The therapeutic relationship is the proper space to communicate and work with clients in order to facilitate their healing journey; the topic of professional ethics in the massage field is an ever-present topic of significance and must be taken into account when addressing the therapeutic relationship.
Due to massage therapists violating ethics, especially choices regarding ethical dilemmas, laws have been created to protect the general public.
The therapeutic relationship concept is a cornerstone curricula in most massage therapy programs. As the practitioner learns how to show this relationship, the level of professionalism increases, and the client-therapist bond grows stronger. Client trust increases while therapists have greater clarity to discover new means to aid clients.
6 Principles
1. The therapist practices a client-centered approach. Regarding the care of the client, this approach indicates that the client’s wishes and needs are placed higher in priority to what the therapist considers most important.
2. The therapist holds the client in high esteem. The therapist respects the individuality of each client and honors his or her dignity as a human being.
3. The therapist expresses empathy toward the client. In the therapeutic relationship, empathy embodies the ability to understand the perspective of a client expressing concerns, problems and challenges.
4. The therapist practices active listening. This type of listening involves intending to truly understand what the client is expressing via verbal and nonverbal communication.
5. Silent attunement
This is the concept that a client and therapist become bonded energetically through treatment. Meaning, the therapist’s total focus remains on the client with no distractions interfering the session either physically within the room or mentally within the therapist’s mind.
6. Awareness
The therapist remains acutely aware of the needs of the client during the session. Aspects pertaining to the client’s sensory sensitivities during a session, including nonverbal cues and perceptions of touch, are mindfully monitored.
Therapeutic Touch
All professional touch performed within the construct of the therapeutic relationship is therapeutic in nature and performed with a purpose that is in alignment with the client’s treatment goals. This includes being acutely aware of initial touch to begin the session, secondary contact throughout the session and grounding practice at session’s end.
Shaping the therapeutic relationship with our clients are our ideas of boundaries, transference, counter-transference, dual relationships, informed consent, right of refusal and scope of practice. Understanding and accepting these concepts allows therapists to perform his or her services with a heightened therapeutic relationship with his or her clients. Let us examine each concept in greater detail.
Boundaries are physical and nonphysical limits determined by individuals to ensure security, safety and well-being. Therapists must be conscious of boundaries when interacting with clients and employ awareness in understanding boundaries created by clients. Boundaries will not be equal among all clients. Some clients may not mind if you stand two feet from them; however, other clients will think you are smothering them physically by standing too close.
Where do boundaries come from? For some clients, boundaries arise from sensitivity to what is perceived by the client energetically. For others, past experiences shape boundaries. Clients’ perceptions of their environment also create boundaries.
Some questions to ask yourself about boundaries include: Am I aware of how my practice environment will be perceived? Does my work environment promote boundary-building? Does my body language, appearance or speech cause clients to create boundaries?
Transference is the displacement or transfer of feelings, thoughts or behaviors related to a significant person or event onto someone else, such as a therapist. Below is a list of signs of transference by clients. Do you recognize any of these signs from experiences with past clients?
• Frequently asking the practitioner about his or her personal life
• Communicating in manners the practitioner has disallowed
• Bringing gifts to each session
• Inviting the practitioner on dates or to social events
• Soliciting help in solving personal problems
• The client displays reluctance or difficulty maintaining personal boundaries, such as disrobing in front of the practitioner or attempting to hug the practitioner after each session.
• The client requests more time during each session and is disappointed when the request is not granted
Transference may occur if the massage therapist provides the space for certain clients to perform any of the acts noted above. Usually these acts are unconscious, as the client feels completely comfortable with his or her therapist. However, boundaries are in question at this point.
If a massage therapist does not honor healthy boundaries, such as by encouraging a friendship to develop, clients are taken out of the normal therapeutic relationship and thrust into a different, interactive, role where transference thrives.
Counter-transference is displacement or transfer of feelings, thoughts or behaviors related to a significant person or event onto a client by a therapist. Below is a list of signs of counter-transference by therapists. Do you recognize any of these signs from experiences with past clients?
• Unusually strong feelings (positive or negative) directed toward a client
• Becoming argumentative toward a client
• Bending professional and personal boundaries to accommodate a client
• Impatience with clients when displaying a lack of progress or effort
• Making exceptions for a client’s inappropriate behavior
• Soliciting assistance from client regarding the practitioner’s personal affairs
• Treating the client in a certain manner because he or she reminds you of someone
Counter-transference indicates unresolved emotions or feelings on the part of the practitioner. Clients should never be viewed as a replacement for professional assistance in dealing with personal problems and unresolved emotions or feelings.
Dual relationships are defined as relationships in which multiple roles exist between a therapist and client. In the health care field, it is the responsibility of the therapist to be accountable regarding dual relationships and not allow these to proliferate.
Some examples of dual relationships include when client and therapist:
• Begin dating
• Create a business partnership
• Include their family in the relationship outside the scope of massage therapy sessions
• Actively support the same charitable, political or religious cause/event
• Attend a social event together
• Exchange finances outside of the context of a massage therapy session
Because the client no longer views the therapist in strictly the context of a facilitator of health, there can be many negative side effects that arise from a dual relationship. First, the quality of care can be greatly diminished. Second, communication in both directions can become less professional. Third, boundary violations become more common. Finally, the client may easily become a former client as professionalism becomes difficult to maintain.
Informed Consent
Informed consent reflects the client’s right to know and fully participate in his or her care. Writing a statement of informed consent is crucial to the success of a massage practice, yet many massage therapists overlook this vital component. An informed consent statement includes:
• A list of services that you offer
• A specific definition of what those services are
• Guidelines for receiving massage
• Your policy regarding cancellations
• Description of your scope of practice
• A statement of your intentions for massage
• A statement of your philosophy on healing, massage and health
• A description of the client’s treatment plans and goals
• Risks involved in treatment; contraindications
After informing a client of your services and philosophy, it is necessary to confirm that the client understands what you mean. Often, clients will agree without hesitation to avoid interfering with the treatment. If you feel this is happening, you can ask a client to tell you what they understand will be happening during and immediately following a session.
Right of Refusal
Right of refusal is an often overlooked aspect of the therapeutic relationship. Clients have the right to refuse services for any reason and at any time. If they determine that the session should be stopped midway, their needs must be respected.
This same right also applies to the practitioner. You can end a session at any time with just and reasonable cause. Consider the nature of the therapist-client relationship with these queries: How healthy is your relationship with the client? Is the client taking advantage of you in any way? Is this situation correctable?
Scope of Practice
Your scope of practice encompasses the actions, methods and perspectives of healing allowed to your profession in accordance with legal and ethical considerations.
According to Ben Benjamin, Ph.D. and Cherie Sohnen-Moe, co-authors of The Ethics of Touch, the scope of practice for massage therapists is influenced by four factors: education training, competency, personal accountability and laws. All four of these factors impact our practice of therapeutic massage application.
Education training and competency are intimately linked. A therapist needs to conduct an honest introspection on his or her level of training. Sugar-coating or self-inflation will do nothing to aid one’s ability to help a client through his or her healing journey. The maxim “fake it ‘til you make it” does not apply to scope of practice issues!
Some questions to ask yourself about scope of practice include: Have I mastered the techniques to the point that I can apply them properly and safely? Do I need more training and/or continuing education in a certain modality? If so, where can I obtain more training or continuing education? Do I have a thorough understanding of the client’s pathology and dysfunction? If not, where can I obtain this information?
Ensure Safety
Regarding personal accountability and laws, massage therapists must assume personal responsibility for knowledge in these areas. The excuse “I didn’t know” does not apply when dealing with personal accountability and laws.
Be sure to keep up with changes in local and state laws and rules concerning massage therapy. Keep in mind that massage laws (and the definitions and rules accompanying these laws) vary by state. It is the responsibility of the massage therapist to obtain the most current information.
The therapeutic relationship ultimately becomes the basis that the therapist should always take into account when interacting within any ethical gray area with clients. Communicating and behaving from this proper stance will likely ensure safety, benefits and positive results from any action taken in handling ethical dilemmas.
Jimmy Gialelis, LMT, BCTMB, is owner of Advanced Massage Arts & Education in Tempe, Ariz. He is a National Certification Board for Therapeutic Massage & Bodywork-approved provider of continuing education, and teaches many CE classes, including “Professional Ethics for LMTs.” His many articles for this publication include “Massage Improves Quality of Life for the Cerebral Palsy Patient” and “Massage for Teens: How to Create Session Safety & Success.”