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All healthcare professionals encounter clients who challenge their professional and ethical boundaries. Analyzing examples of such encounters fosters practitioner preparedness and reduces the likelihood of being caught by surprise and without a plan of action.

Professional codes of ethics dictate appropriate behavior in the professional and therapeutic relationships of massage therapists. Actions and behaviors have a tremendous impact on therapists’ clientele. Beyond the limitations of the client/practitioner relationship, actions and behaviors have the potential to affect clients’ families, colleagues, employers and the community at large. In all of these relationships, a therapist must continually ask whose interests are being served, and whose may be harmed by one’s own thoughts and responses.

While a code of ethics offers guidance in navigating each relationship, the safety and well-being of the client remains the primary focus. Trust and open communication must form the basis of every therapeutic relationship. Establishing and maintaining respectful boundaries between practitioner and client promotes the trust necessary for a safe and viable partnership.

When it comes to the ethics of touch, physical boundaries between a client and practitioner are delicate issues. Whether conversing with a coworker or on line at the bank, people test physical boundaries each day based upon their levels of comfort and safety. As professionals whose work requires close physical contact, bodyworkers are generally more comfortable initiating physical contact and more relaxed about maintaining personal space. Those unfamiliar with massage come from a variety of backgrounds and experiences, and may require some time to adapt to massage’s high level of physical contact.

In addition to physical interaction, comfort and safety concerns can arise from emotional and sexual boundaries. Our touch can both communicate a message and elicit a response in either of these areas. Ralph Napolitano, author of the Institute for Integrative Healthcare Studies’ Ethics: Therapeutic Relationships course states, “In fact, what we communicate through touch is what the client will receive, regardless of the words we say.” For example, unresolved negative, judgmental or sexual feelings toward a client may be communicated through touch. This is where both the intention behind touch and clear communication of boundaries become crucial.

Before boundary issues arise, it is best to be prepared by considering possible scenarios and thoughtfully developing a plan of action. The following scenarios provide the opportunity to think about each situation and how you might best respond.

Scenario One

A female massage therapist has been regularly seeing a male client for four months. Over this time, he has become increasingly demanding and directive during the massage. After working his tight hamstrings and then moving up to work his lower back, during the course of a massage the client rises up from the headrest and states in a loud, demanding voice, “I need more work on those hamstrings!” In response, the therapist quietly obliges the client and returns to working on the hamstrings. During the following massage, the therapist feels timid and unsure of herself throughout the session, following every directive the client gave.

After reflecting on this situation, the therapist realized that this client reminded her of her perfectionist father, who was a demanding and authoritative figure throughout her childhood.

“As healthcare practitioners,” Napolitano states, “we must be conscious and avoid bringing our own personal and emotional baggage into the massage relationship.”

In relationships where a power differential is present, as between a healthcare practitioner and client, there exists a potential for transference and countertransference to surface. Transference occurs when a client unconsciously projects unresolved feelings, needs and issues onto a practitioner. In countertransference, the therapist unconsciously assigns unresolved feelings, thoughts, and perceptions about someone from their personal history onto the client. As a result, the therapist may lose objectivity and misinterpret a client’s actions, responses and needs. These misperceptions can lead to misunderstandings, poor judgment and even negative feelings toward a client.

Negative feelings often arise when a client displays similarities to a person in the therapist’s life toward whom ill will is harbored. On the other hand, displaced positive feelings can arise when a client reminds the therapist of someone they feel favorably toward. Recognizing the signs of countertransference can prevent an awkward ethical dilemma up to and including litigation. The following behaviors are indicative of countertransference:

  • Unusually strong positive or negative feelings directed toward a client.
  • Predominance of impatience or anger when a client is not progressing.
  • Being argumentative with a client.
  • Experiencing an overemotional reaction to or involvement in solving the client’s problems.
  • Making exceptions for a client’s inappropriate behavior.
  • Giving a client extra time and attention before and after a session.
  • Bending our professional and personal boundaries to accommodate a client.

By becoming more self-aware and overcoming prejudices, preferences, judgments and personal issues, health professionals establish clearer boundaries in the therapeutic relationship. When personal feelings are recognized, addressed and put aside, they do not interfere with the commitment to high quality healthcare. Awareness of countertransference marks the therapist’s return to professionalism. Moving beyond this barrier, the therapist in Scenario One can educate her client on the anatomical connection and therapeutic value of working the lower back to release the hamstrings.

Scenario Two

A therapist has been giving treatments to a home-bound client receiving workmen’s compensation, twice a week for 6 months. During the last month, the client begins every visit with a warm hug and a small, inexpensive gift (i.e., a candle, incense) for the therapist. During the session, the client plays music she knows the therapist likes. Further, following the massage, the client invites the therapist to stay and talk while having tea.

The therapist is noticing the boundaries of this therapeutic relationship are being breached.

Transference is the displacement or transfer of feelings, thoughts and behaviors related to a significant person onto someone else, such as the therapist. Individuals seeking help with unresolved needs, feelings and childhood issues are often attracted to a compassionate, helpful and knowledgeable caregiver, and can unconsciously transfer expectations of resolution onto that caregiver. Since vulnerability can stimulate transference, it is the responsibility of the therapist to be aware of this possibility, how it affects the client, and how the therapist’s behavior may affect transference.

A massage session can magnify transference because:

  • There is a striking similarity between the practitioner/client relationship and a parent/child relationship.
  • The client is in an altered state of consciousness.
  • Bodywork involves a high level of intimacy.

As transference is mostly an unconscious behavior, it is up to practitioners to recognize its signs and maintain professional boundaries. It is important to remain firm within established boundaries such as starting and ending sessions on time, proper draping and minimizing dual relationships. These steps reduce the likelihood transference has to destroy the therapeutic relationship.

Transference can be recognized in a client who:

  • Frequently asks about the therapist’s personal life.
  • Calls the practitioner at home when explicitly stated otherwise.
  • Brings a gift to every session.
  • Solicits help in solving personal problems.
  • Has difficulty maintaining physical boundaries (i.e., wants to hug or touch during every interaction).
  • Asks for more time before and at the end of a session, and is disappointed when not appeased.
  • Asks the therapist out on a date.

It is also possible to misinterpret a client’s behavior and subsequently, react negatively due to preconceived notions or fears. Often small gifts from clients are a personal sign of appreciation, as may be the case for clients who cannot afford to tip. Weighing the client’s intention for giving gifts, hugs or invitations to stay after the massage will dictate a practitioner’s ethical plan of action. Whatever the decision, the goal is to create clear and comfortable boundaries between the therapist and his/her clients. As Napolitano asks, “Will the action I choose enhance the therapeutic relationship, or hinder it?”

Scenario Three

A massage therapist attends group therapy for personal development. An opening in the group is unexpectedly filled by one of the therapist’s clients. Although a member of the group for years, now the therapist feels uncomfortable about disclosing personal information with the group in the presence of the client.

A dual relationship is one where multiple roles exist or overlap between a therapist and a client. Consisting of both professional and social roles, examples of dual relationships are when a client is also a student, friend, family member, employee, business associate, teacher or healthcare provider to the therapist. In the healthcare field, it is the practitioner’s responsibility to be informed and accountable for dual relationship repercussions. The power differential that exists within a therapeutic relationship demands practitioners gauge the nature of dual relationships in order to establish and maintain clear relationship boundaries.

Seeing a client at a monthly association meeting or at the gym may initiate a minimal level of intimacy. However, a client who joins a therapist’s gym, church or association to be closer to the therapist may be seeking a deeper level of intimacy. As the massage profession’s nature initiates a certain level of intimacy, each role within dual relationships and levels of intimacy determine a course of action.

Switching roles in the therapeutic relationship can lead to confusion and the possibility of transference or countertransference. Although not a massage therapist during group therapy, the client may transfer their pre-existing respect onto your personal opinions shared in the group. Self-disclosure to a client outside of the professional relationship will impact the atmosphere when bodywork sessions resume. Both parties are often tempted to treat sessions as a time to continue developing a personal relationship rather than maintaining a professional atmosphere. Under these circumstances, boundaries crumble, session length considerations decrease and focus on the client during the session diminishes.
A therapist must ask why they would self-disclose in the presence of a client. If it may benefit the client in some way, such disclosure may be valuable. Timing, method of delivery and the amount of information revealed, will aid in preventing dual relationship dilemmas.

If a massage therapist is lonely and in need of social interaction, it may be tempting to reciprocate the adoration and respect received from clients. Since massage therapists are not precluded from social contact after treatment sessions by their code of ethics, this is a personal decision based on self-assessment and the retention of clear boundaries.

It is up to the therapist to evaluate the potential risks involved in fostering a dual relationship. When evaluating the risks, consider the following:

  • What is the level of intimacy?
  • What is the potential impact of the power differential?
  • Who is accountable for what in the relationship?
  • What is the relative maturity level?
  • What are the consequences of non-participation?

In all practitioner/client relationships, the power differential favors the practitioner, who must use that power to best serve their client’s needs. For example, a massage therapist has a car in need of repair and an auto mechanic as a client. This may appear to be a mutually beneficial dual relationship at first. However, before initiating this dual relationship, consider possible scenarios where the power differential may reverse:

  • What if the mechanic does a poor job?
  • What if the mechanic never shows up on time and causes the therapist to miss appointments?
  • How might this situation spill over into the treatment room?
  • After the car was supposedly fixed, would it be tempting to give a below standard treatment if your automobile problem resurfaced?

Professional ethics require accountability, guide us to do no harm and dictates we help our clients to the best of our ability. Nina McIntosh, author of The Educated Heart, suggests asking yourself the following questions to determine if any action taken is ethical:

  • Does the action keep the focus on safety and well-being of the client?
  • Are you being respectful of the power imbalance and/or the transference effect? Or are you using this power imbalance to your own benefit?
  • Does the action create a dual relationship and make the therapeutic boundaries less clear?
  • Does the action remain within the original contract with our client – or are we exceeding either our area of expertise or the client’s informed consent?
  • Does the action create a safer environment for the client or detract from it?
  • Could the action lead to future problems in the therapeutic relationship?

Massage and bodywork professionals have a license to touch. The type of touch used either establishes a sense of safety and reassurance, or it can make clients feel uneasy, apprehensive and uncomfortable. Establishing appropriate boundaries in regard to the nature and type of touch used and communicating these to clients early in the relationship can avoid potential misunderstandings.

Recommended Study

Ethics: Therapeutic Relationships

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