Originally published in Massage & Bodywork magazine, May/June 2008. Copyright 2008. Associated Bodywork and Massage Professionals. All rights reserved.
I'm concerned about an elderly client who seems to be more short of breath every time I see her. I'm wondering if I should say something to her. She's a weekly client, and I hear her huffing and puffing as she climbs the few stairs to my office. I'm not sure whether it would be appropriate and within the bounds of my work as a massage therapist to tell her what I've noticed or whether that would be encroaching on medical territory.
E.C., Topeka, Kansas
You're not alone in being unsure about what's appropriate in our work, particularly as it relates to Western medicine. What you are wondering about is called our scope of practice, that is, what we are trained to do and what we are legally allowed to do.
In this case, I think you're correct in wanting to express concern to your client. As her massage therapist, you need to be advised of any physical problems a client may have, so that you take those into consideration when you work with her. For instance, you wouldn't want to give a vigorous massage to someone with cardiac problems. (Because of her age, you've probably been giving her a gentle massage already and you would want to continue to be cautious with her, especially in light of your present concerns.)
Although it's within your boundaries as a massage therapist, you still need to take care in how you phrase what you say. You have to avoid presenting yourself as a medical authority. For instance, you would be safe in saying, "I've noticed that you seem to have a harder time catching your breath each time you come here. I'm not a medical expert, however, I do need to know your current physical health so that I can adjust my work with you accordingly. Please see a doctor soon, if you haven't already."
That answer demonstrates three key elements about scope of practice boundaries that are among those I explore in this article: not making a diagnosis, not presenting yourself as an expert (when you're not), and urging the client to go to an appropriate practitioner.Staying Within Our Scope Of Practice
Staying within our scope of practice is an important ethical consideration, but it can be complicated to sort out what our territory is. As massage therapists have become more knowledgeable in addressing muscular problems, we have had an understandably more difficult time delineating our base of expertise. For instance, it can be difficult to distinguish where massage therapy ends and physical therapy begins. On the other side of the issue, as we've become more sophisticated and successful in working with clients' painful conditions, we have sometimes been tempted to inflate what we do know, and some therapists have deliberately presented themselves as having knowledge they don't.
Following are some suggestions for staying within safe boundaries as we work with our clients.Know Local And State Regulations
What we are allowed to do or what we can call ourselves changes from state to state and sometimes from city to city. There's a hodgepodge of rules, usually created by other professionals, such as physicians, chiropractors, and physical therapists, who have carved out their own territory. Check your local and state ordinances and talk with more experienced practitioners to find out what is allowable in your area. Do Not Diagnose
We can tell clients what we have observed, but we shouldn't put a name to it. We can say, "It looks like you have a tightness in your wrist," but not declare that the client has carpal tunnel syndrome. For your own integrity and for the sake of the client, don't even subtly imply a diagnosis. For instance, the massage therapist mentioned above shouldn't say, "I noticed that you're breathing more heavily as you come up the stairs. You sound like my mother did before she had a heart attack." You don't know all the medical facts about this client and you don't need to scare her unnecessarily or put a disturbing idea in her head.
When we see something that our training has taught us might be pathological, we are professionally obligated to tell the client. But we still don't have enough information or legal permission to make a diagnosis. "I have noticed this mole on your face has changed shape. If I were you, I'd get that looked at by a dermatologist soon." Describe what you have noticed in the most ordinary, nonmedical terms and you will be within good boundaries. Avoid Presenting Yourself As Having Expertise That You Don't
Clients will come to trust us and, in doing so, they sometimes expect us to have answers that we don't and know things that we can't be expected to know. Avoid trying to accommodate them by attempting to answer all their questions or to be all things to your clients.
Although it's sometimes impossible to be certain exactly how much training and experience are adequate, one weekend workshop on craniosacral therapy, for instance, doesn't make you an expert and shouldn't find its way onto your business card. Likewise, watching a DVD on a new technique can be inspiring or a reminder of what you've learned about the method in more extensive workshops, but it's no substitute for in-person training.
When commenting on a subject outside of your massage expertise, be clear about whether you are speaking as someone with extensive experience and expertise or as someone who is presenting common knowledge that the client may be overlooking.
Use your judgment about whether clients are likely to be aware already of a problem or whether they might need your input. For example, you probably don't need to advise very overweight clients or smokers of their health risks. Most people know that obesity and smoking are a challenge to their health and wouldn't welcome a reminder.Don't Prescribe: Suggest
If a client comes in with a cold, you might want to say, "I can't speak for the scientific validity of it, but I've had friends who have had good luck using vitamin C for colds." But not the authoritative: "Two thousand milligrams of vitamin C a day will nip that cold in the bud."
Even recommending exercise can be over the line in some states. In these areas, it would be considered "prescribing" to say, "Do 10 repetitions of this exercise every day and I'll check on you next week." However, we can tell a client that a certain exercise sometimes helps his condition. In that case, you need to make it clear that you're not overstepping boundaries. You can say, "I can't diagnose or prescribe, but I can tell you some at-home exercises that might help the areas that I'm working with in your sessions." Don't Interfere With Or Contradict A Doctor's Recommendations Or Prescriptions, And Don't Support A Client Who Wishes To Do So
We never want to go against what a doctor has told a client to do and we never want to suggest any prescription adjustments. However, you can say, "Now that your leg alignment seems better, you might want to go back to the doctor and see if you need different orthotics."
Another example would be a client who wants to stop his antidepressants because he is feeling so much better after weekly massages. You don't want to support the client in making any changes without the client consulting his doctor. It's well known that it can take a while for antidepressants to take effect, and rather than massage being solely responsible for his improved mood, the client may be experiencing the medicine finally working. Whatever the cause, you don't want to encourage a client to go off any medications without appropriate consultation with a medical professional.Refer To And Speak Respectfully Of Other Professionals
Knowing your limits also means knowing when to refer to another professional. It's a good idea to have an experienced massage therapist or even another kind of professional with whom you consult who will help you make these decisions. Sometimes in our enthusiasm for a new method we've learned, we can have an exaggerated idea of our skills and what that method can accomplish, when what may be needed is another kind of assessment or intervention.
Respect that medical professionals have usually had much more training than we have. Yes, they make mistakes. And yes, they can lean too heavily on surgery or drugs and may have little knowledge of the capabilities of hands-on work, but they also have valuable information and skills that we have not been trained in. They have access to tools that we don't--for instance, X-rays and ultrasounds that can show a hairline fracture or an underlying tumor.
It's both unprofessional and harmful to denigrate another professional. It's especially harmful to disparage someone your client is working with. If the client trusts that professional, you are insulting the client's judgment. If you genuinely feel that another professional's advice is harming a client, you can help the client become aware of negative results. "Do you feel better since you've been trying these new exercises?"
Many people have catalogued the problems with Western medicine and it's easy to find much to complain about. In trying to balance the scales, some clients seek help for a physical problem by using both conventional and alternative methods. For them, it can be frustrating and unhelpful to be caught between a practitioner who criticizes Western medicine and a physician who is ignorant of or biased against alternative treatments. Respect What We Offer
Insecurity may make us sometimes want to inflate our own credentials and abilities because of our insecurity. Massage therapy is low in the hierarchy of conventional medicine. However, it's good to remember to value our work: it's noninvasive work and can ease pain without side effects. Even "only" a relaxing massage can help lower stress, and stress levels seem to play a part in many serious illnesses.
Remember also that we are providing an incomparable benefit that is profoundly healing: our time. Where else do clients receive a whole hour of caring attention? We get to know our clients, we listen to their problems, and we ease their minds and their pain. That personal touch can't be overrated.
To stay within our scope of practice we have to educate ourselves, take care with our advice and suggestions, and above all honor the many benefits of massage therapy, knowing that it's enough to have done our best. Author note: thanks to Ruth Werner and Whitney Lowe who loaned their expert consultation to this article, but are not responsible for its content.Nina McIntosh combines more than 20 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. To learn more about professional boundaries and ethics, visit www.educatedheart.com.To learn more about illustrator Mari Gayatri Stein, visit www.mariscardsandmore.com.