Important therapist client relationship boundaries exist between mental health counseling and the kind of communication appropriate during a massage.

Important boundaries exist between mental health counseling and the kind of communication appropriate within the massage therapist-client relationship.

Crossing those boundaries is outside a massage therapist’s scope of practice—and therefore, illegal—and can do harm to the person on your table.

Massage therapist Andrea Jones* had a client, Claire, a middle-aged woman who came regularly for massage for three years. They had a great rapport and often chatted about their families, work and philosophies of life.

Then Claire’s son was killed in Iraq. His wife and baby came to live with her, and her grief combined with the chaos of a newly configured household plunged Claire into an agitated state. Because she felt comfortable with Andrea, she continued to receive massage weekly and talk about her situation.

Andrea felt loyal to, and protective of, Claire, but also noticed that she started feeling overwhelmed by the enormity of Claire’s problems. Claire was having panic attacks, sleeplessness, dark thoughts and disturbing dreams. She told Andrea that massage was the only thing helping her, and at times she cried through the whole massage.

Andrea responded to this by being more supportive and spending more time with Claire after the massage, talking. Without realizing it, Andrea had unceremoniously moved into the role of counselor—but she didn’t have the tools to recognize, evaluate and treat the symptoms of post-traumatic stress disorder, which was what Claire had. Andrea was hooked by her client’s telling her that she was the only one who really helped, and she ignored her own feelings of being overwhelmed.

One day Andrea received a call from a family member, telling her that Claire had been hospitalized. It started as a medical admission due to an anxiety attack, but quickly became a psychiatric stay. Claire was exhausted, in shock and suicidal.

Andrea felt awful about this, but she also learned valuable lessons. She learned that feeling overwhelmed is a red flag for her. (For others it may be a different feeling, such annoyed or helpless.) She learned that a client in crisis might lean on her for more support than she is able to provide, and that it is safer for herself and the client if she recognizes this and directs him or her to mental health intervention.

This example illustrates what might happen when a massage therapist migrates into a counseling role.

Massage therapists should understand that when this migration occurs, they are exposing themselves to liability on the pragmatic levels of licensing and malpractice insurance, and that they may be exposing the client to harm by inadvertently allowing a disturbing emotional state to come up, which might be difficult or impossible for the massage therapist to safely resolve with the client.

There are three general boundaries that need to remain in place between the fields of massage and counseling. These boundaries involve: pragmatic issues; approach and intention; and trust.

Pragmatic Issues

First, on a pragmatic level, there are the licensing, certification and malpractice issues. There are separate licenses that are regulated by separate state boards, and separate malpractice-insurance policies for each profession.

It is vital for your own professional safety that you don’t engage in activities that are outside your scope of practice as a massage professional.

Approach and intention

The second boundary between massage and counseling has to do with the roles that the two professions play, in terms of general approach and intention.

On a very simplistic level, when we massage someone we’re intending that he feel better at the end of the session than he did when he arrived at our office. Even when we utilize techniques to help him work through a difficult spot, such as trigger points, our goal is to make him feel better. We take his lead. If he says the pressure is too much, we back off. We don’t force an issue if the client asks us to lighten up.

We don’t take the attitude that we know better than the client. We don’t try to convince him to get a certain number of sessions, or present him with ultimatums.

If asked our opinion, we offer it, based on studies and professional experience, but we don’t portray ourselves as experts in any category of the health field except for massage. We generally don’t contradict clients. If a client says, “I have bad cramps today, so don’t massage my stomach,” we don’t suggest that she might be in denial and should really let us dig in there.

Massage therapists don’t intentionally raise anxiety in clients, nor do we encourage clients to dredge up old problems. And we don’t confront clients, unless the client is being abusive.

While these examples—of confrontation, contradiction, raising anxiety, persuasion and taking charge of treatment—might sound ridiculous in the context of massage, they are all representative of techniques that are utilized in the field of mental health.

Counselors go through graduate school, supervised practicum and years of practice in order to become licensed.

Along the way they learn about the easier stuff, such as helping people through normal, everyday anxieties and getting them to open up through reflective listening skills—and they also learn how to handle the tougher issues, including addictions, mental illness, recovery from abuse and torture, suicidal and homicidal thoughts, criminal behavior and eating disorders. They also earn to recognize the symptoms that may mask some of those problems.

Touch Generates Trust

The third area of boundaries between massage and counseling has to do with trust. Massage clients take off clothes, lie down on a table, and allow the therapist to touch them for an hour without anyone else in the room. There aren’t too many other forms of therapy that have this much vulnerability built in. When a client comes back to the same therapist, it is because she trusts the therapist. Over several or many sessions, a bond develops.

Massage clients also develop trust in their therapists because of the power of positive, nurturing touch. Even though a client is a paying customer, the timeframe is defined and the therapist obeys the rules of professional boundaries, we should not ignore or underestimate the potential power that touch has to generate strong trust between client and therapist.

This trust can make the client vulnerable to any communication the massage therapist puts forward. Because of the special power of touch to generate trust, a massage therapist should be aware that migrating into a counseling role can cause the client harm, either through things said or through things unsaid.

For example, I recall a workshop in which a massage therapist spoke about a client of his who had been sexually abused as a child. When she began receiving massage from him she was tense and withdrawn, but after several sessions she relaxed and started flirting with him. He thought this was great, a sign of success that she was opening up to a man and to her sexuality.

The teacher of the class didn’t contradict him. I bit my tongue for a while and then couldn’t contain myself, having worked in the field of child sexual abuse for 20 years. In essence, the client’s flirting with the therapist was a sign that she was not healed from her molestation.

She still saw her primary value as sexual, and that’s how she related to him. Her flirting illustrated her poor boundaries and her desire to offer herself sexually, because that’s where she saw her worth. It is easy for us to agree that a 5-year-old girl who flirts overtly with adult men is exhibiting unhealthy behavior. It’s not so clear that flirting by an adult can also be unhealthy.

If that massage therapist had continued thinking that her flirting signified progress, he might have encouraged it and ultimately caused her harm by reinforcing the very behavior from which she needs to heal.

Stay Safe

To keep yourself safe and within your scope of practice, here are some cues to attend to so that you can be empathetic but avoid taking on the role of a counselor:

  • Clients talking about their marriage or relationship problems. Usually, when people talk about romantic or marriage problems without their partner present, it’s because they feel misunderstood or threatened by the potential break-up of the relationship. Without the partner there, you can’t verify any of the accusations or information the person is putting forth.

Your client may assume you’ll take her side because you are so nurturing to her. It’s best in these situations to be empathetic, but avoid giving advice

You can use reflective listening and respond by saying, “It sounds like you and your partner are going through a rough time”—and leave it at that. If the client continues to bring it up, say something like, “You’ve been going through a lot lately and that can put stress on a relationship—it might be helpful to consider getting into counseling, either as a couple or by yourself, to have someone to talk it over with.”

If you believe a client is suicidal, it’s important to protect the client and yourself. Before the situation even arises, get the phone number of the suicide hotline in your community and have it on hand for advice and to give to clients. Be clear in directing suicidal clients to get mental health help. If they go to a counselor but continue to talk to you about suicide, tell them that you want to speak to the counselor or psychiatrist, and take direction from that professional on how to handle the client.

If the client refuses to get mental health help, is still suicidal, and continues to see you for massage, seriously consider discontinuing the sessions. Be clear with him that you’ve recommended he get help and have given him a suicide hotline number, and that it isn’t safe to receive massage while he has a serious, untreated mental health condition. If a client is in imminent danger, evidenced by stating something akin to, “I’m going to kill myself,” call 911.

3 Steps to Referring to a Mental Health Professional

  1. For counseling resources, Google “community information and referral (and your city name).” Most cities have a centralized resource, and they usually have a fully staffed crisis phone line. You can give the number to clients and use it for information if you encounter challenging issues, such as suicidal expression, child abuse or domestic violence.
  2. If clients have health insurance, suggest that they call their insurance provider to find out the names of approved mental health counselors, psychologists and psychiatrists in the area.
  3. If you have clients who are in counseling, discourage them from telling you about their sessions. Keep boundaries clear. Remember, if they talk about their sessions you are only hearing one side. If you sympathize with the client you might be sabotaging the treatment plan their counselor developed.

Listen to Yourself First

Generally speaking, as massage therapists, we know that people are going to talk to us about their lives. Each of us has our own threshold of tolerance for listening to and talking with clients—but it’s important to remember that when people bring up anxiety or depression that lasts for more than a few weeks or interferes with their functioning, when they have experienced significant abuse, or are experiencing breaks with reality from drug use or mental illness, they need more than a compassionate ear.

Clearly, the most important aspect of keeping good boundaries is to listen to your inner voice. You probably will have a feeling of being overwhelmed when a client is nudging you across the border between normal conversation and counseling. Listen to that feeling, and address it with yourself and the client.

I hope that my observations help you, as a massage therapist, to push yourself to grow, through the process of thinking about mental health issues, and to reflect upon some concrete information about possibly dangerous situations you might encounter.

*Names have been changed

About the Author:

Phyllis Nasta was as of this writing a licensed professional counselor, licensed massage therapist and certified school counselor.

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