A painting of two human faces, with a shared, blended space in the middle, is used to illustrate the concept of the therapeutic relationship between therapist and client.

You know what to do with the body — but what about the mind, heart and spirit of your clients?

Entry-level education programs for massage therapy rightly focus on hands-on techniques for being safe and effective with massage modalities, and beyond the skills for manipulating soft tissue, students are offered ethics courses that introduce the importance of boundaries and the concept of scope of practice.

However, most students are not offered much direction for developing healthy therapeutic relationships—for dealing with a client’s story: a client’s frustrations, their love lives, their career challenges, and how they coped with shelter-in-place orders during the COVID-19 pandemic. And yet, all these conditions often show up on our tables.

What is a massage therapist to do when a client discloses something of importance but is in no way related to the musculoskeletal system? Do we pretend we didn’t hear? Do we say, “Sorry, we can’t have that kind of conversation as it is out of my scope of practice?” Do we stop everything and share our own personal stories because it feels so familiar and it might help?

Therapeutic relationship is a term used in health care to describe behaviors and actions that a provider utilizes, beyond their specific discipline, which is intent on supporting the whole person in their care.

A therapeutic relationship honors the boundaries of scope of practice, but doesn’t wall off the human interaction between two people, one identified as the provider and one identified as the client. Instead, therapeutic relationships honor the whole person, stay patient-centered and use a few tricks of the trade.

Case in point: Lisa (name has been changed) is a 37-year-old woman who comes to massage for help with anxiety and a history of body dysmorphia. Her physical issues are always shoulder tension, neck pain and tension, and sometimes upper leg with radiating pain (not sciatica). While on the table, Lisa often shares personal stories and concerns regarding her career and relationships with men she dates.

She describes her family of origin as not supportive in her times of need; she explains she has a few wonderful friends but doesn’t want to burden them with her concerns. She reports now that recently, during our state’s lengthy shelter-in-place orders due to COVID-19, her anxiety increased substantially and isolation was extremely challenging for her.

As her massage therapist, should I A) recommend Lisa not talk about her issues and use the time to relax; B) engage in problem-solving and find resources for her specific challenges; or C) listen and use skillful questions to help facilitate her own inner guidance?

Therapeutic relationships might mean any of the above interactions, but I would suggest for clients like Lisa, who are talkative and openly share their personal concerns and worries, option C is likely the most helpful. Here’s why: If Lisa had good support systems, option A might be best. Option B would never be appropriate, due to scope-of-practice constraints; but referrals to other providers who do specialize in psychosocial needs would be very appropriate.

Maintaining a list of local psychologists, counselors, social workers and support agencies is highly recommended. This allows us to stay within scope of practice and still offer support to whatever the client is presenting.

In this case, however, Lisa mostly needs to be heard and acknowledged in this moment. In order to stay away from closing down her conversation (option A) and not deferring it completely for another time (option B), a few skills from therapeutic relationships could easily, and within scope of practice, facilitate Lisa’s feeling heard and finding her own way.

Two of the many important actions that health care providers use when building successful therapeutic relationships are: 1) skillful questions and 2) therapeutic listening. Here are brief descriptions of each:

A skillful question is open-ended (not inviting a “yes” or “no” answer) and directs the conversation toward solutions.

For example, when Lisa is on the table discussing her career concerns and worries, a skillful question might be, “What has worked well for you in the past?” While an answer in the moment might be “I don’t know,” the question itself suggests she has inner resources to draw from, including her past experiences. The very question empowers her to know her own best solutions.

Therapeutic listening is a great in-the-moment practice to have in your tool kit. When you don’t know what to say, or saying anything is questionable, listening with your heart as well as your ears for what feelings and emotions are being expressed can be helpful. Any gentle, simple acknowledgement, including taking your own full breath, will often be supportive for the client’s mind, body, heart and spirit.

In traditional active listening, the technique is to repeat back to the client what you hear. In therapeutic listening, include any feelings or emotions you heard in your repeat back.

An example might be when Lisa is expressing how much she feels the need for change in her work life: “I can sense you’re feeling a real need for change.” This simple acknowledgment can be quite powerful. It is very important to reflect back the client’s own words and not interpret anything. (Interpretations and recommendations are definitely out of scope of practice.) Acknowledging the client’s feelings is what distinguishes therapeutic listening from traditional active listening.

Every client encounter is a moment in the relationship. Understanding the opportunities to develop therapeutic relationships means staying within boundaries of scope of practice and using techniques to build relationships that are not distant nor draining, but that are therapeutic.

For more tips and information, see “Communication Rx: Transforming Healthcare Through Relationship-Centered Communication” by Calvin Chou and Laura Cooley (McGraw-Hill Education, 2017) and “Hands in Health Care: massage therapy for the adult hospital patient” by Gayle MacDonald and Carolyn Tague (Handspring Publishers, January 2021).

“You Asked” provides answers to questions asked by our community of massage therapists. Join our closed massage therapists’ Facebook group at facebook.com/groups/massagemagazine to participate in polls and for the opportunity to tell us what you’d like to learn.

About the Author

Carolyn Tague

Carolyn Tague, CMT, is a massage therapist at UCSF| Osher Center. She is the founder of Tague Consulting, which offers continuing education courses and consulting. She co-authored, with Gayle MacDonald, “Hands in Health Care: Massage Therapy for Adult Hospital Patients.”