ethics and etiquette
By Terrie Yardley-Nohr
Originally published in Massage and Bodywork magazine, March/April 2010. Copyright 2010. Associated Bodywork and Massage Professionals. All rights reserved.
A frequent topic of conversation among massage therapists is the subject of boundaries and the many gray areas this word entails. Certain facets seem black and white, but there are areas that still prompt a variety of opinions. Massage therapists have unique challenges they must be aware of for the safety of the client and themselves alike.
A boundary defines the difference between acceptable and unacceptable behavior. Most massage therapists believe they have a solid sense of their own boundaries and that it's crucial to have strong foundations. The challenges usually occur with clients they do not know or individuals who push their boundaries--knowingly or unknowingly. It is important to be aware of a client's concept of the boundaries in a variety of categories and how we can address related issues.
When a boundary has been crossed, we may say someone has "crossed the line" or "gone too far." In many cases, a client crosses a boundary in a very innocent way. For example, a therapist may be working on a client's posterior neck when the client may ask the therapist if he or she could adjust the neck, anticipating the equivalent of a chiropractic adjustment. A client may not understand that this is beyond the scope of practice for a massage therapist. Simply educating the client can end that discussion. If the client knows that massage therapists aren't allowed to do neck adjustments and he or she still pushes to have this maneuver done, then he or she is crossing the line.
Experienced therapists understand and know they will encounter challenges from time to time. They have learned ways to help clients better understand boundaries. New therapists may find it challenging to know and articulate what is acceptable and unacceptable in the field of massage. They know what they have learned in school, but that may not be sufficient for the challenges they encounter in the treatment room. Resources such as state laws, rules, regulations, or an association's code of ethics are good foundations for therapists. Confidence and a solid professional foundation go a long way when handling boundary issues.
Most therapists know what behavior they expect from their clients, but how does a client know that the therapist has certain expectations when it comes to behavior on their table? We would like to think that common sense would prevail when it comes to boundaries, but it is many times the gray areas that turn into major issues. Most therapists cover topics such as draping, safe touch, and the type of work the client can expect before the session begins. Other therapists may distribute an orientation sheet to all new clients that gives a detailed description of what is expected, including a code of ethics, state rules and regulations, and the therapist's expectations for the sessions. It is important for each therapist to decide what information he or she feels is necessary to share and what feels like the best approach for each client.
We ask a great deal of our clients. People you have never met before come to your office to receive massage. It is your responsibility to assure them that they can trust you. When we hear a story from a client about some of the unprofessional things she has experienced in the past, we shudder. It makes us angry to hear when a therapist has crossed the line and it hurts everyone in the profession.
Clients come with a sense of what behavior feels safe to them, but that feeling can differ from the therapist's beliefs. It is important to explore the concerns a client may have. Is draping an issue? Communicating with a client and hearing the concerns he or she may unknowingly share is crucial. Helpful questions to ask clients during an intake interview include whether or not they've received a massage before and, if they have, what did they like best and like least about their previous sessions. For instance, if they mention they felt like they were not very well covered, you know draping is important to them.
Divisions Of Boundaries
There are five areas basic areas that a therapist should have a sense of when practicing massage. These are physical, social, emotional, sexual, and professional boundaries.
This is the line a therapist or client must not cross. In some states, laws and regulations clearly define physical boundaries, but the bottom line is the boundary lies in a safe zone for both the client and therapist. For example, when working the inner thigh of a client, the draping creates a physical boundary that the therapist should not cross. A securely tucked sheet gives the client a feeling of safety. It is important for a therapist to also know his or her own comfort zone. But what if the client does not like being draped? This may be against a state regulation and it's clearly against associations' codes of ethics; those facts can be communicated to the client. If there are no rules to fall back on, a therapist must rely on his or her own boundaries. Again, it's crucial to establish firm foundations with clients. When a therapist tells a client that full draping is his or her policy, the statement holds more weight than simply saying draping is someone else's rule.
We have all had clients who may not be able to articulate their comfort zones. The client who barely gets undressed or feels uncomfortable when the therapist works certain areas of the body can send nonverbal messages that a comfort zone is being crossed. Paying close attention to both the verbal and nonverbal communication will help both therapist and client have a more rewarding session.
How do you keep the relationship professional and not social? This is one of the gray areas of boundaries because opinions vary widely. When a client invites you to his or her home for a party, your relationship shifts from professional to social if you choose to accept the invitation. Some therapists are comfortable with this transition. But, family and friends aside, many therapists do not want to cross this line. It can be challenging when you work on a client for years and you may know a good deal about the client's personal life just through causal conversation. A good rule of thumb is to ask yourself if you would feel comfortable inviting this person to your house for a party. If so, then this is probably a person with healthy boundaries who respects you as a professional and whom you respect as a person, but also appreciate as a client.
There are definite limits when exploring the personal feelings and emotions of not only the client, but also the therapist. A therapist may have a client who asks a lot of questions and wants to know too much about the therapist's life. These questions can vary from professional to personal. Therapists know that clients relax better by just breathing and remaining quiet, but perhaps the client is having a difficult time relaxing. There is always the danger of clients talking about their problems and the therapist being drawn into client dramas. It is difficult not to have compassion for a person who has been hurt or abused in some way. These emotions can easily be released as part of their massage session. There is a gentle way of letting a client know that you acknowledge that she has had pain by gently telling her you are sorry for what has happened and she is here now to relax and let go. It is dangerous--and outside an MT's scope of practice--for the therapist to become a part of the client's emotions by offering advice. A savvy therapist will have a mental health professional's contact information on hand to suggest to clients.
Feedback that front desk receptionists, managers, and owners of massage facilities hear frequently is that the therapist talked too much. Every therapist should know that the session is not at all about the therapist, but a release for the client. It is important to put yourself in the client's place and not allow your emotions to leak through into the session. Questions to ask yourself include: Does the client know more than your credentials, education, and type of work that you do? If a client knows the names of your children, your favorite hobbies, where you hang out in your free time, or whom you are dating, the focus of the session has more than likely shifted to being more about the therapist than the client. Even if a client tries to engage a therapist by asking questions, that therapist needs to stay focused on the client in the session.
Massage should never be sexualized. Usually this boundary is specifically spelled out in laws, rules, and regulation. This seems like a given boundary and in the case where a client asks for sex, it is very easy to see that the boundary has been crossed. What may be more difficult to see is when human nature enters into the client/therapist relationship. For example, what happens if you start to feel an attraction for the client? These feelings may be subconsciously conveyed through your hands and body language. The client may pick up on your signals and proceed, or may feel uncomfortable and decide not to come back. If a therapist has feelings for a client beyond the therapeutic relationship, he or she should either get under control or refer the client to someone else. We cannot change human nature, but we can change how the situation evolves. If a client has feelings for a therapist, the therapist needs to explain his or her professional boundaries or refer the client to a different therapist.
Many entities have guidelines and expectations for therapists' professional behavior including associations, states laws, and employers. All therapists are responsible for knowing these guidelines, fully understanding them, and abiding by them. When in doubt, call the originators of the expectations. For example, if a state law mandates that a therapist have proper training in a modality before performing the work, but does not specify the hours or training that is expected, the therapist should contact the state board for clarification.
Another professional boundary that should be respected is discussing other therapists or professions. A client may tell you about other treatments or professionals. It is important to respect the fact that the client is here with you now for a reason. Talking unprofessionally about other therapists is not appropriate or helpful to the client.
An Ongoing Process
Maintaining boundaries is an ongoing process for all therapists. On any given day, a therapist or client could intentionally or unintentionally cross a boundary. In many situations, educating the client on your scope of practice and your office policies will be sufficient and the therapeutic session can continue. If a client chooses to push your boundaries, then the therapist must either end the session or relationship, refer the client to someone else, or decide the client is no longer a suitable client candidate.
If you, as a therapist, have crossed a boundary, it is important to look within and think about the services you are meant to provide. Has the relationship been more focused on your needs and not the clients' needs? If necessary, work with a mentor or other professional and refocus your sessions on the clients.
Being a professional massage therapist is an everyday lesson in learning. You may learn a new way to approach a treatment plan or a modality. Just as important is learning new and effective ways to negotiate boundaries. Clients will know you have their best interests in mind and will feel safe. As a therapist, you will feel more secure in knowing where your boundaries lie.
Terrie Yardley-Nohr, LMT, has been a massage therapist for 18 years, working both in private practice and medical settings. She began teaching massage techniques and ethics 12 years ago and became program manager at Allied College in St. Louis, Missouri, nine years ago. She is the author of Ethics for Massage Therapists (Lippincott Williams Wilkins, 2006). Contact her at firstname.lastname@example.org.