A massage therapist’s ability to recognize the importance of, and to engage in, personal conduct that comprises professionalism is vital to a successful career. 

The core elements of professional conduct are carved out of the principles of morals, ethics, business planning and risk management. 

Massage therapy is inherently a risk-filled profession based on the hands-on manipulation of soft tissue while alone with a client in a closed environment. Although that fact seems self-evident, the need to exercise professional conduct extends well beyond the privacy of a massage room. 

It starts with the therapist’s education and bridges to career and practice development based upon how clients are treated with integrity, transparency, fairness and respect.

The characteristics required to build a successful career will at the same time safeguard against the risk undertaken by performing massage therapy.

The acknowledgement that ethics is an essential component of a good business practice is a relatively new concept. Outside of religious and cultural teaching, ethics was confined to discussion in philosophy and sociology. 

Business instruction didn’t routinely examine the necessity to exercise ethical or moral conduct. Many businesses have and some still attempt to operate by sidestepping legal and ethical rules of conduct. However, many businesses have found themselves on the losing side of legal action that resulted in building an awareness that it was cheaper to do the right thing rather than get caught doing what was wrong. 

Risk management evolved out of the recognition that every action carried a weight of risk that must be considered. From there, more formalized rules of conduct and business practices grounded in ethics evolved. The benefit of professional conduct for massage therapists can’t be understated and is codified by the authorities that grant licenses and professional membership. 

Professionalism & Standards of Care

The “right and wrong” of how a massage business should operate didn’t become a priority until recently. The National Certification Board of Therapeutic Massage and Bodywork (NCBTMB) recognizes the need to define and instruct massage therapists on how to operate a professional and ethical business. 

The nature of massage therapy raised concerns as to the implicit requirement for ethical conduct by the therapist and it became necessary to dispel the public’s perception associated with massage parlors. This trend helped to promote massage therapy as a viable entity for health and wellness and to establish a place within the health care profession.

Reach within your own frame of reference and you can probably name dozens of variables that help to define professionalism. 

These variables may include, but are not limited to: recognizing the limits to practice, draping appropriately, maintaining confidentiality, documentation, operating the business following state and federal tax laws, striving for professional excellence, refraining from discrimination, setting appropriate boundaries, refraining from sexualizing relationships, limiting self-disclosure, determining the risks of dual relationships, and refusing gifts or benefits—to name just a few.

Every professional massage therapy organization has developed a code of ethics and standards of care for its members. The NCBTMB defines ethical practice as that which “develops trust and confidence, enhances the reputation of the profession and safeguards the interests of individual clients.” 

Think of what you observe and experience at a doctor’s office today. You witness the application of patient (client) rights, privacy, respect, disclosure and confidentiality, which is the same as what is advocated for massage therapy practices. The general public expects standards of care that provide safety and positive results whether the business entity has a goal of relaxation or the relief of pain.

Determining the Best Possible Outcome

My belief is that when we put our hands on someone, we have a tremendous responsibility. In the client-therapist interaction, the development of trust is imperative and with that trust comes responsibility, before, during and after a session. 

No one can predict what situations will present themselves in any given therapy session. There are instances when you are unexpectedly asked about something that may not be within your normal business practice. 

These are the red-flag moments when you need to pull from your training in ethics to stay on course. 

For example, a client asks you for a receipt that is greater than your fee in order to get full reimbursement from their insurance carrier. Don’t jeopardize the reputation or your business trying to please the client when they’ve asked you to do something that isn’t part of your business policies. 

We all have these moments when the course of action isn’t totally clear. In these circumstances, you may want to consider calling a trusted colleague to discuss an issue. Just remember to keep the identity of the client in-question out of the conversation to maintain confidentiality.

Therapists who have been in the profession a long time can attest that there are many situations that lead us to contemplate what the best answer is. This is why it’s important to know your code of ethics, refresh your knowledge in ethics, talk to associates and evaluate what is the best way to handle the situation. 

Case Example for Scope of Practice Referrals

Several years ago, I had a therapist email me and ask for assistance on how to handle a situation that began to make her feel uncomfortable. She stated she had a client who was obese. The client’s health had been declining over the years and the therapist had concern over her weight and found it difficult to manage administering therapy due to her escalating medical issues. 

Additionally, she had concern over the weight limit of her massage table and whether she was able to achieve therapeutic results any longer. There were several steps to get into the office and the therapist had serious concerns the client could navigate the steps safely. The therapist didn’t know how to handle the situation as there wasn’t anything that addressed obesity in any reference books. 

She didn’t want to discriminate, truly cared about her client and wanted to refer her to a facility that was better equipped to meet her needs: elevator in the building, adjustable tables and therapists trained in medical massage. When she suggested going to another facility, the client insisted she didn’t want another therapist.

This is a sensitive issue and one that if not handled correctly, could cause personal injury. If a solution wasn’t found, it could jeopardize the therapist’s reputation or cause a lot of hard feelings.

Since the therapist had already established a good therapeutic relationship with the client and had an ability to have an open rapport, she needed to have a personal conversation about how they needed to work together to find the right solution that could bring about the best possible outcome for her. 

Having established trust within the client-therapist relationship can help the therapist avoid misunderstandings and avoid liability.

Honoring Boundaries

The NCBTMB Code of Ethics clearly tells us to; “respect the boundaries and integrity of each person and, therefore, not engage in any sexual conduct or activities … ” and to “respect a client’s boundaries with regard to privacy, disclosure, exposure, emotional expression, beliefs … ”

The therapist is responsible to maintain professional boundaries and not staying within them, may put themselves in a situation that can be misinterpreted. 

For example, touch on the table may be viewed differently than touch off the table. Over-sharing during a therapy session can change the nature of the relationship. Discussing inappropriate topics can make the client uncomfortable. Challenging a client’s belief may put the client on guard. Asking invasive questions that have nothing to do with the therapy session can lead to the client never coming back. Staying true to office policies and procedures helps the therapist to prevent topics and conversation that result in transference or countertransference. 

In transference, the therapist is viewed like someone familiar to the client. Counter-transference occurs with the therapist reflecting back to the client in a way that is familiar to them. There is a redirection of emotions on both sides that can confuse the relationship. Recognition by the therapist that transference or countertransference is occurring is important so it can be stopped.

A good rule is to put curiosity and self-interest aside and adhere to your scope of practice, meaning, do what you have been trained to do, massage therapy, and steer clear of any conversation that may develop into an unhealthy one.

For example; Tanya is a 33-year-old cyclist who came to the office to alleviate pain in her neck. She is bright, friendly and is very health conscious. During a therapy session, Tanya reveals she lost her mother in a car accident two-months ago. She began to cry as she shared her mother was her best friend. The therapist, in turn, shared that she also lost her mother and is empathetic. 

She told Tanya that she often talks to her clients about her personal loss and feels she can be helpful in sharing how she overcame the depression and sadness that comes with someone’s passing. They talked at length and before the session was over, they seemed to have developed a bond (here is where transference and counter-transference can begin). Tanya feels comforted and the therapist feels needed.

Tanya decided to make massage therapy part of her health care program and came in once every other week. Tanya continued to have difficulty with her mother’s loss and talked about it often in session. The therapist provided her with words of encouragement and felt she gave good advice to Tanya. 

As they moved more toward a friendship rather than a therapeutic relationship, the therapist began introducing Tanya to enjoy social events with her friends and they began shopping and having lunch once or twice a week. The therapist was thrilled with Tanya’s improvement as her mood seemed to lift and Tanya seemed more optimistic.

Several months later, Tanya lost her job and she began calling the therapist during her sessions insisting she needed to talk. The therapist cancelled several sessions with clients in order to meet Tanya and help her through her issues. It became so disruptive to her practice that she began shutting her phone off and didn’t return her calls. 

In hindsight, the therapist needed to be a good listener during her sessions, teach Tanya to relax during therapy and provide her with a counseling referral. If a therapeutic relationship isn’t clear and expectations are outside the scope of the massage therapist’s practice, it changes the nature of the relationship and leaves the therapist vulnerable to problems. 

Tanya transferred her need to have someone emotionally comfort her, like her mother used to, and the therapist counter-transferred by forsaking her responsibility as a massage therapist and became her friend and confidant. The nature of their relationship changed. 

Foundational Documentation: The Case History Form and Office Policy

Two vital documents should be used regularly; a case history that includes informed consent and an office policy. From a properly conducted case history interview, the therapist can design an effective care plan that ensures the best possible outcome from their client. It also provides an inside look into the past and current health of the client.

An informed consent paragraph should be added to the case history that defines the expectations and limitations of treatment. The case history form should always be signed (and) dated. 

An office policy, on the other hand, gives the client information regarding your policies on things like selection of services, late or missed appointments, hours of operation, cost, and insurance reimbursement along with the mission statement of your business.

The case history form and the office policy statement can be sent to a client prior to an appointment or made available when they arrive at the office. Most healthcare professionals send materials to their patients prior to an office visit and massage therapists can do the same. 

It gives the client time to complete the case history form in the comfort of their home and gives them the ability to access the names of their medications and to review the office standards outlined in the office policy.

The case history form also provides the therapist with important information that will determine if the therapist’s skills match the needs of the client and when it might be more appropriate to refer the client to someone else. 

Ask yourself the questions when a client presents with conditions that may be considered complicated: “Am I qualified to treat this person?” “Do I know enough to treat this person effectively?” “Could treating them make their condition worse?” 

Be sure to establish a solid foundation of understanding between you and the client before treatment begins to ensure a safe and trustful environment. 

Referrals Make Good Business Sense

Over the years, I’ve gained respect within my community by developing a reputable referral base. When a complicated case presents itself, know your referral base. Just be sure to check out those referral sources before sending your client to them.  

Make an appointment to meet the person or call and ask about the services they offer so you can gain an understanding of their philosophy on patient care. It may be totally different than your own and might not be a good match for your client. Ultimately, ask yourself, “Would this be a good fit for your client?” Check your referral resources and see if there is someone better equipped to provide service. Remember, when in doubt, DON’T treat! 

Additionally, working within your scope is not only ethical, but is important to risk management as poor or harmful treatment can lead to negative word-of-mouth or worse yet, litigation. Referring a client exhibits professionalism and decision-making that gains greater respect.

In the past, when I attended licensure revocation hearings or served as an expert witness in lawsuits, I was saddened to learn how the therapist ignored the code of ethics and proceeded when numerous red flags were in plain sight. 

For example, a massage therapist doesn’t take the time to review all the information on the case history form and later realized they missed something that would be a contraindication to treatment. Another example is when the therapist fails to inquire what medications the client is taking when the client wrote, “Too many to mention” on the case history form. If the therapist doesn’t question it and treats anyway, there could be a host of contraindications to those medications if massage is performed.

Many cases end up in litigation because a therapist may not have adhered to their own policy to require a completed case history form because the client came in and used a gift certificate or the client only had a chair massage. 

Thinking that a case history form is not needed when the client will be there only once may place those therapists into a state of having to defend themselves without any source of documentation. The completion of the case history form protects you and your client. 

There is never a reason why it shouldn’t be completed. It should always be reviewed accurately before an initial therapy session and must be updated every six months in the event the client hasn’t been in recently.   

Every state law requires therapists to document the treatment they perform on a client. Therapists also have a responsibility to safeguard that information. 

A client could leave a massage feeling great and later that evening be feeling flu-like or even feeling like they have been hurt. Circumstances can change post-treatment. Be sure to spend adequate time educating the client about what they can expect after treatment and the importance of staying hydrated. 

Don’t Only Accept the Tip as a Signal of Satisfaction

Just because the therapist receives a tip doesn’t necessarily mean the client was happy with the massage. Many people who file a lawsuit state that the reason they gave the tip was because it was expected, (even though they may not have been satisfied with the care they received).

A client comment card may give a much better idea of the satisfaction of the client or issues they may have had during the massage. Adopt the policy of having one completed after a session.   

Reporting Misconduct

What do you do when you learn of or observe another therapist engaging in misconduct? It is each therapist’s obligation to report unscrupulous practitioners. 

For example, Pennsylvania’s Standards of Professional Conduct states the massage therapist has the responsibility to perform “safe and functional coverage/draping practices” and lists the areas of the body that require draping. Therapists also have the responsibility to “act to safeguard clients from incompetent, abusive or illegal practices of other massage therapists or caregivers. 

If it is evident that a violation has occurred or is occurring, most state laws have a hotline that allows a person to make a complaint. These forms are completed on-line and are done confidentially. It is up to the state to act upon the complaint and to bring it before the state board if the complaint is valid.

Moving Forward

Massage therapy has come such a long way from the historical perception of massage parlors. Therapists today enjoy working in a variety of practice settings—private practices, spas, health clubs, clinics and alongside medical practitioners. 

Thanks to an abundance of research that has unveiled the health benefits associated with massage therapy, it is rightfully viewed as a viable therapeutic entity. Our profession is growing exponentially and the opportunities are endless. 

The need for professionalism is vitally important to maintain the gains that we have achieved and to advance the profession.

This is Part Five of a special multi-part series on professional development from the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). This series covers areas that NCBTMB Board Certified massage therapists possess. Read Part One, “Brick by Brick: 3 Ways Professional Communication Helps You Build Your Practice,” Part Two, “Brick by Brick: This is How Your Knowledge of Pathology, Movement, Anatomy & Medication Improves Your Massage” Part Three, “Brick by Brick: The Value of Adding Massage Assessment to Sessions” and Part Four, “Brick by Brick: Understanding Advanced Massage Techniques Will Elevate Your Practice.”

About the Author:

Nancy M. Porambo, CNMT, BCMT, LMT, wrote this article for MASSAGE Magazine on behalf of the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). She is the owner/operator of The Therapy Option, Inc. in Jim Thorpe, Pennsylvania for the past 29 years. She specializes in the relief of chronic pain utilizing neuromuscular therapy. Porambo is a past National President for the American Massage Therapy Association and currently serves as an advisor to the American Medical Association’s Health Care Professional’s Committee (HCPAC). She is seated on the Pennsylvania Massage Therapy Licensing Board and holds the first license in massage therapy in her state. She serves as an expert witness and has given opinion on many cases throughout the country.