don't have it don't have it Well, and I think it makes the contract complete. To go back to your earlier point, in that you know, you, if it is clear to consumers and to the practitioner what they can expect from you, our overcommitment and our you know discomfort with not meeting the needs is potentially lessened. That you know, if you go to this type of massage therapist, you can expect this and as this type of massage therapist, therapist, you're expected to know and do these things, whereas if you're in this other tier, here are the, the set of understood expectations at that level.

Corey Rivera: 43:09

Yeah, so they're. Yes, I never actually thought about it that way with the contracts, but your job description becomes much better defined and I think there's a lot of struggle with massage therapists and like just from marketing on up. So how do you market yourself? How do you talk to your clients? Uh, oops, I don't think that clients for me, um, like all of that could be just taken away and cleared up or at least, um, maybe neatened. Maybe we could fold the clothes and put them in the basket, and maybe not necessarily in the drawer, but like in the basket.

Cal Cates: 43:46

Yes.

Corey Rivera: 43:47

That's job demand and effort reward and balance. So the other um really big thing in occupationally and this goes for all occupations is that isolation piece that we've been talking about. So isolation includes poor supervisory and colleague support, so it is the people you work with and the people you work for, and social integration. So any type of social integration increases, like the protectiveness that you can have against suicidal risk. So whether that those social interactions happen at work or they happen at home or they happen at the roller rink, like any of them count to protect you. So there's a conversation that I read in an amazing study of 2000 people in Korea who are in service jobs. The study was fantastic, but it talked about how it is not just fostering relationships at your work. It is your work allowing you to foster relationships outside of your work, by helping you with your work, life balance, by giving you time off, by encouraging you to go to your kid's basketball game, by, you know, flexibility. All of those things help with the isolation problem. And for massage therapists whoa buddy, do we have an isolation problem? You've heard me talk about it on this podcast. Again, I will continue talking about it until we figure out what to do about it.

Corey Rivera: 45:17

But massage therapists go from a class of maybe two people or maybe 20 people in school. They leave that class. They go into possibly, private practice A lot of us maybe they go into a franchise situation. But either way, you work with clients alone in a room and that is your job and we don't do things together and we don't really know how to do things together and we're taught scarcity, so we're sort of taught to dislike each other or to be in competition all of the time and that's messed up. Like it's just. It's just messed up. We gotta stop doing this, guys. I know it's hard to connect. I, it's just messed up. We got to stop doing this, guys. I know it's hard to connect, I know it's hard to have time.

Corey Rivera: 45:58

I think a lot of massage therapists really think that having a social interaction means trading massages. But that's doing more work Like, and nobody. Like we all want to get a massage but nobody really wants to do more work. Like it's not. And then trades get weird right, because I owe you and then you owe me and then like it's all messy and then that relationship is weird, like we just need to spend time with each other in a supportive manner. You don't actually have to touch each other. I know it's weird to say to the massage therapist, but you don't.

Corey Rivera: 46:52

So the next part is risks that I think are specific to massage therapists, and I want to be clear that it's not just us, but these are things that I see wins is the one that capitalism provides for us, which is that this new technique will make you rich and successful, and following that, if you did not become rich and successful, it must be your fault. I liken this to the celery juice thing, which is that celery juice will make you thin, but only if you have this specific juicing machine and you do it at this exact time of day, for this temperature, and it needs to be four hours before eating. And if you didn't do that, well, it's not the celery juice, obviously. Like it must be you that sucks, and like this is. This is how our marketing rolls right. So this one special technique will make you lose 12 pounds of belly fat. Um, it's, it's everywhere and it is ingrained in our continuing education. Uh, and I presented this argument to ruth werner and she was like ah and I was like what, what?

Corey Rivera: 47:53

and she said from the educator side, it is extremely hard to sell classes that do not use this promise. So we're just eating our own tail. So massage therapists want to make more money and buy that class, and people who teach classes want to teach classes, but in order to sell them also kind of have to teach that class, and then we don't nobody learns anything. Have to teach that class, and then we don't nobody learns anything. And massage therapists don't have the time or the money to take classes that they can't see a direct benefit for, because we're so strapped for cash and if you don't work you don't get paid.

Cal Cates: 48:29

Well, and let's not forget that massage therapy instructors are massage therapists trying to make more money, right. And creating a class and spending time in the classroom is expensive. But yeah, I mean again, we've got the dog chasing its tail, the hustle hustling the hustlers, and there's a lot of hustle going on that.

Corey Rivera: 48:47

maybe it's a lot of hustle, yeah yeah, which goes back to that scarcity thing that just keeps us apart. So that's education, marketing, marketing and bootstrapping, and then sort of added on top of that like the worst icing ever, um terrible icing made of like broccoli, broccoli icing it's broccoli fondant.

Corey Rivera: 49:14

Yeah, so I call it the funhouse mirror of social media. So this is that we all pretend on social media. Everybody pretends that they are successful. Their Instagram shows all of the pretty pictures that have been edited and filtered. We all pretend that we are happy and nobody wants to speak up first. And it is. This is in the literature, by the way, guys like it is not just social media, it is in academic literature.

Corey Rivera: 49:41

So the wonderful Clary Jordan found an article the other day that I cannot get a copy of to save my life, so I just have the abstract, but it's called Working Conditions and Complementary and Integrative Health Care Professions, and this study is bonkers. And complementary and integrative healthcare professions and this study is bonkers. So it's like all of these integrated healthcare professions like they have good hours and people are satisfied at their job. But the health professions included are massage therapists, chiropractors, naturopaths, midwives, and I think there's like three other jobs that have nothing to do with each other. We have nothing to do with it. They're not similar at all, except that you decided they were all integrative. So one of the things is they were like. All of these people said that their work-life balance and flexibility schedule is pretty great and I was like I don't think midwives have a particularly flexible schedule. I think the babies come. When the babies come, it's certainly a surprise.

Cal Cates: 50:40

Variable, but not flexible.

Corey Rivera: 50:42

But not like yes, that's flexible, indeed. So no one wants to be the first person to admit they're unhappy. Everybody pretends they're happy and that means again, with the isolation, you sit in a corner and you're like, if I'm unhappy it's my fault and there must be something I'm not doing that everybody else is doing and I guess I'll just stay in my corner alone and it's just not true. It's not true. There wouldn't be so much hustle from that education standpoint on both sides if everybody was just doing great. And then that also brings us back to the idea of what's great, right? Massage therapists don't make a lot of money. We just don't. We like our clients, we like the job that we're doing. If you can afford to do this job, that's great, you can be happy. But a lot of people can't and maybe could be great at it. I don't know. The emperor's got no clothes guys.

Cal Cates: 51:43

Yeah, and I feel like the other piece that we're missing in our not looking at ourselves and how this is possible is that, in my experience, a number of the massage therapists who are happy and feeling appropriately compensated are people who have a spouse or a partner who has a much more, is much more gainfully employed and so, as the person who is not primarily responsible for the household budget, that makes it a lot easier to be cool with, like people canceling last minute or just not making ends meet on your own, and I am deeply curious about how many people in the massage profession are in a situation like that where, in fact, if they were the only person, making money for that household, they would be at or below the poverty line.

Corey Rivera: 52:34

That would be a great question for our survey for the massage therapy profession. Yes, indeed.

Cal Cates: 52:42

Let's collect that data.

Corey Rivera: 52:43

Whoever's listening. You want to help us collect that data? Please let me know. Love to hear from you.

Corey Rivera: 52:49

Let's do it. The last thing I want to talk about is I'm not going to say it's pure speculation, because it's not pure speculation, but it is a story that I'm telling myself. The suicide rate data is from the year 2021 and it is impossible to talk about 2021 without talking about the COVID shutdowns and what they meant for our profession. There's a lot of thoughts. I have a lot of thoughts about what kind of things this could mean. So if you have thoughts about it too, please text the show. There's a phone number now in the show notes that you can call and leave a message that I will get. I would love to hear from people about your experience and what you felt and what this could mean for us. So, and what this could mean for us.

Corey Rivera: 53:37

So, during the pandemic shutdown, I feel like our amount of moral distress just skyrocketed, and it skyrocketed in a different way than people who had to go to work at a hospital every day and deal with not having enough PPE and not like. It was a different experience and, I think, still just as scarring. So I live in Michigan and in Michigan they just gave everybody money. Essentially, they were like if you can't work because of COVID, here is money and I got it within two weeks and they kept giving it to me every two weeks so I could stop working and was safe. But they are massage therapists who live in places who did not do that um and did not care and did not protect people really at all, and those places tend to be places that refuse to have mask mandates and, in fact, became hostile to people who did wear masks wear masks. So if you were a massage therapist in a situation like that, not only could you not protect yourself because you couldn't stop working, you couldn't protect yourself or your clients because wearing a mask became political and controversial. So even like the small amount of protection you might've had got taken away and that's entrapment, like that's so much entrapment, what are you supposed to do?

Corey Rivera: 55:00

So there was this whole conversation that started happening online with massage therapists about massage therapists insisting that they were essential workers. And, aside from the fact that, no, you're not, because there's not enough PPE to go around and that personal protective equipment has to go to hospitals for people who are just swimming in COVID right now, I've started to think a lot about what people meant when they said essential workers, because if you'd asked massage therapists three years before that if they were essential workers, they probably would have told you no, or nobody would have used that language. That was kind of new language for us during the lockdowns. So when somebody tells you that they are an essential worker and very clearly believes it, what they are saying could be a multitude of things. It could be that they are saying it is essential for me to keep working because I will be homeless. They could be saying it is essential for me to keep working because, like psychologically, this is so stressful that I cannot handle it. It could be I am an essential worker because my clients are in pain and I understand that they're in pain and they're telling me that they're in pain and there's nothing that I can do about it, and that is extremely. That's a lot of moral distress to deal with. So this part of the conversation is kind of like it would be, I think, a nice theoretical thing, except that we're going to have another pandemic, like it's going to happen. It's just going to happen and that makes this idea and this problem extremely pertinent, because what happens next time that we do it?

Corey Rivera: 56:43

As far as HealWell goes, calcates wrote a blog post that you can read that I will link in the show notes about the worst game of hot potato ever, which was that nobody did anything to help the massage therapists. The states didn't have guidance. The associations told people to look to their states for guidance and that was it. That was all people had. So they were finding solutions in each other and we all know how well the internet works finding solutions on our own for people with a ton of incomplete information, solutions on our own for people with a ton of incomplete information, and we were all just guessing at the time anyway. So I worry about the statistic. I worry about whether the statistic is still happening the suicide rate statistic that happened in 2021. And I worry about whether it's going to happen again and what we're going to do about it.

Cal Cates: 57:33

Well, and I think that we would be irresponsible to not discuss the impact of the COVID lockdown and the potential of the window where the survey data was potentially collected, and also all of the things we've discussed that put massage therapists at risk are true, whether or not there is a pandemic. Are true, whether or not there is a pandemic. So there's plenty of work to do, even if you lean toward being unwilling or unable to believe that this was related to any sort of isolation exacerbated by the pandemic.

Corey Rivera: 58:07

So send me a text, leave me a message. I promise we'll listen, I promise we'll read. We want to know what your experience was like. Any last words? Cal Gates.

Cal Cates: 58:25

You're not alone out there, and thank you for listening. And let's change some of this. Let's make this kind of job that feels connected and alive and sustainable.

Corey Rivera: 58:38

Thank you for listening.