Tip #1 for Longevity as a Massage Therapist
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Adapted from Pre-and Perinatal Massage Therapy by Carole Osborne
The question most practitioners consider first when contemplating massaging pregnant women is how to accommodate that ripe belly. Safety, comfort and therapeutic effectiveness affect both prone and supine positions during pregnancy. These same considerations point favorably to working with expectant women while they lie on their side.
Prone Positioning Restrictions
While stomach sleeping may be a safe, comfortable resting position, once sufficient pressure is applied for an effective massage this is no longer a reliably comfortable and safe position. Prone positioning on a flat therapy table can exert strain on the lumbar, pelvic, and uterine structures. Prone positioning shortens posterior musculature; compresses and anteriorly displaces the lumbar vertebra and lumbosacral junction; rotates the sacroiliac joints; and increases strain on the sacrouterine ligaments. Prone position, particularly in later pregnancy, often aggravates the causes of many women’s back discomfort.
Pillows or specialized equipment that is marketed for pregnant clients can mitigate these problems, but neither pillow props, body cushions, pregnancy pillows, most on-site massage chairs, nor tables with cut-out ovals completely solve the problematic aspects of prone positioning. These alternatives can either (1) further strain posterior structures and the taxed uterine ligaments, or (2) create increased intrauterine pressure, particularly when you apply sufficient pressure to address the posterior structures therapeutically.
In most uncomplicated, low-risk pregnancies, some increase in intrauterine pressure is acceptable. Additionally, during the first 13 weeks the anterior iliac spines usually protect the uterus from increased pressure. Use the prone position in the first trimester, but keep in mind that avoiding increased intrauterine pressure is of particular relevance when there are placental abnormalities, or a higher risk of such conditions. Be cautious if there is heightened concern about fetal blood supply or uterine competence. Women diagnosed with these conditions are often uninformed about their impact on receiving massage therapy. Some of these problems go undetected until screening tests are performed, or until bleeding, cramping, or other overt signs of problems have occurred to warrant further diagnosis. Prone positioning, even in the first trimester, can be problematic when the embryo is larger than normal, with twins or other multiples, and when the mother is obese. Use sidelying and semi-reclined positions after the first trimester with all pregnant clients to avoid the risk of excessive intrauterine pressure.
Some other considerations: Prone positioning exerts pressure on sensitive, enlarged breasts. Because of increased mucous production and the inadvisability of using alleviating medications, many women become unacceptably congested in prone position. Some women are uneasy with “lying on their baby.” Finally, the confines of face cradles often hamper verbal and emotional sharing.
For the comfort and safety of the pregnant woman, eliminate the prone position after the first 13 weeks, regardless of your or the client’s perception or preferences in this regard. Use caution and make reasonable adaptation for its use in the first trimester.
Supine Positioning Guidelines
Prenatal supine positioning also involves safety considerations. In this position the weighty uterus rests against the inferior vena cava. Extended compression of the vena cava will result in low maternal blood pressure and decreased maternal and fetal circulation (supine hypotensive syndrome). Some women report uneasiness, dizziness, shortness of breath, or other discomforts when lying flat on their backs, although others seem entirely content; however, with or without notable negative effects, decreased fetal circulation occurs, particularly if the placenta is embedded posteriorly.
Some healthcare providers advise never lying supine, primarily when there is increased concern about fetal oxygenation. Though it appears safe throughout pregnancy for most women receiving massage therapy to lie on their backs briefly, for a two to five minute maximum, always follow these instructions when present. In second and third trimesters, be prudent and take mitigating measures for more extended anterior work. Options in early pregnancy include use of pillow support under the right side of the torso to shift uterine weight toward the left. After 22 weeks, elevate the torso to a semireclined angle of 45°-75°. Use the sidelying position as both a prone and supine alternative.
Sidelying Positioning
For all of the reasons above, sidelying (lateral recumbent) position offers maximum safety and comfort throughout all pregnancies. When sufficiently supported by pillows, bolsters, and/or cushions, most women can relax in this position. Sidelying minimizes strain on any of the uterine ligaments or on the musculoskeletal structures. It prevents increased intrauterine pressure, increased sinus pressure, and it tends to encourage somato-emotional integration. Physicians and midwives recommend the sidelying position to help ensure placental and fetal circulation when complications occur and in many high risk pregnancies. The left sidelying position allows maximum maternal cardiac functioning and fetal oxygenation, though most pregnancies are perfectly safe with mom on either their left or right side. The safest position for prenatal massage thereapy is the sidelying position, regardless of possible inconvenience to or preference of the practitioner.
Here are the basics of comfortable and safe sidelying positioning: Use several sizes of firm and soft pillows, a long body pillow, and/or a contoured bodyCushion. Support the woman’s head so that her cervical spine is aligned with her torso, and not hyperextended or sidebent. Use sufficient support to accommodate the space between the acromioclavicular joint and the head so that her shoulder is not uncomfortably compressed beneath her upper torso weight.
Tuck a small foam wedge or pillow, approximately eight inches square and two to four inches thick, under her abdomen near the pubic bone to support the uterus and prevent uterine ligament and lumbar strain. Place another similarly-sized pillow under her waist to support the lumbar spine if her hip and waist proportions are markedly different. Provide an additional pillow to support her upper arm, relieving pressure on tender breasts and preventing anterior torso rotation.
Extend her bottom leg, and position it on the table posterior to the other leg to avoid restriction of venous flow. For the uppermost leg, place supports of sufficient height and density to maintain a horizontal line between hip, knee and ankle, and to moderately flex this hip and knee. This will prevent strain on the sacroiliac joints and the lumbar spine, and anterior rolling of her torso. Proper leg height also mechanically assists in the reduction of leg edema, and provides relief from painful varicose veins.
The almost fetal sideling position offers psychological comfort for most pregnant women. Nestled comfortably on her side, she may feel more able to talk about her excitement, and her concerns, without the obstruction of a face cradle, as when prone, or the confrontational effect of talking face-to-face, as when supine.
The next time you have a pregnant client, you now have a basic overview of why, when, and how to position her. You may also want to learn more prenatal physiology, how to adapt your work for pregnancy’s demands, and specific prenatal therapeutic massage and bodywork techniques.
Carole Osborne-Sheets is the author of and Pre- and Perinatal Massage Therapy, and a contributor to the upcoming textbook Teaching Massage Therapy, as well as numerous other publications. The work outlined in this article is adapted from portions of the author’s textbook.
First Published in Massage Magazine, Nov/Dec 1993, Issue 46, 44-52
Melissa B. Mower, author and interviewer
My first real introduction to Carole came in February 1991 just after I had written a comprehensive article for this magazine about the development of a national certification examination for massage therapists and bodyworkers. When I sought her opinion on the piece as an editorial advisory board member of magazine, Carole criticized some aspects of the article.
We had a long discussion about the article, and while we basically agreed to disagree on some of the issues, we were able to openly speak our minds and maintain mutual respect for one another.
This was the foundation for our professional relationship. Since then, we have continued to communicate warmly, and I have been able to rely on her candor on other subjects as well.
In order to better understand what Carole’s work was all about, I asked if she would be willing to give me a mini-session. She took nothing for granted of me as a client. Her work was done with a sparing amount of oil as I lay face up in a room lit by the natural light of the windows. She explained that much of her bodywork is done face up, primarily because it’s easier for her to monitor the breath and that for most people, especially if emotional processing is involved, lying on one’s back is more comfortable.
A lot of her work involved deep holding with movement. It felt as though each part of me was being embraced and hugged. At times it seemed as though she was probing the depths of my soul, though her touch was never invasive or in any way felt threatening. She encouraged my breathing and free movement by simply and frequently saying “yes.” My comfort was of primary importance. It was wonderful session, one that instilled a sense of peace.
As a person and a professional, Carole embodies sensitivity with strength, compassion with caring, as well as empathy and enthusiasm with little ego involvement or judgment. She’s a delight to be with and to learn from.
I understand you were inspired toward bodywork through a group, called Arica. Would you tell us about that?
Osborne-Sheets: “Arica offered me a distillation, so to speak, of many of the traditions around the world of development of enlightenment and consciousness practices and had a very heavy emphasis on body-related methods.
“It is a school that relied a lot on Tai Chi and Tai Chi-type exercises, a lot of movement, meditation and some bodywork. It had a sense and a psychology of the body and of the psyche that truly acknowledged what seemed to me to be the truth – that we had a physical part of ourselves and an emotional part of ourselves and there was something intellectual that was there as well. Uniting all of that was a sense of spirit or life force or soul….Arica was extremely important in reconnecting me with my Source.”
How do you feel your psychological and consciousness background has benefited your current practice?
Osborne-Sheets: “What I have gotten from the theories of the psyche from Arica, and the Jungian theory of an internal male inside each of us women and an internal female inside each man…is that balance is achieved as you move freely between those two sides….
“When I first was introduced to the idea of yin and yang energies from the Eastern cultures, it was the first time I heard a theory that coincided with what my perception of what reality was….All of this affords me as a practitioner a relatively easy non-judgmental stance because I can see both sides, and I believe that both sides are valid. That means that I can give my clients a tremendous amount of permission to be.”
You advocate that physical and emotional balance is crucial for a therapist to accomplish his or her work. How do you maintain balance?
Osborne-Sheets: “My most consistent practice has been in Tai Chi. One of my purposes in coming to San Diego was to study Tai Chi, and I have continued to do that, studying under Abraham Liu. I do a lot of writing and journaling and emotional clearing on my own….
“One of the ways that I maintain emotional balance is that I experience myself and I think of myself in relationship to my clients as almost a neutral element that just provides some sort of environment.
“When I think I am going to fix someone or that I am going to help someone, I find it is emotionally unsettling. It depletes me, and I don’t generally do a very good job at fixing or helping someone….My family life helps me keep perspective that bodywork is not the only thing in life and makes a big difference.”
Describe the work that you do and what makes it unique.
Osborne-Sheets: “There are two aspects to the work that I do. One of the things that I do is somato-emotional integration. I work with people to explore what the relationship is between their physical tension and their emotional tension. I do that through using a very firm but gentle and deep pressure called deep tissue sculpting, done simultaneously with passive joint movements that are rhythmic and very gentle, for the most part.
“That sets up an environment that, if someone is interested, they tend to be able to feel and understand and have an ability to explore: What is my body saying? How does that relate to what my emotions are? What are my belief structures? In what ways am I unable to move freely in my body, feelings, or mind structure?
“I think what is perhaps unique about my work is that I don’t have an agenda with a client. It is not my idea that what we would do should have to create an emotional release or that there would be some kind of catharsis.
“I frame what I am doing as an exploration and often times those things happen… The second part of my work is work with women during the childbearing year, focusing on their pregnancy, the birth of their babies, their birth as a mother, and their interaction with their babies afterward, using the same techniques in working with people who are exploring their emotions, and also utilizing a number of other techniques.
“The approach that my (now former) business partner, Kate Jordan, and I have in this kind of work is unique in that while we are technically and medically very attentive, there is not exclusivity. It is equally as important as providing a place this mother can feel that she can talk about some of the fears she has, for example.
“The uniqueness of the deep tissue work that I do and that I teach lies in my feeling that I don’t feel benefit in creating pain in my clients. The work I do is not painful, at least not predominantly painful; it can be very intense, and I work very deeply, but I take the time that it takes biomechanically to enter into a body and enter in slowly enough so that it is not painful or invasive. I think many forms of deep tissue work and myofascial work can be very aggressive and painful for some people. I know that a lot of people accomplish some very wonderful results from that kind of work, but it is just not my style.
“One of the things that I think is unique about my touch is the way in which I combine a constant pressure and omni-directional movement. As far as I know I haven’t run across anyone who combines technique in that kind of way….
You were a co-founder of IPSB, formerly the Institute of Psycho-Structural Balancing. Do you still utilize the psycho-structural balancing approach that the school was founded upon?
Osborne-Sheets: “Yes. My apprenticeship training with Ed Maupin was and continues to be profoundly impactful, although the focus of my work is not structurally oriented. Ed, a psychologist, was one of the first few students Ida Rolf trained in structural integration.
“The wisdom and the genius of Ida Rolf, as Ed conveyed it to me, continues to be a foundation for my understanding of the structure of the body. That coincides with the Tai Chi principles of grounding through to the earth, and at the same time extending up to the heavens that you accomplish through alignment of the spine. On a physical level those structural parameters are the basis of my work. The psychological orientation is a ‘well, what does that mean in terms of what this person feels and what this person believes and how they perceive themselves and how they interact with the world?”‘
How would you say your work has evolved?
Osborne-Sheets: “My view of the structure is still based in that sense of alignment but instead of seeing a shoulder that is higher than another one, for example, what I now see is an expression of where someone is in their structure and in their emotions….
“When studying [Milton] Trager’s work, and in having lively discussions with him about how one could combine deep tissue work and passive joint movement, I gained a tremendous amount arguing each of our perspectives about that.
“I had the opportunity to work in an osteopathic physician’s office, and I learned strain/counterstrain work, some muscle energy work, myofascial release, and just the osteopathic perspective on health and disease. While I am not practicing craniosacral work, my sense of the body changed tremendously through taking a [John] Upledger course.
“Movement wise, I have been greatly influenced by a woman named Emilie Conrad-Da’oud. The focus of her workshops is rather eclectic and esoteric in some ways. They focus on micromovement, cellular movement.
“Her work is called continuum movement, and I’ve always combined some form of movement with whatever deep tissue work I do. Focusing internally on that level of movement has really enriched my work.
“I’ve learned a tremendous amount from Kate. When Kate and I began collaborating on the childbearing year class, I learned a very different and complementary approach to the body….
“I’ve got an amalgam of influences. Throughout all of it there has been the steady precision of pressure, holding pressure. That is what I started with in my own self-explorations before doing anything that you might call massage. That has been the stable center from which all sorts of other things have been added. Also the attention to the client’s emotions through the body has been consistent throughout. This amalgam is what I continue to teach in my courses at IPSB.”
What evaluation techniques do you utilize in assessing a new client?
Osborne-Sheets: “I use a lot of visual cues including my sense of vertical alignment, horizontal planes, of structure and the balance of fascial planes. I also evaluate visually for places where the body feels empty or where the body feels full or where there is a feeling of a lack of vitality. That is a visual impression that comes when I soft focus my eyes, when I let my eyes go and see without focusing on anything.
“Also, a lot of my assessment is in the words that I hear. I get a lot from what someone says to me, not just the words themselves and the choices of words, but also from the tone and the expression, what isn’t said….
“Maybe even more importantly than those two, I assess kinesthetically. I assess with omni-directional movement in the form of gentle rocking and shaking movements that help me to feel where the body is not moving, generally a place where there is some myofascial restriction…”
How would you say that massage therapists can better develop their abilities to read the areas of tension and then evaluate a client?
Osborne-Sheets: “I think probably the first thing I’d say would be to gain an internal understanding of the kinesiology and the way the structure is intended to be. Have some sort of paradigm for evaluating the structure…. Understand how bodies move, what are the components of gait, and how does one erect the spine.
“The second thing would be to develop the ability to see individuals without a preconceived idea of who they are or what they are….
“It seems to me that one of the best ways for a therapist to be able to assess is to truly commit themselves to some type of internal discipline that provides for clarity of mind, appropriate use of the body, and attention to the essence of things….”
What kind of issues come up for clients who are adult children of alcoholics or incest survivors, and how can practitioners be prepared to deal with them?
Osborne-Sheets: “The kinds of issues that will frequently come up are, first of all, body awarenesses that can be alarming or unexpected because there hasn’t been attention paid to the body.
“There needs to be ability on the practitioner’s part to stay with the client, stay with whatever intensity level the client is experiencing. The best way to do that is to stay in touch with one’s own breathing and to monitor what is happening with the client’s breath. It is the simplest and yet the most profound indicator and connection between what the body is experiencing and what the feelings are saying.
“I think it’s important for therapists to realize that just being with someone is profoundly therapeutic…What it requires of the practitioner is an ability to be with (the client) and to recognize and own when you are uncomfortable being with and, at least, have a recommendation of someone who you know who can be with (the client).”
Do you recommend that these clients also seek individual counseling?
Osborne-Sheets: “Absolutely….I have a tremendous amount of respect for what psychotherapists and counselors are able to do. I see us as complementary, neither one better than the other. We probably are the same profession and just don’t know it. Our tool is just different. As bodyworkers I think we grasp the soul through the flesh, and they grasp the soul more through word and through thought….
“Until training programs substantially prepare bodyworkers for the emotional aspects of the work, I think it’s an ethical imperative that we only work in a way that is respectful of the limitations of what our training and our abilities are….
“I don’t require every client to be in therapy, just those who are interested in pursuing somato-emotional integration. I’ve got clients who are coming for general stress and relaxation, who come for pregnancy, and I don’t require that. If at any point our work is going in a direction that I feel as though that would be appropriate, I do ask it then….”
Do you make yourself available emotionally when memories and emotions surface for clients, and at what point do you refer out?
Osborne-Sheets: “When, within the exploration that we’re doing, memories and feelings come up, I am available. How I work with that is: I stay with the bodily experience of that memory or that feeling so that I help to hold up ‘the mirror,’ so to speak, to that individual of what their body is saying about this in terms of what movement it wants to make.
“I focus on a real observation of their bodily experience and allow the body to have its say, to let it speak, if there are words that need to be spoken, or if it’s movements, or if it’s body postures to express something that wasn’t able to be expressed at the time….
“Within the context that I am working I am usually in communication with a psychotherapist, if that kind of thing surfaces within the context of our work, allowing that bodily expression if appropriate, even though it is a reflection of an emotional state.
“Because I’m usually already working with a psychotherapist, I usually don’t have to refer out. However, I do sometimes discontinue bodywork temporarily, or sometimes for a long amount of time, if the individual is having difficulty coming back to a grounded, everyday reality. That’s saying to me that they’re overwhelmed by the amount of information that’s coming up, that there’s too much for them to assimilate….”
Describe the integrative body therapy that you provide for these clients.
Osborne-Sheets: “What I provide is an experience of touch that is to the bone deep but very gentle so that it’s not invasive. It’s on the borderline of pleasurable, yet there’s an intensity level that says, ‘hmmm, something’s stirring here’ but, at the same time, it feels good.
“Combined with that, I use omni-directional and rhythmic movement that helps the neuromuscular system not be boxed into its repetitive patterns. Those together provide a physical experience of being profoundly attended to without any pressure to particularly do anything. Within that context, self-awareness is more likely to occur.”
How do you go about providing safety for incest survivors?
Osborne-Sheets: “I don’t require an incest survivor or any of my clients to tell any more than they volunteer. I provide for a sense of privacy in that way. I offer a lot of options in terms of how one will be touched or where one will be touched.
“I ask all my clients, whether I know they are an incest survivor or not, if there are parts of their bodies that they are uncomfortable with having touched. I offer the option of remaining seated and fully clothed, and numerous gradations between that and being undressed on a table. I request feedback regularly from a client on what they’re experiencing, and on their comfort level with what I’m doing.
“If, in fact, I know that someone is an incest survivor, I state very clearly that I will not touch them in any sexual way, and, if there is any way in which I touch them that they perceive as sexual, that’s not my intent. There is a profound range of what kinds of touches can be perceived as sexual to people.
“For any of my clients, I am committed to a level of confidentiality in not revealing their work in any way. I think one of the other ways in which I offer a level of protection to incest survivors is that I don’t see that as their identity. Whatever brought a person into my room, I try to initially look at them with a more encompassing viewpoint.”
How can deep tissue sculpting be helpful to women with eating disorders, as mentioned in your book, Deep Tissue Sculpting?
Osborne-Sheets: “My hands-on work is very much a blend deep tissue work simultaneously with movement. The two of them together work the most magic, but it creates a kind of paying attention that requires for many people a shift in consciousness, a shift into an internal awareness.
“For people with eating disorders oftentimes that internal awareness is asleep or shut off in some kind of way. The work is non-invasive, because it’s gentle and nurturing as well as demanding. For many people, their eating disorder is part of a defense mechanism and a protection system and so this kind of touch doesn’t further fortify that defense system. In fact it kind of renders that defense system a little obsolete.
“There’s an ability to drop some of that defensiveness and be more able to pay attention on a physical and an emotional level….Because of the structural paradigm with which I am working, there is much more body organization. Rather than their bodies feeling so difficult for them, they begin to feel more comfortable within that body, more pleasure within their kinesthetic sense. That just leads them to more pleasure in their body from a positive perspective, and that then leads them into behaviors that are going to tend to help them to develop their internal self-worth and their sense of the positive that comes from the body….
What was the most challenging case you have encountered, and how did you address it?
Osborne-Sheets: “Well, first I’ll give an example of what I considered in some ways to be a failure story. I think it’s important that we all recognize that we aren’t successful with everyone and often times you only hear the success stories.
“I had a client who was sent to me by his psychologist who on a physical level had irritable bowel syndrome and panic attacks and managed to maintain his job, but the rest of his life was pretty nonexistent because of the level of anxiety that he experienced.
“I saw him weekly for a number of months, and I was seldom able to keep his awareness in his body for longer than three minutes at a time in all that time. We were not able to successfully bring him to enough awareness of his body that he could even learn any breathing techniques to reduce the panic attacks. He had the most staunchly defended body that I ever had the pleasure to work with.
“When I was working my best, I was able to continue to focus my awareness on him and work with him with the faith that perhaps some part of him was in fact there and that at some point it would awaken, and he would remember maybe even all of this that had happened. I never got to witness any of that happen. When I was not working at my best, of course, I was feeling like I hadn’t done things right or that I was very ego-involved in the outcome of the sessions.
“On a more successful note, I had a woman who had a multiple personality disorder and had some physical problems with her neck and shoulders. It was very challenging to work with. She had only a single split so that there were two individuals inside her, but they had a different body manifestation… Once I felt what she felt like in each personality, I could feel her shift. I got so I could tell she was shifting on me on the table. It was very challenging to organize this woman’s body because in fact there were two people’s bodies that I was working on.
“What I did was stay focused on the body, enabling her to be able to compare for herself and observe her two bodies. She started being able to find ways to not be so different. Now, I don’t take credit for the healing of this woman. I take credit for a part. She had a most glorious spirit and maybe no matter what she would have done she’d have healed herself because she had that kind of soul.”
Can you recall your most rewarding healing experience?
Osborne-Sheets: “You know it’s interesting, because I’d say a good 90 percent of the time I have a rewarded feeling every time I work with someone. The word ‘reward’ implicates some sort of something that happens at the end of a goal having been reached with some sort of goal orientation to it. The places where I’ve been the most rewarded have been the places in which I haven’t been focused on a goal, focused on a reward, and especially not focused on it in terms of what it means as to who I am or how effective I am or any of those kinds of things. The most reward generally comes when I am the least personally involved and the most empathetically involved. That’s probably true for most practitioners, I would guess.”
What excites you about your work?
Osborne-Sheets: “It’s never the same. Never. There’s a freshness and an aliveness and, in a sense, a contribution to my own spirituality in that my intention has to be to stay current on a moment-by-moment basis with what’s happening. I can’t assume or expect that anything’s going to be the same….
“The combination of science and artistry excites me. You cannot do this work, and do it well, with either one of those pieces. You can do fine intuitive work or fine technical work but to really do fine work, you must have both….
“The more I develop my intuitive side, the more I’m able to truly see the way in which paired muscles work. That excites me. I guess both sides of my brain feel satisfied by it.
“I am very excited by the very concrete contribution that hands-on touch makes to individual lives, to our society and to the planet. I think it makes a phenomenal change in people’s lives that affects politics, economics and culture….”
What advice do you have for those practicing in the field?
Osborne-Sheets: “Pursue some type of internal discipline….1 would also encourage our profession to see what touch truly is. Touch is a part of human existence, it’s a part of family life, and it’s a part of the family….
“For bodywork to be an integral part of our society is appropriate, as is whatever contribution each of us can make to have our work be a part of rather than separate from society.”
In your opinion, how can massage therapists and bodyworkers bring further legitimization to their work in the medical and insurance arenas?
Osborne-Sheets: “I think the most important thing for us to recognize is that higher standards of education are crucial. I happen to think that the best way to accomplish this is through the tiered concept of a structure, such as how the nursing profession presents itself….
“I would hope that we would pursue means to validate the benefits of our work more extensively than they have been. I would hope that would be a priority for us as individuals and of our professional organizations.
“I think that the power of massage therapy as an educational tool is equally important, its role as part of self-awareness and understanding of ourselves is as important….”
What is your vision of the future for bodyworkers in the next 10 years?
Osborne-Sheets: “As I understand the cycles of health care, I think that we’re on an upswing in that cycle, which provides a kind of window of opportunity for us right now. When I first started doing bodywork, it was definitely an upstream swim.
“I think we’re on that upswing and I think over the next 10 years we will enjoy increasing public awareness of the benefits, public acceptance and a continued decrease in the association of our work with prostitution and quackery kinds of activities.
“Unless we have a serious economic collapse, I think that we will be able in the next 10 years to establish enough of a foundation for our profession that most of us will be able to make a reasonable living doing work that we love and that makes a significant contribution….”