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Informed Consent
Heart of Bodywork

By Nina McIntosh

Originally published in Massage Bodywork magazine, February/March 2007. Copyright 2007. Associated Bodywork and Massage Professionals. All rights reserved.

Floating along enjoying her massage, Sally is startled when her practitioner suddenly applies a noisy electric percussive device to her back.

Bob grows increasingly perplexed and frustrated when his massage therapist silently holds her hands above his injured knees for several minutes. He wonders when the massage will start.

As professionals, we know our clients should understand what we're doing and why we're doing it. We recognize clients must agree to our treatments and procedures, and they have the right to decline them at any time. These basic clients' rights are called the right to informed consent and the right of refusal. Although in theory they may sound straightforward, in practice they can be challenging to convey to clients. As practitioners, we must make sure clients fully comprehend our methods--and also wholeheartedly agree to them.

We may not always think it's necessary to spell out what we're going to do, but it is. A new client says she wants a massage, and you agree to give her one. Simple, right? But your idea of massage and your client's may differ. A great many laypeople think of massage as nothing more than relaxing effleurage strokes. Yet, many of us use a wide range of techniques and modalities, including deep tissue and energy work. Unless we've educated clients about these, and clients have agreed to them, they may wind up unpleasantly surprised. Even gentle stretches can be annoying to someone who expects only to be soothed. Less "traditional" practices--such as the energy work used on Bob--can be downright off putting to clients, especially if we haven't explained their purpose. If these uncomfortable moments start piling up for clients, they won't be able to relax fully during a session and might even start looking for another practitioner.


Optimal Communication
At the beginning of the session," complained one client, "my massage therapist started chanting. I didn't understand what he was doing. It really freaked me out, but I didn't say anything."

This remark points to a reality we, as manual therapists, should recognize and respect: clients will usually suffer in silence rather than risk offending us. Or if they don't understand a vague or complicated explanation, they may pretend they do to avoid seeming dense. It's our job to find clear words that convey our message in simple terms.

The practitioner in this example could easily have said, "I've found that chanting can help me get more centered for your massage. It'll take just a few minutes, but if you'd rather I didn't, I have no problem with leaving it out." (Personal rituals such as these should also not cut into the time clients are paying for. Reassuring them in this regard may also help set them at ease.)

Here are some guidelines for optimal communication:

First, your client has to be capable of understanding and giving consent. Avoid trying to explain or get permission for new techniques from a client who is deeply in an altered state and not fully conscious. Of course, if you're working with a minor or anyone not legally responsible for himself or herself, you need the permission of that person's parent or guardian.

You should always get agreement from your clients in the beginning, explaining your usual modalities and techniques. In the same regard, clients should be informed if you propose to add any new techniques. Extreme caution and clarification is needed to work near a client's genitals or a woman's breasts, assuming the latter is legal in your state and you have the appropriate training. If you routinely work in the abdominal or buttocks areas, it's a good idea to let your client know in advance that this treatment is optional. (What's taboo and what's permissible in terms of body areas may vary depending on your state or local licensing. Be sure you're up to date on current regulations where you live.)


No Surprises
It's important to have a written explanation of the services you offer, along with a listing of their benefits and risks, if any. Give this to every new client and ensure they have time to read it and ask questions before you start working with them. As therapists, we take some aspects of bodywork for granted, but our clients may not. Even at the risk of being redundant, it's best to make sure they know what to expect. For instance, mention that a massage may leave them sore or achy for a day or so, especially after deep-tissue work. Tell them any recommendations you have to help them with this, such as drinking plenty of water in the forty-eight hours after a massage. Let them know that after a session, they may feel too relaxed and "right-brained" to deal effectively with work or detailed chores right away and to plan accordingly.

Once clients have had a chance to assimilate your information, have them sign a statement that they understand the risks and benefits. Even then, it's a good idea to double-check that they really do understand--especially any procedures they might not expect. Tell them anything you think might surprise someone who's never had a massage (even if your client has some massage experience): "Even though it's your neck pain that's getting your attention, it's not a good idea to work only on your neck and ignore the stiffness throughout your body The discomfort in your neck will probably benefit more from a broader approach. Does that make sense?"

If you want to introduce a new technique during the massage, make your explanation clear and brief: "I think your right shoulder area would benefit if I apply pressure to one point for longer than I usually do. Is that okay? If you don't like it, please let me know." Keep it simple. There's no need to give a history or long explanation about trigger-point massage at that point. Also, although it can sound reassuringly professional to use anatomical terms, we have to make sure clients know what we're talking about. Remember that clients on the table are in or on the way to a right-brained state, and we don't want to bring them out of it by making them think too much.

If you are qualified to do breast massage, make sure you explain thoroughly--before the massage starts--what you propose to do and why. Breast massage is a controversial technique, and it lends itself easily to misunderstandings. You'd be wise to avoid introducing the idea during a massage and to reserve it for ongoing clients with whom you've already established a degree of trust.


The Right of Refusal
The inherent power difference in our relationships with our clients makes it easy for them to slip into a compliant, passive role. As already mentioned, clients may be reluctant to refuse, interrupt, or stop a treatment for fear of offending. Because of that, the burden is on us to make sure they understand they can choose not to receive a particular treatment and that they can ask us to stop at any time without having to explain why. Let clients know that they're in control of what happens. Reassure them we won't take it personally if they don't want to continue with a treatment.

It's best to ask clients for permission to apply a new technique before the massage begins. Sometimes, though, we may decide to add a new or different technique in the middle of a treatment. When this happens, we have to be especially careful that the client has room to say no. Our tone of voice, and even our body posture, is part of the communication. You might remove your hands and step back from the client slightly; then pose the question clearly and gently. Asking when you're poised on the brink of action can communicate a nonverbal cue that makes clients feel too rushed or pressured to choose freely. Even the most innovative technique is useless when a client is clenched against it.

The same is true for deep-tissue work. Clients will often grit their teeth and bear discomfort when the pressure is too much for them. They may think "no pain, no gain" or that we know what's best for them. They need to know the opposite is true and healing works best when they are open and relaxed.

***

Honoring the client's vulnerability is an essential part of being effective. We can do that by working with a client and not just on them. Clearly communicating our goals and being partners with clients can protect us from misunderstandings and help clients feel more safe and able to receive our good work.

Nina McIntosh combines more than twenty years of experience as a bodyworker with her previous years as a psychiatric social worker. She is the author of The Educated Heart: Professional Boundaries for Massage Therapists, Bodyworkers, and Movement Teachers, now in its second edition. For more information, contact Lippincott Williams Wilkins at 800-638-3030 or visit www.lww.com.




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