Massage therapists are in a unique position in the world of health care. In some states, we are recognized as licensed health care providers; in others, we are not. While most of us strive to meet the highest standards of practice, there is one way to guarantee that we will not: when we deviate from the scope of our professional practice.
Deviating from scope of practice also assures that we have less credibility as a profession. We have an ethical responsibility to ourselves, our clients and our field. When we do not adhere to the highest professional ethics standards, we can harm ourselves, our clients and our industry. Client-centered care should be our primary goal.
Because we are in a profession where legal scope can vary so greatly from state to state, things can often get complicated. That said, it is the responsibility of every massage therapist to understand the ethical and legal implications of deviating from the scope of their license, or scope of practice.
The safety and well-being of our clients can be jeopardized when we are not properly trained in an area of massage but do the session anyway. This is also the case when we offer advice or services that are outside of what we are legally allowed to do, as dictated by our state regulatory boards and the terms of our liability insurance.
Through the Clients’ Lens
It is important to examine what we do through the lens of the clients we work with. It takes extraordinary trust for our clients to get on our tables and allow us to work on them. Most have no idea what we can and cannot do within our legal scope of practice, and they trust us to be ethical about that.
When we say that we are trained in a certain modality, for example, our clients have no reason to doubt us. No matter how well-meaning our intentions are, when we embellish or exaggerate our training and skill set in ways that benefit us more than the client, we are not only deviating from our legal scope, but we are being unethical.
It is important to consider how we would feel if we were the client on the table.
Imagine, for example, that we sent a loved one with severe lymphedema to a massage therapist who claimed they were competent in manual lymphatic drainage when they were not. What if there was a negative outcome? The therapist responsible for that negative outcome has now opened themselves up to some real consequences. Their professional liability insurance is very unlikely to cover the claim. In addition, their licensing board may be notified and forced to take disciplinary action.
The worst part of this outcome for most of us would be the fact that we caused harm to a client. It can and does happen.
Truth in Advertising
When we knowingly work outside of our scope, this invalidates the trust of our clients, and we could easily be putting them in harm’s way.
At a minimum, we are robbing them of the chance to have a session with a therapist who is better suited to their current needs. It is imperative that we as therapists understand our strengths and our limitations so that we can offer alternatives to our clients to best meet these needs.
Employers should be particularly mindful of the risks of their therapists working outside of scope. While it might be tempting to tell a potential client that a therapist on your team can work on a stage-four cancer patient, for example, even without the proper training, it opens your business up to real liability risks if you were not being truthful and that client is injured or harmed.
All employers who hire massage therapists should have a thorough understanding of what their employees can legally and ethically do. A well-rounded staff with many specialties makes referring far easier. This is not always possible, however.
Common Deviations
The following are some common ways massage therapists deviate from professional scope:
Offering advice on nutrition or supplements. Why could this be so dangerous? Imagine that a newly hired therapist on a hospice team recommended nutritional supplements or dietary changes to a patient.
Now let us consider whether this supplement or dietary change would interfere with the medications they are taking. What if it was not recommended by their medical team? What if they had a swallowing disorder and could not tolerate the pills that had been recommended without serious health risks?
I assure you, things like this happen.
Our clients trust us to provide them with information they believe is within our area of expertise. It is up to us to let them know when something is not within our scope.
According to the American Nutrition Association, massage therapists should not provide any type of nutrition counseling unless: “1. The practitioner has a state license or state certification that recognizes nutrition counseling as part of the legal scope or practice; or2. The practitioner’s nutrition guidance is covered under an exemption to the nutrition/dietetics licensing law.” (Nutrition Regulations by Profession, American Nutrition Association)
Offering services you are not trained, certified, or competent in. None of us want to lose clients, and it can be tempting to offer a service we do not feel adequately trained in. My experience has been that clients are grateful to have therapists tell them the truth and to refer them out when necessary.
Oncology massage and medical massage are prime examples. If a therapist does not understand the side effects of chemotherapy drugs, the risks of working with someone with bone metastasis, or what pressure should be used on someone with low platelet counts or lymph node removal, they can do real harm to a client.
Taking a chance like that is more about satisfying our own ego, or feeding our financial fears, than it is about safely helping a client in need. We cannot be experts in all aspects of massage, and we should not attempt to be. What we do is incredibly important, and we should be proud of what we are best at.
We are being ethical therapists when we refer to people who have put their time, money and hard work into excelling in the areas of massage that we do not. Building a solid referral network is extremely valuable and should be utilized often.
Overstepping your scope when working with clients with trauma. Trauma-informed care is critical, and it is something that all massage therapists should have a solid educational foundation in. Providing a safe environment for our clients and allowing them to autonomy to collaborate fully with the therapist is key.
There are far too many areas of trauma-informed care to discuss in this article, but being trauma-informed is far different from providing mental health advice or otherwise stepping out of our scope of practice.
Be mindful of what you are asking your clients. Does your intake form keep you within your legal scope? Are you using credentials that imply that you are a mental health professional? Does your website or other advertisement draw a distinction between your trauma-informed massage and mental health care?
These types of actions can often be construed as boundary violations within our industry if we are not incredibly careful about what our clients can infer about our practice by the credentials and language we use.
Using techniques or credentials that may not be valid. There are many classes that are offered to massage therapists that have components that do not fall under the legal scope of practice in the state we practice in. Pay attention when a class you are taking is offered to many different professions.
For example, a class may have components that are all within the scope of practice of a classmate who is a physical therapist, but only some may be under the professional scope of a massage therapist. It is up to us as ethical practitioners to decipher what our states and our insurance policies allow.
I suggest reaching out to the instructor before signing up to take a class. They may not be familiar with the regulations in your state, so make sure you are fully aware of those as well. Just because you have taken a class does not mean you can always use all the information or credentials you earn in your massage practice.
Protect Yourself and Your Clients
Having a clear section in your intake form that outlines your scope of practice and the purpose of the massage session is especially important. Having a client/therapist relationship in which honesty, trust, and communication are paramount will also go a long way when it comes to staying within your professional scope.
About the Author
Jennifer DiSilvio is a hospice and oncology massage therapist currently working on the Integrative Medicine Team at Yale New Haven Hospital. She is also an NCBTMB-approved massage educator and is currently pursuing her master’s degree in Licensed Clinical Social Work. She believes strongly in a holistic and client-centered approach to massage therapy.