The Therapeutic Relationship | My Assignment Tutor

C H AP T E R 2The Therapeutic RelationshipMegan E. Lavery, Susan G. Salvo“Today I shall behave, as if this is the day I will be remembered.”—Dr. SeussLEARNING OBJECTIVESAfter completing this chapter, the student should be able to:1. Define the therapeutic relationship and state several key characteristics.2. Discuss the importance of professionalism, including confidentiality andmandatory reporting.3. Define boundaries and describe types of boundaries.4. Compare and contrast transference and countertransference, as well as how tomanage boundaries.5. Define and discuss dual relationships and reasons why they can beproblematic.6. Define and give examples of sexual misconduct, sexual risk management, andidentify steps to take when a colleague is accused of sexual misconduct.IntroductionInterpersonal skills help form the relationship between massage therapists andtheir clients. This relationship, the therapeutic relationship, is the basis of alltreatment approaches regardless of their specific aim. During our initial contact, aclient needs to feel that we are reliable, trustworthy, and consistent. The clientneeds to also feel that the relationship will be conducted within appropriate andclear boundaries. A boundary helps establish personal and professional space, canimpart a sense of self, and promote feelings of safety and security.The therapeutic relationship is a creative process and distinct to each therapist.Although this relationship serves the best interest of the client, each personbrings to the table his or her own uniqueness. The efficacy of the therapeuticrelationship can be substantiated scientifically. Research has found repeatedlythat a good therapeutic relationship is one of the best predictors of positiveoutcomes in therapy.The Therapeutic RelationshipThe therapeutic relationship is the relationship between the therapist and theclient in which the therapist provides services that benefit the client. We agree toact in the client’s best interest and we are held accountable for our actions. If webehave irresponsibly, there may be legal consequences, such as malpracticelawsuits, licensing violations, and even criminal charges. Clients also have aresponsibility: to comply with the agreed-upon treatment plans.The quality of the therapeutic relationship is based on our ethical behavior,interpersonal skills, and capacity to communicate each person’s roles andexpectations. It also depends on our ability to gather client information, apply thisinformation to our knowledge of health and illness, and then formulate acondition appropriate client-centered session and to do this process repeatedly.Everything we do for our clients emerges from this relationship. It provides aframework for our thoughts, feelings, and actions. This relationship is establishedduring the first session and maintained throughout subsequent sessions.However, the duration of this relationship is highly variable and depends on thelength of service, which spans anywhere from a single session to the client’slifetime. Other terms used to describe the therapeutic relationship are therapeuticalliance, helping alliance, working alliance, or therapeutic use of self.Carl Rogers, an American psychologist, asserts three characteristics thatpromote positive growth and change and that these must be present in thetherapeutic relationship: empathy, unconditional positive regard, and genuineness. Tothis list, we will add respect as a component of unconditional positive regard,congruency to signify genuineness, and trust as essential characteristics of thetherapeutic relationship (Figure 2-1).FIGURE 2-1 Therapeutic relationships: key characteristics.This chapter offers guidance in navigating the landscape of therapeuticrelationships, which involves recognizing what does belong in the relationshipand what does not belong. We will also focus on ethical behavior, professionalboundaries, confidentiality, and conflict resolution.EmpathyEmpathy is the ability to comprehend the unique world of another personthrough their perspective. Empathy is often described using metaphors such as“standing in someone else’s shoes” or “seeing through someone else’s eyes.”Empathy is recognizing and understanding the client’s feelings and experienceswithout mistaking them for your own. Sympathy, on the other hand, is feeling theclient’s feelings as your own; it is a comingling of the client’s world with yourswithout differentiation. Empathy depends on knowing yourself deeply and havinggood boundaries.Effective treatment planning often depends on our ability to empathize. Clientsare often more willing to disclose information if they feel the therapist isempathetic to their needs, genuinely wants to know more about them, and has thecapacity to process their information. Empathy and deep understanding are alsodemonstrated in situations where the client’s goals are met best by collaborationwith or referral to other health care providers.Empathy has another important aspect to massage. Studies indicate that whenphysical touch is combined with empathy, the hormone oxytocin is released.Oxytocin is associated with a deep sense of emotional connection, a feeling ofbonding, and a peaceful happy state of mind. Discussions about oxytocin wereinitially focused on its roles in childbirth and lactation, but newer studies give abroader perspective.RespectRespect is the choice to treat someone or something with value and consideration.Respect can be given to yourself, to others, and to situations regardless ofconflicting beliefs. Respect is exhibited through words and actions. How do weshow respect?We show respect when we take care of ourselves by making healthy choices,eating the right foods in the right amounts, by exercising regularly, by gettingenough rest, by expressing our emotions appropriately, and by using proper bodymechanics. Chapter 4 is dedicated to self-care.We show respect for emotions when we acknowledge our feelings and thefeelings of others. We show respect for privacy when we deliberately refrain fromdisclosing personal information. We show respect when we explain the who, how,why, and when of treatment. We show respect when we listen to clients andrespond to their questions. We also show respect when we modify pressure duringthe massage when requested by the client.We show respect by having and implementing professional boundaries. Wevalue and take into consideration the client’s personal space, their thoughts andfeelings, their time, and any financial restrictions they may have. Draping, aphysical as well as an emotional boundary, can be viewed as an act of respect.We show respect when we refer clients to appropriate health care providers asneeded to help clients fulfill therapeutic goals. We also demonstrate respect whenwe acknowledge and do not abuse the power differential that is inherent totherapeutic relationships.We show respect to our colleagues and to other health care providers by notdenigrating them or their methods. Working within our scope of practice showsrespect for the legal parameters of our professional activities. We show respect toour profession and other professions by not performing services for which we arenot licensed (such as joint manipulations, prescriptive exercise, or counseling, allof which are under the practice of chiropractic, physical or occupational therapy,and psychotherapy, respectively). We show respect by following our code of ethicsand by dutifully following laws that apply to the society in which we live.We also show respect for people from other cultures by a willingness to learnabout them and by accepting their customs, their beliefs, and way they view theworld. What may be commonplace to us may be inappropriate to others. Forexample, the “thumbs-up” symbol in America is a sign of approval but in theMiddle East, it means to “stick it where the sun does not shine.” The “okay” signmeans satisfactory in America, but it means money in Japan and zero or worthlessin France. In Brazil, the “okay” symbol is the equivalent of sticking up yourmiddle finger.Unconditional Positive RegardUnconditional positive regard is acceptance of another person regardless of whathe or she says or does. When we accept the whole person unconditionally, wevalidate and respect their humanity including physical, mental, spiritual, andemotional aspects.This validation has the potential to be deeply healing for the client. Too fewtimes in life do people truly feel understood and accepted for who they are.Rogers is given credit for this term and he believed that unconditional positiveregard is essential to the therapeutic relationship and provides the best possibleenvironment for positive therapeutic outcomes.This means that we use our knowledge, skills, and abilities to best serve theclient goals without inserting our own agenda. For example, when clients requestrelaxation massage because they feel extreme stress, you do not derail the sessionby turning it into a clinical massage session for their neck and shoulders. Theirgoal for the session was relaxation. Targeted techniques on the neck and shouldersor offering stretching tips and feedback about their tight upper back muscleswould invalidate the client’s wishes and not be in accord with unconditionalpositive regard. When a therapist puts their own goals ahead of the client’s goals,the client may leave feeling like they were not heard by the therapist.Unconditional positive regard means that we acknowledge to ourselves thatwhile treatment planning is a co-creative process, fulfillment of therapeutic goalsis dependent on factors out of our control. We suspend our own therapeuticagendas and truly regard and accept the client’s progress or lack of progress. Forexample, while reassessing range of motion, we avoid thoughts or statementssuch as “I wish you would stretch more,” or “I wish you would relax more.”Accept clients for who they are right now and let go of thoughts that reduce youracceptance of them. The ability to hold clients in a container of unconditionalpositive regard (also called highest personal regard) shows deep respect, becausewe accept them even if we do not agree with them.Unconditional positive regard is demonstrated legally when we obtain consentfor therapy, stating that we cannot discriminate, specifically in regards to race,nationality, gender, religion, or sexual orientation.“When we work from a place of compassion, it is a place of non-judgment, noncomparison, without the need to understand. With compassion we are notentrained in the drama of the client’s story, we are just with them. This is love,which resides in the heart.”Fritz Frederick SmithCompassion into ActionSometimes having unconditional positive regard means we have to look at ourown judgments and identify our own prejudices. We have to really see the clientas a person and find a way to view them with compassion. Imagine a client whocomes in complaining of severe neck pain from her shoulders to her occiput. Shestates that she does not want for you to work on her in the prone position,because it would mess up her makeup. She lays supine on your table andinstructs you not to work on her scalp or mess her hair up. It is not hard toimagine that it would be frustrating to try to work with this client and that manyof us would have judgmental thoughts about her insistence that her hair andmakeup not be mussed. Now think about this woman’s self-worth, her selfesteem. What led her to the belief that looking good is more important that beingpain-free? What was she told as a child about what was good and valuable aboutherself? How was she loved? How does she feel about herself? When we think ofthese aspects of who she may be, using empathy, most of us would have a changeof attitude. We now see her as more than just a person who does not want hermakeup messed up. And from this place we can hold her in compassion, inunconditional positive regard. And when we do, we can most likely be verycreative and find a way to work on her neck and shoulders while honoring herrequests.—Megan LaveryTrustTrust is a feeling of confidence in someone or something. It requires a willingnessto take risks and to be vulnerable to the actions of another. Trust and confidencegrow when risk taking is met with fulfilled expectations. If expectations arefulfilled, the person is likely to trust again.Within the therapeutic relationship, feelings of trust may lead to clearercommunication and better identification of client goals and expectations, whichmay result in better therapeutic outcomes. Be sure to disclose what the client canexpect from your treatment methods. This includes benefits and potentialnegative side effects, such as soreness and bruising. Even when negative sideeffects occur, clients are more likely to perceive you as trustworthy when youdisclose all the facts.If your demeanor, attire, or speech is inconsistent with the level ofprofessionalism that the client expects, he or she may become alarmed andmistrustful of the competence of care (Figure 2-2).FIGURE 2-2 The massage therapist is a professional in demeanor,dress, and speech.Trust is also demonstrated when we safeguard the therapeutic relationship.This is accomplished by professional boundaries, which protect the sanctity of thetherapeutic relationship. Clear boundaries and a relationship that is predictablehelp promote feelings of trust and safety.Trust can be easily upset by important issues and by seemingly insignificantthings. For example, it is best not to tell a client that he or she can call youanytime. Although you may be sincere in wanting to help the client, you may beuncomfortable receiving a call at 3:00 AM. A careless statement may mislead theclient, weaken trust, and possibly damage the therapeutic relationship. Do notmake or imply promises you cannot keep.Power Differential and VulnerabilityEach person in the therapeutic relationship has a different role. One person, theclient, has a particular need and asks for help from another person, the therapist,who has knowledge, skills, and abilities in specific areas. This situation creates apower differential with the client in the more vulnerable role.A power differential is an increase in the amount of power that exists in anyposition of authority. Power itself is neutral. It can be used to help or to harm.Anytime one person has knowledge and skills or things needed by anotherperson, that person is in a position of power and the other person is in a positionof vulnerability. Vulnerability is susceptibility of being wounded or harmedphysically, mentally, and emotionally. There are many types of vulnerability suchas social, cognitive, economic, and institutional. An example of power differentialsand vulnerability is if a young healthy man left his car lights on and his car batterydied. He is in a vulnerable position. If an older adult woman has jumper cablesand parked next to him, she would be in a position of power. She can jump-starthis car, using her power for good or she can laugh and drive away, using her powerto make him more vulnerable.In therapeutic relationships, this imbalance of power occurs naturally and, inand of itself, is not a problem. However, problems can arise when power is used toserve our own interests instead of the client’s best interest. When the person withthe greater power and authority does not recognize or respect power or it is notwell-bounded, client abuse and neglect can occur. Problems can also arise whentherapists do not acknowledge or are uncomfortable in the position of power. Newtherapists may not view themselves as powerful. There may be a belief thattherapists and clients are equals because we collaborate during treatmentplanning. And although we do collaborate with our clients, we still are in theposition of power. Not accepting the power that goes with our role as therapistscan make it more difficult to maintain boundaries. Maintaining boundaries is ourresponsibility (Box 2-1).Box 2-1In the Service of LifeIn recent years the question “How can I help?” has become meaningful to manypeople. But perhaps there is a deeper question we might consider. Perhaps thereal question is not how can I help, but how can I serve?Serving is different from helping. Helping is based on inequality; it is not arelationship between equals. When you help you use your own strength to helpthose of lesser strength. If I am attentive to what is going on inside of me when Iam helping, I find that I am always helping someone who is not as strong as I am,who is needier than I am. People feel this inequality. When we help we mayinadvertently take away from people more than we could ever give them; we maydiminish their self-esteem, their sense of worth, integrity, and wholeness. When Ihelp I am very aware of my own strength. But we do not serve with our strength,we serve with ourselves. We draw from all of our experiences. Our limitationsserve, our wounds serve, even our darkness can serve. The wholeness in us servesthe wholeness in others and the wholeness in life. The wholeness in you is thesame as the wholeness in me.Helping incurs debt. When you help someone they owe you one. But serving,like healing, is mutual. There is no debt. I am as served as the person I amserving. When I help I have a feeling of satisfaction. When I serve I have a feelingof gratitude. These are very different things.Serving is also different from fixing. When I fix a person I perceive them asbroken, and their brokenness requires me to act. When I fix I do not see thewholeness in the other person or trust the integrity of the life in them. When Iserve, I see and trust that wholeness. It is what I am responding to andcollaborating with.There is distance between ourselves and whatever or whomever we are fixing.Fixing is a form of judgment. All judgment creates distance, a disconnection, anexperience of difference. In fixing there is an inequality of expertise that caneasily become a moral distance. We cannot serve at a distance. We can only servethat to which we are profoundly connected, that which we are willing to touch.This is Mother Teresa’s basic message. We serve life not because it is broken butbecause it is holy.If helping is an experience of strength, fixing is an experience of mastery andexpertise. Service, on the other hand, is an experience of mystery, surrender, andawe. A fixer has the illusion of being causal. A server knows that he or she isbeing used and has a willingness to be used in the service of something greater,something essentially unknown. Fixing and helping are very personal; they arevery particular, concrete, and specific. We fix and help many different things inour lifetimes. But when we serve we are always serving the same thing. Everyonewho has ever served through the history of time serves the same thing. We areservers of the wholeness and mystery in life.The bottom line, of course, is that we can fix without serving. And we can helpwithout serving. And we can serve without fixing or helping. I think I would go sofar as to say that fixing and helping may often be the work of the ego, and servicethe work of the soul. They may look similar if you are watching from the outside,but the inner experience is different. The outcome is often different, too.Our service serves us as well as others. That which uses us strengthens us. Overtime, fixing and helping are draining and depleting. Over time we burn out.Service is renewing. When we serve, our work itself will sustain us.Service rests on the basic premise that the nature of life is sacred, that life is aholy mystery which has an unknown purpose. When we serve, we know that webelong to life and to that purpose.Fundamentally, helping, fixing, and service are ways of seeing life. When youhelp, you see life as weak. When you fix, you see life as broken. When you serve,you see life as whole. From the perspective of service, we are all connected: Allsuffering is like my suffering and all joy is like my joy. The impulse to serveemerges naturally and inevitably from this way of seeing.Lastly, fixing and helping are the basis of curing, but not of healing. In 40 yearsof chronic illness I have been helped by many and fixed by a great many otherswho did not recognize my wholeness. All that fixing and helping left mewounded in some important and fundamental ways. Only service heals.By Rachel Naomi Remen, MD“In the Service of Life,” adapted from a talk given by Rachel Naomi Remen at IONS fourth annual conference,first appeared in the Noetic Sciences Review, (Spring 1996, issue number 37), published by the Institute ofNoetic Sciences (IONS), and is reprinted with permission of IONS (www.noetic.org), all rights reserved.Copyright 1996.The law holds the professional to a higher standard of behavior because of thepower differential. The power differential can disempower clients—it may bedifficult for clients to say “no” easily. Laws exist to protect vulnerable populationssuch as children and elderly from maltreatment. This is called the “duty toprotect.” More information can be found in the section on Mandatory Reporting.Clients come to us and are often in pain or under considerable stress. Clients liedown, often undressed and draped, while we stand over them. This positionduring therapy may enhance vulnerability in clients who already feel vulnerable.We should do whatever we can to reduce feelings of apprehension by respectingthe therapeutic relationship and by using our position to serve the best interestsof our clients.CongruencyCongruency occurs when the external presentation of your words and actionscoincide with your internal world of thoughts and feelings. It means that you aresending a picture of the real you. When you are authentic and genuine, what isdisplayed outside matches with what is going on inside. Rogers calls theintegration of thoughts, feelings, and actions congruency.Congruency is conveyed by listening to and communicating with clientswithout distorting their message. You must sincerely believe that clients and theirproblems are important and worthy of consideration. When this type ofconnection is made, a deeper examination of their problems, implications, andsolutions are possible.Being congruent and authentic also means that while I am aware of mythoughts and feelings, I choose whether or not to express them. We self-reflectbefore we self-reveal and disclose only what is appropriate in professionalsettings. This does not mean that you say everything that you think or feel. It doesmean that what you say and do is consistent with your understanding.Being congruent also means that we maintain a conscious awareness of whereour thoughts and attention are during the session. This heightened self-awarenessand focused attention is called mindfulness. We acknowledge (nonverbally) anypersonal feelings we have when we are with clients. We hold all feelings asnormal, be it fear, anxiety, joy, peace, or boredom. We can be most fully present forour clients when we fully embrace ourselves nonjudgmentally first. When weaccept who we are, our faults, our strengths, our past, our wounds, when we haveself-knowledge and self-love, then we can truly be with and accept others.Think about a situation where you felt someone’s words did not match theirbody language. Perhaps a social situation where we were taught to say little whitelies, such as we enjoyed a meal when we did not like it at all. It is confusing whenwe hear untruths—it undermines trust. Our words and actions must match. Forexample, if a client asks us how our day is going and we are not having a good day,it may be confusing for clients to hear we are doing great when we look like we arenot. Instead say that we are happy to see them and deflect the question by askinghow they are doing. To do this, we have to know ourselves well. Being congruentand genuine allows me to be present with clients while allowing my ownexperience to emerge. This type of presence is not possible when you are detachedemotionally and not honoring yourself.When you are congruent and genuine, your clients are more likely to trust andrespect you, which may lead to a more meaningful relationship. You also becomea role model for congruency and help clients evolve a more authentic sense of self.The classic children’s story The Velveteen Rabbit talks about what it means to bereal.“When a child loves you for a long, long time, not just to play with, but REALLYloves you, then you become real … by the time you are Real, most of your hairhas been loved off, and your eyes drop out and you get loose in the joints and veryshabby. But these things don’t matter at all, because once you are Real you can’tbe ugly, except to people who don’t understand.”Margery WilliamsNeuroscience and the Therapeutic RelationshipThere are many new areas of research that are investigating how the nervoussystems of two people interact. One remarkable finding is mirror neurons. Theywere discovered in the early 1990s when scientists noticed that a certain set ofneurons fired in the brains of monkeys when they picked up a peanut. The sameset of neurons fired when monkeys watched a laboratory assistant pick up apeanut. These “mirror neurons” fired whether monkeys did the task or observedthe same task (Di Pellegrino and associates, 1992). Scientists have mapped similarneural patterns in humans using MRI technology. It turns out that “humans…have mirror neurons that are far smarter, more flexible, and more highly evolvedthan those found in monkeys… The human brain has multiple mirror neuronsystems that specialize in carrying out and understanding not just the actions ofothers, but their intentions, the social meaning of their behavior, and theiremotions” (Blakeslee, 2006).Mirror neurons may also help us empathize. Research has shown whenparticipants observed expressions of emotions, such as smiles or frowns,portraying feelings of happiness, sadness, or pain, their brains reacted as if theythemselves were experiencing the same emotion as they saw on the faces ofothers (Keyers, 2011).Empathy can give us a deeper understanding of clients and facilitateattunement. Attunement is an experience of connectedness that is sharedbetween two people (Erksine, 1998). The ability to “tune in” to clients rests on ourcapacity to be mindful or fully present, to listen actively and understand whatclients are saying, and to communicate this understanding back to clients.Attunement is metaphorically being in your client’s skin.Mindfulness comes from our ability to be aware of our surrounding, both inexternal and in internal environments. Awareness of our internal physicalenvironment, such as sensations from muscles, the heart, or intestines, is calledinteroception (Seigel, 2012). This awareness helps us monitor how our nervoussystem is responding as we interact with clients. If you notice tension in yourshoulders and your heart, and the breathing rate increases in response to whatyour client has said, you may also notice your client is having the same responsesin their body. Conversely, if you notice that your shoulders are relaxed and thatyour heart and breath rates are slowed, you may also notice the same patterns inyour client. This information can help you better serve your clients through adeeper connection with and understanding of their experience.ProfessionalismProfessionalism is the adherence to a set of values and obligations, formallyagreed-upon codes of conduct, and reasonable expectations of clients, colleagues,and co-workers. Key values of professionalism include acting in the client’s bestinterest and putting their interest before your own, maintaining standardsexpected of other members of the profession, and staying current with changesand discoveries in the field. Knowing and abiding by the laws and standards thatgovern the profession are part of our responsibilities as massage therapists.Professionalism needs to be understood, practiced, and refined as much as one’stechnique.Professional standards include many aspects of ethics and the therapeuticrelationship, such as confidentially, integrity, decency, accountability,responsibility, and honor. Health care professionals should possess psychosocialand humanistic qualities, such as caring, empathy, humility, compassion, socialresponsibility, and sensitivity to the culture and beliefs of others.Professional AppearanceYour professional appearance includes attire and grooming. Your appearanceshould be consistent with other professionals in your locality, and for the type ofsetting in which you work (Figure 2-3). What is appropriate for working in a dayspa in Boston may be very different than what is appropriate when working atriathlon in Hawaii.FIGURE 2-3 Therapists in professional attire.In any setting your appearance should be clean and neat, no scents or odors,nails trimmed and hair held back from the face. Your clothing should be such thatit will not drape or hang on the client during the session yet it should not be sotight fitting as to be revealing, or so low cut as to show cleavage on women.Tattoos, body art, and body piercing are becoming more common. While thisrepresents personal choice, therapists who have visible body art might considerhow clients might view them. A 20-year-old client from Los Angeles might viewbody art differently than a 60-year-old client from Tulsa. Body art could have anegative impact on a job interview or during the initial contact with a new client;your professionalism might be called into question. Because of this, weigh all prosand cons when considering alterations in your appearance.DisclosureFrom the initial contact and throughout the therapeutic relationship, clients willdisclose their past and current medical information and treatment goals. Whenclients share personal information such as their thoughts, feelings, ideas, andinsights, it is called disclosure. Over time, clients will disclose more information ifthey feel you are empathetic, trustworthy, and genuinely curious about them.Self-DisclosureClients often want to have some sense of who you are as a person. They aredisclosing personal information, as well as letting you massage them. They mayfeel more comfortable knowing something about the person with whom they arein a relationship. This may lead to personal questions about you.Revealing our own thoughts, feelings, and personal history to clients is calledself-disclosure. There is a fine line between disclosing too much and too little.This topic is debated among professionals. Many scholars in the fields ofpsychotherapy, medicine, ethics, and massage recommend that we disclose verylittle about our personal selves, letting us be a blank slate so the relationship isentirely about the client. Others argue that giving clients some personalinformation can help them relax and feel comfortable, knowing we are human.Appropriate information might include how long we have lived in the area andwhy we moved there. Clients often want to know about our family. This level offactual information is generally considered safe to self-disclose.Too much self-disclosure or inappropriate self-disclosure can be confusing forclients, especially if therapists disclose their own current needs or problems orwhen there is no clear connection to the client’s goals. Especially important is notdisclosing your personal experience related to a similar problem your client ishaving. It is important that clients have their own experience and this type of selfdisclosure may lead clients to minimize their own experience and perceive yourexperience as more significant. For example, if your client is grieving after thedeath of a parent and you share your own experience of a parent that died theprevious year, the client may feel overly concerned about your feelings, anddiscontinue talking about their own grief. This may prevent your client fromhaving their needs met because they are concerned with taking care of you. Toomuch self-disclosure can also lead to transference (discussed later in the chapter).When disclosing personal information, consider your reason for doing so. Doesit serve the relationship, the client, or you? Does it create boundary problems?One clear sign that it is not in your client’s best interest is when you self-discloseto satisfy your own social needs and that you are using your client as a friend.Finally, ask yourself if you are disclosing personal information without realizingit. Social media makes our personal lives more accessible to our clients. Are youdisclosing more than you intended? What would clients find if they did a Googlesearch on you? How will you respond to a client’s friend request on Facebook orTwitter? Allowing clients to be Facebook friends with you allows them into yourinner circle. How much personal information do you share on Facebook? Considerthat privacy settings really do not create privacy and anything you post can getreposted. How will a client respond to seeing you at a party? Or on vacationskiing? Or wearing revealing clothes? Could transference issues be inflamedmore? What might happen if clients see you doing something that does not fitwith their views of you as a therapist? How will they feel or react if they see thatyou support a group or viewpoint that they disagree with? All of the informationabout you online is available for your clients to see.Electronic Communications and the Therapeutic RelationshipMany people communicate primarily by e-mail or texting. It is worth planningahead how you will communicate with clients. If you use either of these forms ofcommunication, neither is fully private. You need to consider the HealthInsurance Portability and Accountability Act (HIPAA) requirements forelectronic communication. And you need to consider the boundary issues aboutcommunication with clients outside of session time. If communications arelimited to scheduling appointments, it is fine. But what if a client uses e-mail tocontinue the session? To ask for more information about stretches or self-care youdiscussed? What if they want to report about the after effects of an emotionalresponse? What if it happens once? What if it starts to happen every session?How quickly will you respond? Is there a difference in the response time expectedif the communication is by e-mail or text? All of these things are issues that youneed to have clear policies about to maintain clear boundaries with clients.ConfidentialityConfidentiality is the act of keeping information private or secret. In theassurance of confidentiality, the client is “confident” you will not discloseinformation without consent. Even as we discuss our cases with other therapistsand health care providers, client information should not be traceable back to themand their identity should remain unrevealed. A breach of confidentiality is oftenboth illegal and unethical (Box 2-2).Box 2-2Legal Versus Ethical IssuesLegal issues are associated with laws, rules, and regulations. The primarypurpose of massage therapy laws is to protect the public from injury or fromfraud. This is done by providing rules for obtaining and maintaining licensure.Ideally, laws promote smooth functioning of a society. If laws are broken, thencivil or criminal charges may occur. Upon conviction, therapists may be fined,imprisoned, have their licenses revoked, or suffer other penalties as determinedby the courts.Ethical issues are associated with human duty, appropriate right conduct, andresponsibility. Professional ethics are the values and ideals that a particularprofession creates for itself, setting the standards of conduct for its members. Ifthese principles and standards are not followed, professionals may be suspendedor evicted from the professional society of which they have membership, asdecided by peers.Thus not renewing a state license and continuing to practice massage is illegal.Offering stone massage after only watching a video is unethical, but not illegal.Can an issue be both illegal and unethical? Yes. An example of this is a breachof confidentiality. And in some states any issue that is unethical is alsoconsidered illegal. For example, your state licensing law may include a provisionthat all licensed massage therapists adhere to the state board’s code of ethics.Therefore, any action that is listed in the code of ethics as unethical (such asdating a client, or providing services without adequate training) would also beillegal and could result in a fine or suspension of license.Personal information shared by the client is closely guarded and every clienthas the right to privacy in the therapeutic relationship. Even the fact that they area client cannot be disclosed. And although you cannot disclose this information,clients can certainly tell family and friends details of their session and theirperceived quality of care they received.Even in social situations, avoid disclosing that someone is your client. If youdisclose this fact, you risk offending the client and may weaken trust. Namedropping is rarely impressive and only reveals us as therapists who do not protecta client’s privacy.When you receive a referral from a client, avoid sharing information regardingthe common acquaintance with either client. This means not disclosing when theother has an appointment, even when asked directly. Let us take this concept onestep further; if you are treating a married couple separately, refrain fromanswering questions about the other. Avoid answering even caring questions suchas “Was my spouse’s neck range of motion better when you saw her yesterday?”Your reply might be “Due to confidentiality I cannot share this information withanyone other than that client. I hope you understand” or “I can’t answer that, butI’m sure she can.”In social settings that include both you and your client, avoid initiating aconversation with him or her. Perhaps make eye contact, smile, and give a nod ofpoliteness. If the client initiates a conversation, do not reveal treatmentinformation if other people are nearby. Because many social settings exist in whichboth you and your client may be present, you may wish to discuss how thesesituations will be handled beforehand, perhaps as part of your initial visit duringdiscussions of informed consent and your policies regarding confidentially (seeChapter 10).Respecting confidentiality also means that treatment rooms are in a privatesetting and should be soundproof so that people nearby cannot hearconversations in the room with the door shut. Additionally, client interviews areconducted in private, never in public areas.Limits to ConfidentialityThe code of ethics published by the National Certification Board of TherapeuticMassage and Bodywork states that certificants will: Safeguard the confidentiality ofall client information, unless disclosure is requested by the client in writing, is medicallynecessary, is required by law, or necessary for the protection of the public.What does that mean? If clients instruct us to share their information, we areobligated to do so. They have the right to have their treatment notes released toother health care providers so that congruent treatment plans can be developed.Clients may instruct us to release their information to lawyers or insurancecompanies, or even to a translator to reduce a language barrier. In these cases,obtain the client’s dated signature before releasing the information (see Chapter10).When might it be medically necessary to disclose client information? If a clienthad a medical emergency while at our office, we need to disclose necessarymedical information to first responders if clients are unable to do so. For example,we would disclose information regarding medical conditions, such as diabetes;prescriptions; medical devices, such as a pacemaker; or prior surgeries.What is required by law varies greatly state to state. Every massage therapistshould have carefully read their own state laws and reread them when questionsarise. One universal legal requirement is to comply when client records aresubpoenaed by court order.Other situations when we must breach confidentiality include suspicions ofchild or elder abuse/neglect or when there is a threat to self or others.Mandatory ReportingMandatory reporting is legislation that requires specific individuals orprofessions to report concerns of neglect or abuse to protection agencies.Individuals or professions who are required to report usually have regular contactwith vulnerable populations such as children, disabled persons, and the elderly. Inmost states health care providers, mental health counselors, and teachers aremandatory reporters and the physician-client privilege does not apply. It isimportant to know what your state laws are and if you are a mandatory reporter(in which case you must break confidentially to report) or if you are not (in whichcase you would not break confidentially). A document entitled Mandatory Reportsof Child Abuse and Neglect is available from the Child Welfare Information Gateway[www.childwelfare.gov]. This website also contains a State Statute Search to helpyou determine if you are a mandatory reporter and, if so, who you report to. Forexample, in Kentucky (KY), “all health professionals” are required to report butthe extensive list of professionals does not include massage therapists. However,KY law also clearly states, “All persons are required to report,” which wouldinclude massage therapists. KY law also states that “privileged communications”shall not be grounds for refusing to report, except attorney-client privilege. Sotherapists licensed in KY are mandatory reporters and if you suspect abuse orneglect toward or by a client, you must break confidentially to report.Similar information about the duty to report elder abuse can be obtained fromthe National Center on Elder Abuse at http://www.ncea.aoa.gov. Follow the linksto State Resources and locate the state in which you practice.Mandatory reporting legislation applies to you even when they are notaddressed specifically in your state massage laws.Another possible legal reporting requirement is when a client poses a risk toself or others. If a client makes a direct reference to suicide, mental healthprofessionals are required to take action. This is called the Duty to Protect andmany other health care professionals are also required to take action. Theseprofessions are trained to assess the validity of a threat and diagnose mentalhealth conditions. But rules vary greatly from state to state. Be sure to investigatewhether your state law considers massage therapists to be health careprofessionals (some do, some do not) and then you need to know what your staterequirements are regarding threats to self.If you work in a hospital or other setting where a health care professionalsupervises your activities, reporting the incident to your supervisor is the bestaction. If your supervisor, or their supervisor, has a higher level of medicalqualification then the duty transfers to them. And it is up to them to determinethe appropriate action.There is also a Duty to Warn in many states when a client makes a direct threatto harm another person. The rules about this are complicated and usually apply tomental health care professionals and medical professionals. In some states theprofessional may breech confidentially, in other states they must. If your clientmakes a direct threat to harm another person while in your office, seek advicefrom an attorney with expertise in client confidentially. Ask if you, as a massagetherapist, have any duty and if you are legally required to breach confidentiallyand to whom you should report.Human Sex TraffickingAccording to the Federal Bureau of Investigation or FBI, human sex trafficking isthe fastest growing business of organized crime and the third largest criminalindustry in the world. As massage therapists, this impacts us since massage is themost common front for trafficking organizations. Fake massage businesses useforce, fraud, and/or coercion to control women and get them to provide sex. Mostwomen are not United States’ citizens, are in debt, and are isolated from anysource of support. They are promised a better life in the United States and arrivehere to find they are indebted, have no job, no legal status, and no choices. Theyare moved frequently from state to state and not able to create a support network.There are also an increasing number of victims who are U.S. minors, recruited orforced as young as 12 years old into prostitution.The NCBTMB asks all certificants to sign an Anti-Trafficking Pledge agreeing tobe informed on human trafficking and to support NCBTMB’s efforts to combattrafficking. More information about human sex trafficking is found in Chapter 1.“The quality of the therapeutic relationship has consistently been shown to be moreimportant than the therapist’s clinical outlook.”Kalman Glantz and John PearceBoundariesBoundaries are guidelines, rules, and limits that we create in relationships.Boundaries help determine reasonable, safe, and acceptable ways to interact withothers. Professional boundaries in the therapeutic relationship have also beencalled the “therapeutic frame.” Boundaries are based on our roles in relationships.They delineate differences between you and your clients. Boundaries help clarifyindividual responsibilities and define expectations—what we expect and whatothers can expect from us. Boundaries must also be flexible and some boundariesare negotiable as we will see in the “Location Boundaries” section.Boundaries are part of all healthy relationships. The more aware we are and themore respect we have for our own boundaries, the more we can recognize andrespect the boundaries of others. Boundaries create a sense of predictability. Thispredictability helps promote feelings of trust and safety. Good boundaries pavethe way to achieving fulfilling relationships, ones that embrace empathy, respect,trust, and congruency.Boundaries have another important role: protection. Good boundaries help usfrom becoming manipulated or enmeshed in relationships with others who do nothave good boundaries. Unintentional or intentional neglect or abuse is morelikely in relationships without boundaries. Good boundaries create emotionalseparateness, a sense of autonomy, and a safe place for the client’s experience. Letus consider Chapter 11 of the Tao Te Ching translated by Stephen Mitchell:We join spokes together in a wheel,but it is the center holethat makes the wagon move.We shape clay into a pot,but it is the emptiness insidethat holds whatever we want.We hammer wood for a house,but it is the inner spacethat makes it livable.We work with being,but non-being is what we use.The irony is that good boundaries cannot be learned from a book. We have allexperienced boundaries in the past beginning in early childhood and these wererole modeled to us by family and friends. Hopefully, they were examples of goodboundaries and healthy relationships. If so, we know how it feels to be withsomeone who is clear and careful with boundaries. If not, the process ofestablishing and maintaining healthy boundaries may be challenging. In thesecases, consider approaching individuals who you feel have healthy boundariesand ask them to be your mentors. A mental health counselor may also be helpfulin exploring boundaries.The analogy of a cell might be helpful when visualizing boundaries. Imaginethat you are surrounded by a semipermeable membrane. This membrane letsnutrients in and keeps toxic materials out. This membrane also defines the cell’sexistence by separating it from other cells. Healthy cells also have an innateintelligence; it knows it is a brain cell and that brain cells and liver cells aredifferent types. Another analogy of healthy boundaries is an intact immunesystem, which helps to maintain the boundary of the body’s unique individuality,distinguishing what is me and removing what is not me.Having good boundaries is one of the many gifts we give to our clients; a giftthat is often unacknowledged.Types of BoundariesWithin the general context of professional boundaries, there are specificboundaries regarding touch and our physical bodies, boundaries surroundinghow we handle expressions of thoughts and feelings, boundaries about how andwhen we provide our services, and boundaries about what and how we charge forour services. These boundaries are important aspects of a professional practice asthey support the therapeutic relationship and demonstrate our commitment toquality client care.Physical BoundariesPhysical boundaries provide a barrier between you and another person. Theyinclude your physical body and your sense of personal space. Each person has aslightly different amount of personal space that feels safe to them. In Americanculture, the distance is approximately 3 feet. If we stand closer than the person’s“comfort zone,” it may feel invasive to them. Conversely, if we stand further away,it may feel like we are being distant.Physical boundaries define the who, when, where, how, and under whatcircumstances we feel safe with touch. Touching without the person’s consent is aboundary violation. Even with consent, touching that does not feel good is aboundary violation.Physical boundaries are flexible and adapt to different situations. Althoughmost Americans like to have 3 feet around them, they allow people closer incertain situations. Have you ever noticed that when a line starts, say at a movietheater, people tend to line themselves up a normal personal distance of a few feetapart? And as the line grows longer, the distance between people gets smaller.Over time, we might find we are standing within inches of the person in front ofus, and it does not bother us. This is an example of boundaries being flexible.In massage relationships, physical boundaries change quickly. We greet ourclients in the waiting room while standing a normal distance from them. We sitcloser during the intake process. We stand next to them and touch them duringthe massage. At this point, the physical boundary is literally skin to skin. Once themassage is complete, we return to a more normal distance. Just because clientsallow physical boundaries to shrink during the massage does not mean that itwould be appropriate to continue touching them after they are off the massagetable.We establish physical boundaries during treatment planning as clients indicateareas that need focused attention and areas that will be avoided (i.e., localcontraindications). Others physical boundaries during the massage include:• Letting clients choose the level of disrobing for clients who want to remainpartially or fully clothed and using techniques that do not require skin lubricant• How clients are draped• How the drape is moved• Refraining from working under a drape• How deep an area is worked• How long an area is worked• Not touching clients inadvertently with your clothing or body parts not engagedwith the massage (be careful how you lean against the table)• Obtaining consent before working on the abdominal, gluteal, pectoral regions• Use of scents or aromatherapy• Type of massage/bodywork you perform• Making sure clients know they are empowered to speak up if they feeluncomfortable with anythingHuggingSome therapists like to hug clients on their arrival or their departure. But huggingalso represents a physical boundary. Some questions to consider are:• How do you know you have permission to hug someone? Was it spoken?Unspoken?• Who initiates the hug?• How long does the hug last?• What is the norm for your geographic area?• What type of work setting are you in?• Do you hug only opposite gender clients? Same gender clients?• Do you hug only attractive clients? Unattractive clients?• Do you hug only young clients? Mature clients?• What determines who you hug if you hug some clients and not others?Answers to these questions will help you formulate your own hugging policy.Some therapists only hug clients who request one and only with the door open.Other therapists do not hug any clients, stating that other health care providersdo not hug their clients. Whatever you choose, hugs should respect the client’sphysical boundary and not be forced upon them.How you handle hugs should be flexible and depend on circumstances. If youhave had a long relationship with a client and she is moving away, a hug might beappropriate to close the relationship. If a client had a particularly difficult week,became emotional on the table and asked for a hug, to not do so may seemunkind. If you suspect there is any element of sexual attraction on the part of theclient, hugging would be inappropriate. Avoid hugging any client you feel a sexualattraction toward (see “Sexual Misconduct” section).Intellectual BoundariesIntellectual boundaries encompass our beliefs, thoughts, and ideas, as well assafeguard our self-esteem. When others agree with us, we tend to feel safe,validated, and close to the like-minded person. Conversely, we may feel vulnerablewhen someone disagrees with us. When the disagreeing person is an authorityfigure, we may feel especially vulnerable, perhaps reverting to how we felt when agrade school teacher scorned us when we did not produce the “right” answer.Do you show respect for intellectual boundaries? Do items in your officechallenge a client’s beliefs? Posters, calendars, or art prints that espouse yourphilosophy may offend clients with different beliefs. Even our choice of art couldbe offensive if they depict nudity or sensuality. This is especially true with regardsto political, religious, or spiritual beliefs. We are violating intellectual boundariesif we impose our political, religious, or spiritual beliefs on clients who do notshare them.Clients have their own unique ways of knowing and understanding. They havethe right to choose what to think and what to do (within the limits of the law), aswell as to accept the consequences of their choices.Keep this in mind when you offer information to clients. Do you ask if they areinterested in learning more about a topic before you present to them? Is theinformation tailored to their needs and wants? We are violating intellectualboundaries when we impose our beliefs about the latest fads of nutrition andexercise on them.We also violate intellectual boundaries when we disregard a client’s belief abouttheir problem even if we do not agree with or understand their belief. Imagine aclient who is seeing you for shoulder pain, and they believe that they had itbecause their mother and father both had shoulder pain. Or they believed it wasbecause of karmic punishment for past deeds. Or they believed it was because ofan emotional imbalance. Or they believed it was caused by a nutritionalimbalance. All of these examples could be true according to various models ofhealth and healing. According to your training and evaluations, you find weak andrestricted rotator cuff muscles. To disregard the client’s beliefs and insist youknow what is causing the pain would be violating an intellectual boundary.Offering them your information “according to the model in which I work” wouldbe respecting both them and your own training.Emotional BoundariesEmotional boundaries help identify our own feelings and keep them separate fromthe feelings of others. When we have good emotional boundaries, we help createan environment where clients feel safe and supported. Clients will trust us if theyfeel they can share their emotions and not be judged; that we both understandthem and accept them for who they are and how they feel.An emotional release is letting go or releasing suppressed emotions. When wehave strong emotions and do not express or process those emotions appropriately,we may suppress them. An example is a feeling of deep grief over the death of aloved one. This feeling may be too painful to bear at the time, so it becomessuppressed. Suppressed emotions may surface and find a way to expressthemselves during a massage session as clients relax and in a safe environment.The most common expression of emotions is crying. If clients begin to cryduring a session, approach the situation with complete acceptance. Support themwith statements such as “Crying is normal,” “You are in a safe place,” “I amcomfortable with your tears.” Come up with statements that you are comfortablesaying in the situation. When clients finish crying, help them acclimate to theirsurroundings with statements such as “Take a few deep breaths,” and “Feel themassage table beneath you.” Again, find statements that you feel comfortablesaying.When clients share their feelings, they demonstrate trust in the therapeuticrelationship. To strengthen that trust, we safeguard client information includingtheir feelings. If a client has an emotional release during one session, we refrainfrom mentioning it in subsequent sessions unless the client brings it up. There isan exception to this rule. If the emotional release occurred during the massage,obtain consent before working on the area that led to the emotional release. Forexample, if your client had an emotional release while massaging the feet, askpermission before working on the feet during the next session. Be sure to avoidmentioning the emotional release when you ask permission. This demonstratesrespect for emotional boundaries.Clients may feel vulnerable and exposed during an emotional release evenwhile feeling safe with the relationship. Recall a time you have cried unexpectedlyin front of someone. How did you feel? Were you concerned that the person wouldjudge you, or think less of you?When clients tell us about emotional concerns in their lives, we can help bringthe focus back to the body by questions such as, “Where do you feel that in yourbody?” or “Can you tell me what you notice in your body as you say that?”Anytime the focus of massage becomes more about the client’s emotions andless about the client’s body, emotional boundaries have been crossed. There ismounting evidence to suggest that release-based cathartic therapies may feelgood at the time but have no lasting benefits for the client’s health and well-being.Cathartic emotional releases may serve to retraumatize clients. Massagetherapists are not trained to differentiate between emotional experiences that arehelpful to clients and those that are harmful. A good guideline to follow is “seeknot, forbid not.”Even if a therapist is cross-trained in a recognized form of body psychotherapy,a different license is required to practice the method. This will be discussed in theChat Room Box entitled Dual Licensure and Dual Roles.To reiterate, scope of practice does not allow massage therapists to:• Persuade clients to share emotional content• Process client emotions• Delve for deeper held emotions• Evoke emotional responses intentionallyTime BoundariesTime boundaries provide guidelines for how we spend our time at work and helpseparate our professional time from our personal time. Unlike personalrelationships in which time is somewhat flexible, we have an agreement with ourclients regarding time. Clients essentially rent our time for the length of thesession. The massage session is often described as structured time. Timeboundaries include: (1) Being ready when clients arrive with music playing (ifappropriate) and clean linens on the table. (2) Beginning and ending the sessionon time. (3) Focusing on the client during the session and avoiding distractingactivities such as talking or texting on the phone or conversing with other clientsin the waiting room.When does the session officially begin? Some therapists believe the sessionbegins at the start of the massage. Other therapists believe it starts with the clientintake. Whichever you chose, be sure to disclose this information when obtainingconsent for therapy. It would be confusing to clients who are paying for a 60-minute massage and the hour actually consisted of a 15-minute intake and a 45-minute massage. It also shows disrespect for time boundaries when we areinconsistent and a 1-hour massage lasts 60 minutes one session, 75 minutes thenext, and 50 minutes during another session.Time boundaries also include the days of the week and times of the day youschedule appointments. Other aspects of time boundaries are how you handlecancellations and no-shows. These situations violate time boundaries and possiblyimpact financial boundaries.Questions to consider are:• What are your office hours?• Do you schedule appointments at different times? Under what circumstances?Do you charge extra for after-hours or off-day appointments?• What if clients arrive late?• What if you are running late?• Would you allow sessions to run over time? Under what circumstances? Wouldyou ask permission if you wish to extend the session time?• What if clients arrive early and you are ready to begin their session? What if youare not ready to begin the session on clients who arrive early?• What is your cancellation policy? How far in advance do you expect clients tocancel? Do you charge the full amount or partial amount for cancellations?• What is your policy regarding no-shows? Do you charge the full amount or apartial amount for no-shows?• What is your policy if clients cancel or do not show in cases of emergencies?• What happens if you miss an appointment?Location BoundariesLocation boundaries provide guidelines about where services are provided. Be sureyour location projects professionalism whether in a spa, clinic, home office, orother location. Sometimes massage services are provided at a client’s residence ora residential care facility as a house call.Many therapists work out of their homes. Ideally the client entrance and workarea is separate from your living area. If this is impossible, be sure your workareas are clutter-free and contain few or no personal items. Be in compliance ofany local zoning restrictions.When doing a house call, be sure you know in advance about the space theclient has designated for the massage. Inquire about where you should park yourvehicle. Be realistic about how far you can carry your equipment and supplies. Besure to have a policy in place for house calls with clients you do not know. Thismight include contacting a third party and letting them know who the client is,where you will give the massage, the time and length of the session, and that youwill contact them upon your arrival and departure. Because this policy exampleinvolves disclosing client information, the client must consent to this policy.If you are giving a massage in a private residence or residential care facility, it isunlikely you will be able to control the massage environment so be flexible. Ifvisitors are present, introduce yourself and let them know why you are there. Bewilling to massage your client in a care facility room with visitors. If health careproviders are in the room or arrive during the massage, discuss with them how tobest coordinate services. It may be best to postpone the start of the massage ortake a short break to give this time to the health care providers. These decisionsare shared, so discuss options with the other party. Again, be flexible. Keep inmind that when providing services at the client’s residence, there is an increasedrisk of becoming involved in the client’s private life. More vigilance is needed tomaintain boundaries.Public places or social events are inappropriate settings for massage. Thisstandard applies to practicing therapists and students. If you run into your friendBob while shopping and he asks you to rub his sore neck, you might reply, “I amshopping right now and can do a better job at my office. Here is my business card.Please contact me for an appointment.” This demonstrates good boundariesregarding both location and time; in this case, your time off.Also avoid giving professional opinions or advice during social events. You areheld accountable for professional advice given in all settings, including socialsettings. You may not have all the information needed to formulate your opinionand might carelessly ill-advise current or potential clients. Instead, offer abusiness card and ask them to call you.Financial BoundariesFinancial boundaries in therapeutic relationships involve issues of money.Therapeutic relationships are also business relationships and money is animportant part of our professional practice. Our time, focused attention, andexpertise are of value to clients. We offer this in exchange for money. If you areuncomfortable with money or have issues around money, it may affect how youestablish and enforce financial boundaries.Inform clients of your fee schedule, payment procedures, and policies such ashow insufficient funds transactions are handled. Even if this information is givenwhen clients schedule their initial appointment, mention this information againwhen obtaining consent for therapy. Be sure to inform current clients in advancewhen fees and payment policies change, perhaps by posting it in your office andon your website.Some therapists have sliding fee scales, allowing clients to pay differentamounts depending upon the client’s ability. If you choose to use a sliding scale,be sure you have a method to keep track of what each client is charged. Slidingscales can become a boundary issues when money gets in the way of therapistsbeing fully present in their therapeutic role. Imagine how you might feel if a clientwho was getting a discount came in all excited about their upcoming Caribbeanvacation or their new expensive car. What if you had not been on vacation for a fewyears for financial reasons?Financial boundaries include how you handle payment arrangements whenreceiving massage from fellow therapists. Will you offer and/or expectprofessional discounts? Will you trade for services? What if you charge more foran hour than your fellow therapist? How will you address the difference in fees forthe same time spent, if at all? If you are trading services, when will trades bescheduled? What will happen if the therapist you are trading with has scheduledthe third session with you and you have only received one session from her? Willyou stop trading until the number of trades are equal? Or will you expect paymentfor the third session? Ideally, these types of situations should be discussedbeforehand and mutually agreed upon.Dual Licensure and Dual RolesA dually licensed massage therapist is someone who has a second professionallicense to practice in a different profession. For example, you could be a licensedmassage therapist and a licensed professional counselor. When this occurs, theperson refrains from wearing two hats simultaneously. For example, operating inthe capacity of massage therapist, provide only those services within that scope ofpractice. When operating as a different professional, provide only those serviceswithin that particular scope of practice.Keep in mind that all professions have their independent codes of ethics. Thecode of ethics for a licensed mental health counselor for example will be differentfrom the code of ethics for a massage therapist. The profession with the strictestcode of ethics prevails and becomes the standard of conduct in every therapeuticrelationship.Transference and CountertransferenceTransference and countertransference occur in all relationships: therapeutic,personal, and professional. Psychotherapists have long been taught aboutexperiences of personalization that happen in therapy and counseling. SigmundFreud was the first to describe it. Even though massage therapists are notpsychotherapists, we encounter transference and countertransference andtherefore should learn how to recognize them and reduce their negative impact onthe therapeutic relationship.As you explore these concepts, remember that transference andcountertransference influence relationships in ways that, under certainconditions, may be helpful to the client. Transference and countertransference are,by their nature, complex and interrelated. Therapists will remind clients of otherpeople in their lives, past and present. Clients will remind therapists of people intheir own lives. Power differentials in the therapeutic relationship play a role inamplifying the occurrence.TransferenceTransference occurs when clients transfer feelings, thoughts, and behavior theyhave for a significant person in their early life onto the therapist. The therapistassumes a more significant role in the client’s subconscious mind. Transferencemay occur when needs not being met in the client’s personal life are now beingmet in the therapeutic setting by the therapist. This includes touch needs, theneed for attention, listening, validation, and nurturing.During transference, the client begins to personalize the therapeuticrelationship. Vulnerability may actually facilitate transference as can unresolvedpast events. Instead of seeing you as a member of a profession providing aservice, the client sees you and relates to you as if you were a significant personfrom their past. Transference can produce powerful feelings of love (positivetransference) or destructive hatred (negative transference), both of which arebased on misperceptions.For example, if you remind your client of her father, the client’s perception ofyou may change which leads to a change in behavior. Her behavior depends on thetype of relationship she had with her father. Was it loving and nurturing or filledwith violence and abandonment? During positive transference, she may bring youraisin cookies that her father liked, do things her father expected, and want to betreated as a special daughter “client,” such as spending extra time on her orscheduling appointments outside your normal office hours. A client experiencingpositive transference is not likely to question your actions (even ones that deservequestioning) and may invite you to lunch or ask questions that encourage a morepersonal relationship.But when you do not reciprocate by treating her special, she may feel hurt oreven angry. And if you happen to make her feel special by preferential treatment,transference may continue and even intensify. After all, who would not be willingto bend the rules for a client who brings us gifts and does favors for us, right? Butour deliberate reinforcement of transference serves to perpetuate the problem,distorts the true nature of the therapeutic relationship, and removes the focusfrom the client’s therapeutic goals.Clients may develop a romantic infatuation toward the therapist. Clients bring avariety of feelings, including pain, both physical and emotional, to the massagetable. Therapists who unrealistically represent the epitome of kindness,sensitivity, and warmth may inadvertently fill the client’s unmet emotional needs.It is not hard to fathom clients wanting to be friends with their therapists.Therapists are, in most cases, kind, thoughtful, and willing confidants; this type ofperson is perhaps missing in the client’s life.Keep in mind that you cannot control how clients think or how they feel. Learnto recognize when clients are in transference and do not encourage it or leadclients to feel that their affection is reciprocated or that their fantasies have aplace in reality. Successful navigation requires maturity, integrity, and ethicalprofessionalism. Seek professional supervision when needed.CountertransferenceCountertransference is emotional reactions of the therapist toward the client andmay occur from unmet personal needs, unresolved emotional issues, or internalconflicts that are brought into the relationship unconsciously.Countertransference can occur when we view clients as people from our past.Countertransference runs counter, or in the opposite direction of, transference(therapist to client instead of client to therapist).Countertransference can occur if we cannot maintain professional boundariesor detach ourselves from clients. Detachment is not thinking less of a client butrather thinking of a client less. Countertransference can be caused by theattention gained from a client’s transference. You may find yourself taking apersonal interest in a client or play along with and acting on a client’s infatuation.Countertransference can also occur when the client reminds you of someonesignificant from your past and you start treating the client differently, perhaps lessprofessionally.Countertransference can also occur when you see aspects of yourself in yourclients. For example, your client may be of the same age, recently divorced, orhave children with ages similar to your children. Because of these similarities, youmay believe that the client will be best served by the same type of work orsolutions that helped you. Remember, both transference and countertransferenceinvolve seeing a person as someone else; not who they truly are.Countertransference may prevent us from ascertaining a client’s unique historyand therapeutic goals, therefore not acting in their best interest. Signs ofcountertransference are:• Having intense feelings, positive or negative, toward a client• Becoming angry or depressed when a client cancels an appointment• Becoming impatient, angry, or depressed when a client is not progressing withtreatment• Being argumentative with a client• Seeking to or becoming involved in a client’s personal life• Thinking excessively about the client between appointments• Making excuses for a client’s inappropriate behavior• Giving a particular client additional time during appointments• In extreme cases, romantic and sexual fantasizing• Ignoring or relaxing professional boundariesSo what can you do if you find yourself suddenly in countertransference? Beginby taking a closer look at what might be causing it. Are your getting your personalneeds met? If not, how can you begin doing so outside the therapeuticrelationship? Does your client remind you of someone significant in your life? Asstated previously, self-awareness is vital to healthy boundaries and key to avertingcountertransference. If you fail to identify reasons behind countertransference,this pattern may continue or repeat itself with other clients. Consider seekingguidance from a trusted colleague or mental health counselor. This will help youidentify areas of unmet needs and develop appropriate ways of getting them met.In some cases, it is best to terminate the therapeutic relationship and refer theclient to someone else if countertransference has become irrevocable. Use cautionduring termination of the relationship because the client may feel rejected. Seekguidance from a trusted source before talking with the client if you are unsurehow to proceed and how to best serve your client’s highest good.Keep in mind that feelings are just feelings and are impermanent. And if youhave an emotional or sexual attraction to a client, this does not mean thatsomething is wrong with you. It is normal. Just do not act on those feelings. Thesefeelings and infatuations typically have a short lifespan of a few hours or a fewdays. Again, supervision can be helpful.“A helping relationship is …….a relationship in which at least one of the parties hasthe intent of promoting the growth, development, maturity, improved functioning,improved coping with life of the other….put another way, a helping relationshipmight be defined as one in which one of the participants intends that there shouldcome about, in one or both parties, more appreciation of, more expression of,more functional use of the latent inner resources of the individual.”Carl RogersBoundary ManagementOnce boundaries are established, they need to be managed throughout the courseof the therapeutic relationship. Defining the boundaries and consequences forcrossing them should be outlined when we obtain consent for therapy. This willreduce or eliminate misunderstandings. When boundaries are unclear or when wecontinually bend or disregard them, we may be viewed as unprofessional, whichcan harm or even destroy the relationship.It is helpful to remember that our role as massage therapist never goes away—our professional license does not suddenly become suspended when we leave theoffice. Even though we see our clients in professional settings, we are still theirmassage therapists as we shop at the market, go to the movie theater, and attendour children’s school functions. When our clients see us in these settings, we muststill exhibit professionalism.To establish and maintain professional boundaries, it is important that we (1)be aware of the boundary, (2) clarify the boundary, (3) meet our personal needsoutside the therapeutic relationship, and (4) develop and follow a treatment plan.Crossing boundaries means that we are behaving unprofessionally andirresponsibly. Boundary violations vary widely and range from mildinconsiderateness to the more serious sexual misconduct. You, the professional,are held accountable for any negative consequences resulting from lack ofboundary management.Remember that professional boundaries extend from our clients to othermassage therapists and health care providers. Our responsibilities often includeconfronting a fellow therapist if we hear allegations of professional misconduct.Steps to take in these instances are discussed later in the chapter.Meet Personal Needs Outside the Therapeutic RelationshipBe sure you are taking care of your personal needs outside the therapeuticrelationship. If you are not doing this, you risk trying to get those needs met inthe therapeutic relationship consciously or unconsciously. To avoid this, conductperiodic self-evaluation of your personal needs and how those needs are beingmet. As you inventory these, ask yourself if they are being met in appropriateways; make any needed changes. We need to be clear about our intentions,focusing on the client and putting his or her needs before our own. It is helpful todevise a self-care plan. Information about identifying personal needs andappropriate ways to meet those needs is located in Chapter 4. The therapeuticrelationship is not a place to have personal needs met; doing so opens the door fordual relationships, transference, and countertransference.Develop and Follow a Treatment PlanOne way to manage boundaries is by developing and following a treatment plan.This plan also provides guidance with professional boundaries. Because treatmentplans have an intended outcome, our professional activities are geared towardthese outcomes; putting client goals before our personal needs. Whendetermining if an action is appropriate, ask yourself the following questions.• Who benefits the most from the action?• How would others perceive the action?• Would I tell my colleagues about the action?• Will the action cause confusion for the client about my role as a massagetherapist?• Will the client expect that all massage therapists do this? Will performing theaction cause difficulties when other therapists will not or cannot do the same?We also must be clear about what our treatment methods can and cannotaccomplish. In cases where the client goals are beyond our scope of practice orbeyond the limits of the therapeutic relationship, we must direct the clientelsewhere.“When we work from a place of compassion, it is a place of non-judgment, noncomparison, without the need to understand. With compassion we are notentrained in the drama of the client’s story, we are just with them. This is love,which resides in the heart.”Fritz Frederick SmithClient Abuse and NeglectWhen any professional, whether a physician, attorney, minister, or massagetherapist, does not recognize and respect the rights and boundaries of clients,abuse or client neglect may result. The potential for harm exists in allrelationships in which there is an imbalance of power. In therapeuticrelationships, the therapist has the more powerful or authoritative position. Theclient has chosen to enter the relationship because we have particular knowledge,skills, and abilities. The client may feel vulnerable both physically andemotionally because he or she is usually lying down and draped, whereas westand over them during the massage and remain clothed. When someone removeshis or her clothing, he or she may feel psychologically naked and vulnerable.Neglect is improper treatment of someone due to carelessness orthoughtlessness. The client is harmed because of action or inaction, but it isunintentional, accidental, and reckless. Neglect often comes from lack ofunderstanding of the importance of boundaries or lack of professional knowledge.An example of neglect is mistaking a cyst for a trigger point. Another example istrying to counsel a client who is crying rather than simply providing emotionalsupport.Abuse is also the improper treatment of someone but it is intentional anddeliberate, often for personal gain or benefit. Abuse can be physical, mental,emotional, financial, or sexual in nature.Abuse and neglect harm clients and the therapeutic relationship. Abuse andneglect look the same on the outside, but the internal experience or motivationbehind the action is quite different. Examples of abuse are listed next.Physical AbusePhysical abuse means knowingly crossing a client’s physical boundary. Anexample is intentionally ignoring the client’s request for lighter pressure becauseyou believe that more pressure is better. If a client becomes bruised or injured as aresult of the physical abuse, you may be liable and the client may file batterycharges. If you discover clients who bruise easily (e.g., taking platelet inhibitors, isan older adult, or inactive) you must discuss the potential for bruising so clientscan weigh risks and benefits of treatment to make informed decisions.Financial AbuseFinancial abuse is intentionally taking advantage of a client’s financial resources.This may mean charging more than the standard rate because you know a client isin a higher income bracket. Accepting expensive gifts from clients or accepting aninvitation to use a client’s vacation home for a long weekend can be financiallyabusive. For more discussion on guidelines for accepting client tips and gifts, seeChapter 17.Sexual AbuseSexual abuse may be physical, verbal, or nonverbal. Examples of sexual abuserange from verbal advances to leaning your body against your client during themassage. For more discussion, see the “Dating Clients” section and the “SexualMisconduct” section.Crossing Boundaries: Common MistakesThe following is a list of the more common mistakes therapists make when theycross professional boundaries. These are examples of both client abuse and clientneglect. Being forewarned is being forearmed; therefore, by exploration of thesepitfalls, you can avoid them.Lack of Proper Training and ExperienceAvoid the weekend workshop warrior syndrome, which is you representing yourselfas qualified in specific techniques or methods without proper training andexperience. Avoid taking one workshop in a new method then promoting yourselfas skilled in the new method without proper certification. Doing this may harmyour client. While practice is necessary to hone a new skill, inform your client thatyou are learning a new method and use caution in the interim between initialtraining and certification.Disregarding ContraindicationsAvoid working on clients with absolute contraindications. Check currenttextbooks such as the most recent edition of Mosby’s Pathology for MassageTherapists to help you make this determination. This may be difficult if you workin a setting in which deviating from a routine or suggesting massagepostponement is discouraged (i.e., salon or day spa). Or perhaps you have anoverwhelming urge to help the client with a contraindication and believe thebenefits of massage outweigh the risks. Be sure to discuss your reasons formassage modifications or postponement with your client during treatmentplanning (see Chapter 10) and use a method other than massage therapy. Whenclients need medical evaluations or services outside of your scope of practice, referthem to an appropriate health care provider.Comments about a Client’s Body or AppearanceBecause of the vulnerability clients may feel, comments made about their body orappearance have the potential to impact them deeply. For example, telling clientsthat they are the “tightest person I have ever worked on” may seem harmless, butthey may take it to mean that something is wrong with them and it becomes partof their self-definition. Clients who are dealing with depression or anxiety orrecovering from addictions such as eating disorders may be deeply affected bycomments about their appearance. For example, after hearing a compliment abouttheir shoes, clients with low self-esteem may feel as if nothing else about themwas worth complimenting. These types of comments can traumatize the client andinterfere with a client’s therapeutic progress. These comments could be misreadas abusive or even seductive. Comments made about a client’s body or appearanceis best avoided.Asking Clients to be Your FriendThis issue is common enough to merit a lengthy discussion under the “DualRelationships” section later in this chapter. It is easier to maintain goodboundaries when we avoid creating dual relationships. Dual relationships occurwhen clients are also friends. Some of the dangers of dual relationships are clientabuse and neglect, transference, and countertransference (see appropriatesections in this chapter).Playing PsychotherapistUsing techniques intended to evoke emotional release is another commonmistake. Legal statutes do a good job outlining our scope of practice. However,situations arise that can “muddy” the waters. We need solid and impeccableboundaries regarding the types of service we offer clients. When we playpsychotherapist, we endanger our clients both mentally and emotionally.Although the body and emotions cannot be completely separated in theirphysiologic functioning, we must be absolutely sure that our treatments, advice,and focus remain on the soft tissue of the body. We can recognize the imprint thatthe emotions make on body tissues, but we should not use techniques thatintentionally evoke emotional responses in clients, nor engage in exercises whoseprimary purpose is to address the human psyche directly.We also cross professional boundaries when we attempt to process emotionalmaterial that naturally surfaces during a session. An academic degree andseparate license are required to practice individual counseling or psychotherapy.Additionally, playing psychotherapist shows disrespect for our clients and formental health professions. If clients need a referral to counselors orpsychotherapists, have their contact information available for distribution.Conflict ResolutionA conflict is a situation in which one person feels that someone or something iskeeping them from achieving their goals and is incompatible with their needs andconcerns. In the therapeutic relationship, conflicts can arise when boundaries arevague or nonexistent and when expectations are not met. Examples of unmetexpectations include (1) not starting the massage on time, (2) not adequatelyaddressing your clients’ area of concern during the massage, and (3) cancelingyour client’s appointment for the third time this month.Conflicts cannot be avoided. They can be viewed as evidence of collaborationand provide opportunities for exploration. During conflict, it is important to fosterempathy by (1) recognizing your own emotions, (2) paying attention to the client’semotional message, (3) being aware of your own unconscious message or whatyou are saying with body language, and (4) being receptive to negative feedbackand opportunities for growth.As soon as possible, take action when a client is unhappy with the service beingprovided. Be willing to listen carefully and sincerely to the complaint withoutinterjecting opinions or becoming defensive. Once the client has completelystated his or her position, consider asking, “What would you like for me to do?”Comply within reason. It is also important to communicate with I messagesinstead of you messages. You messages can be perceived as blaming clients for theconflict. Instead of saying “You keep texting me when I have asked you not to.”Say “I feel stressed when I get texts from anyone. I don’t have a texting plan sothey cost me money, and I have no clear way of tracking texts, so am concerned Iwill not respond quickly.”Take full responsibility for your own actions and communicate clearly aboutwhat you want and need. Pick your battles carefully, asking yourself if this conflictwill matter in 5 years. If you or your client becomes angry, take a break and calmdown before resuming conflict resolution (Table 2-1).TABLE 2-1Healthy and Unhealthy Conflict Resolution Strategies STRATEGYACTIONBYFightTrying to impose one’s preferred solutionon the other partyInsisting, blaming, criticizing, accusing, shoutingSubmitLower aspirations and settle for less thanone would have likedGiving in or giving upAgreeing to simply end the conflictSurrendering to what the other wantsFleeChoose to leave the scene of the conflictCeasing to talkLeaving physically, cognitively, and/oremotionallyChanging the topicFreezeChoose to wait for the other’s next moveWaitingDoing nothingProblemsolvePursue alternatives that satisfy both sides;develop a win-win strategyTalking, listening, gathering information,thinking, generating options, resolving Sometimes, it is best to offer dissatisfied clients a refund or gift certificate, evenif no negligence exists on your part. Giving an immediate refund to a clientwithout question may save you a mountain of aggravation later.Conflicts of Interest: Selling ProductsA conflict of interest is a situation in which a therapist could exploit a relationshipfor personal gain. Remember that trust is a characteristic of therapeuticrelationships. Trust is important because clients are in the position ofvulnerability and therapists have the position of power. This is known as a powerdifferential. Conflicts of interests arise when we use the relationship to serve ourinterests rather than the client’s. When determining potential conflicts of interest,ask and answer honestly the question, “Whose interest am I really serving?”One common scenario is selling products to clients. In this situation, we may befaced with choosing between what is in our best interest and what is in the client’sbest interest. Can we be truly objective when we are making a profit on the sale?Therein lays one possible problem. Even without direct monetary gain, a conflictmay exist if we receive points leading to fulfillment of established work goals forcareer advancement and promotion.Selling anything to clients other than professional services creates a dualrelationship; you are therapist and salesperson. Dual relationships are oftenproblematic. A power differential exists and we have influence in the relationship.Is the client really free to refuse the offer? Might the client purchase products justto please us or do it to get us to like them more? Perhaps the sales pitch simplyfeels awkward to the client. This uncomfortable feeling may lead clients toschedule their next massage with therapists who do not sell products.Suppose clients have allergic reactions to the supplements or herbal cream yousold them. What would happen if clients believed they did not gain the benefitsyou said to expect? How would these and similar issues be handled? Be sure toconsider these and other possibilities before selling products to your clients.In some work settings, you may be expected to sell products. There are varyingopinions in the profession as to how to handle this situation. In some settings, theproduct is visible and you do not mention it unless asked. In other settings, youmay be expected to approach clients about purchasing products. Be sure todiscuss product sales with your employer and understand his or her expectationsbefore accepting a position if it involves sales. If possible have another employee,such as the receptionist, handle the actual sale. Be aware that any situation thatinvolves selling products to clients may put stress on the therapeutic relationship.Dual RelationshipsDual relationships refer to situations when two or more different relationshipsexist between clients and therapists. There are several types of dual relationships,such as social, professional, business, communal, and sexual. Social dualrelationships include friendships and having clients who are also your “friend” onsocial networking sites such as Facebook. Professional dual relationships occurwhen you socialize with colleagues such as while attending or copresenting atcontinuing education classes, state conferences, or national conventions. Businessdual relationships include having clients who are also business partners or personswho provides business support, such as legal or accounting services. Communaldual relationships occur when clients live in the same community and youparticipate in the same activities at the same time. For example, you both belongto the same church or synagogue or shop where your client works. Communaldual relationships are easier to avoid in large cities where there are many storesand restaurants. However, in smaller communities, there are fewer places forworship, business, and specialty shops so communal dual relationships areunavoidable. Sexual dual relationships occur when you are involved sexually withclients. Sexual dual relationships are always unethical and often illegal. Thissection addresses only nonsexual dual relationships. Sexual dual relationships, orsexual misconduct, are addressed in the next section.Good boundaries will help us manage dual relationships and keep the focus onour clients and client goals. They also help us distinguish which role we are in.When we are in the role of therapist, be a therapist. When we are in the role offriend, be a friend. When we are in the role of family member, be a familymember. Our professionalism and ability to focus on our clients may be thwartedwhen we enter into dual relationships with them.It can be challenging to maintain boundaries when we have more than one rolein a client’s life. Treating all clients equally is difficult when some are friends andothers are not. Boundaries become blurred, conflicts are more complicated, andthe potential for abuse and neglect is heightened. You cannot promise thatentering into dual relationships with clients will not affect the therapeuticrelationship; no one can make that promise. Remember that the therapeuticrelationship is not a relationship of equals. A power differential exists, similar to aparent-child or teacher-student. Each person in the therapeutic relationship hasexpectations. Our clients expect us to perform our professional duties andresponsibilities. We expect our clients to comply with the treatment plan, keeptheir appointments, follow our office policies, and pay for their treatments. Whenwe have additional roles with each other, such as a client who is also ouraccountant, a different set of expectations now exist.Strangely, one of the reasons why we initiate dual relationships is because theyare convenient. A potential friend, accountant, or attorney is right in front of us.Or in the case of a friend, a potential client is right there. Maintaining boundariesand preserving ethics is not the client’s responsibility—it is ours. The powerdifferential makes it nearly impossible for a client’s behavior to be unethical. Andthe professional is held accountable for any negative consequences that arise fromdual relationships.Next, we will examine dual relationships with friends, family, and situations ofdating clients.FriendshipsThe most common dual relationship is clients who are also friends. When clientsare also friends, we assume several different roles in their lives. Being in aprofessional role exclusively is challenging when clients are also friends. Imaginehow hard it would be not to chat with friends during massage. Excessive selfdisclosure creates a different atmosphere during the sessions. You and yourclient/friend may treat appointments as opportunities to develop your friendship;sessions may become more social events than professional sessions. You maybecome careless, not keeping your focus on the needs of your client/friend. Whoseinterest is being served now?How do therapeutic relationships differ from friendships? Friendships involvechoice, mutuality (both parties voluntarily enter the relationship), trust, pleasure(both parties enjoy the relationship), and reciprocity. In friendships, therelationship is ideally 50/50 and a certain amount of give and take exists. Youknow as much about your friend as he or she knows about you. You also supporteach other. In therapeutic relationships, you know much more about your clientsthan they know about you. You support them and offer them a professionalservice. They do not emotionally or physically support you. Mutual familiarity isnot common in therapeutic relationships. A power differential exists and it is notan equal partnership. Therapeutic relationships involve choice, mutuality, trust,and pleasure, but not reciprocity (Figure 2-4). Some therapeutic relationships feelclose, but they are not as intimate as friendships. Each party is receivingsomething of worth from the relationship, but it is not equal or reciprocal. This isas it should be, and helps keep the safety of the therapeutic relationship intact.Nina McIntoshEverybody studies ethics, right?Today, ethics training is mandatory for massage students all across the country,and it feels impossible that it could ever have been otherwise. There are all sortsof texts available that cover issues such as professional boundaries, dualrelationships, and projection. But as hard as it is to believe, in 1999 there was onlyone: The Educated Heart by Nina McIntosh.McIntosh was born and raised in Memphis, Tenn., in 1943, and lived there untilheading to study psychology at the Newcomb College of Tulane University. Aftera few years of employment in New Orleans, she then continued her education,earning her Masters of Social Work (also from Tulane).Armed with her freshly minted MSW, McIntosh moved to Denver and beganworking as a psychiatric social worker. The experience was educational, but alsodistressing. She watched as the staff in the psychiatric hospital where she workedset up extremely rigid personal boundaries between themselves and theirpatients. They were discouraged from having physical contact with the patients,who were there because of their mental health issues, not body-related illnesses.McIntosh became convinced that both the body and the mind needed careful andcompassionate attention, and that neglecting the body could only be detrimentalto mental health, even when ostensibly done in the name of professionalism. Thisexperience began McIntosh’s lifelong fascination with appropriate boundaries inprofessional settings, as well as the importance of the health-promoting role oftouch.Determined to explore this idea further, in 1978 McIntosh enrolled in theBoulder College of Massage Therapy, and then went on to study at the RolfInstitute in Boulder, becoming a Certified Rolfer. During her career as a Rolfer,she traveled widely and settled for a while in California before returning to herhometown of Memphis to care for her aging parents.McIntosh’s parents died in 1995, leaving her with the free time to write downher understandings about professional boundaries in the massage therapy field,inspired by her experiences in psychology, social work, and massage. This becameThe Educated Heart, which is still used in massage therapy schools today.McIntosh moved to Asheville, N.C. in 2005. Although she retired from Rolfing,McIntosh never stopped thinking or writing about massage ethics, and remainedan active member of the massage therapy community for the rest of her life. Herpopular ethics column in Massage and Bodywork, “The Heart of Bodywork,” ranfor nearly 10 years, and The Educated Heart finally found a publisher in LippincottWilliams & Wilkins, who published not only the second edition of the book in2005, but also a third edition in 2010. The book, which is still one of the bestselling ethics texts in the massage therapy community, is immediately useful,easy to read, and occasionally hilarious, with its real-life stories aboutprofessional boundaries gone wrong, and done right. If your brain is exhaustedfrom too many anatomy exams, reading The Educated Heart is the perfect way to fitsome more studying into your life without it actually feeling like work. There is areason it is such a classic.In 2009, McIntosh was diagnosed with amyotrophic lateral sclerosis, betterknown as Lou Gehrig disease. As her physical health began a rapid decline, shemaintained her sense of compassion and justice, volunteering with her church,advocating for wheelchair accessibility, and befriending a man who had beenunjustly imprisoned for 15 years. She also kept up her wry sense of humor as herbody failed her in an increasing number of ways, eventually losing even theability to speak.In 2010, she was awarded the Aunty Margaret Humanitarian Award at theWorld Massage Festival in Berea, Ky. She was too weak to attend the ceremony,and with typical humility said, “I don’t think I’m much of a humanitarian.”McIntosh died 1 month later, with joy and dignity. Her work lives on in herwritings, and her ethics classes are still taught by Laura Allen, fellow massagetherapist, educator, and McIntosh’s personal friend.What started out as a self-published book by one woman with a devotion toethical bodywork has since blossomed into a nationwide conversation about theethics of professional touch.FIGURE 2-4 Friendships versus therapeutic relationships.Besides, can we call what develops between clients and therapists a friendship?Nina McIntosh examines this question in her book, Educated Heart. Do we go toour client’s offices, remove our clothing, lie on their desks, get a massage, and payfor their time? McIntosh also states that we typically do not show our clients whatshe calls our lower selves, the part of us reserved for only those closest to us.Negative aspects of our lower selves include our pettiness, neediness, jealousies,idiosyncrasies, and quirks. Ideally, we project our higher selves in professionalsettings. Positive aspects of our higher selves include empathy, compassion, andaltruistic loving kindness. Because of this projection, clients often see only ourhigher selves.Turning clients into friends may also interfere with our relationships with otherclients. How would you feel if your therapist Michael was friends with his clientMary and not with you? If not hurt, you may question his professional boundaries.Friends Who Become ClientsFor therapeutic relationships to emerge from friendships, professionalboundaries must be established, just as with all clients. Both parties need tounderstand their individual roles and responsibilities. You, the therapist, willprovide a service for which your client/friend will pay a fee. During the session,keep the conversation and focus on the client/friend.In some cases, it is better if friends go to therapists with whom there is noprevious relationship. Remember that therapeutic relationships serve clients.Friends may not be willing or able to give you the authority you deserve, receivefull benefit from sessions, or take your work seriously as they would withtherapists who are not also friends. Friends may expect special treatment,consciously or unconsciously. After all they are your friend. Maintainingprofessional boundaries may become challenging. Will you feel comfortablecharging friends who violate cancellation policies? What if friends arrive late andexpect a full session? What if friends want to pay for a session next week insteadof that day? Anytime we do not enforce our professional practices we need toexamine why. If we treat friends differently than clients—letting them play by adifferent set of rules, we are likely not serving them. This may indicate that we arenot staying fully in our professional role. Crossing some boundaries can make iteasier to cross others.Friends and Massage SchoolYou will practice massage techniques on fellow students while in school. Thesesessions need to be treated with the same respect and acknowledgement of theirboundaries as you will treat sessions with future clients. This means not talkingwith the students at the next table, not chatting about your pathology test the nextday, and not discussing your plans for the weekend. Stay focused on theclient/student recognizing the power differential that exists for the time he or sheis on your table.Massage students also often practice on friends while in school. Let friendsknow that, after licensure, a fee will be attached. If you know what the fee will be,let them know early so they will be prepared to pay the requested fee at theappropriate time. This is also an opportunity to practice your role of therapistwith professional boundaries intact and to treat practice sessions as you would inprofessional settings.Friends and Social Networking SitesSocial networking sites such as Facebook and MySpace have brought thecomplexities of dual relationships to a new level. Now, it is easy for clients toknow more about you including your likes, dislikes, relationship status, andsometimes your personal schedule. Participation in this social environment canmake boundary management with our clients trickier. The Internet can be atremendous boon for marketing and networking, as long as we are cautious aboutwhat we post. It is best to regard social networking sites as an open public folderin which its contents can be read by everyone. Chapter 17 has a more detaileddiscussion including digital citizenship and self-reflective questions to considerbefore posting content. These are found under Marketing ≫ Social Media.Family MembersMaintaining professional boundaries is more challenging with family members,yet vitally important. It can be a source of great joy to work with family,particularly when they are in pain or need our services. However, there is atendency to carry over any family dynamic into the therapeutic relationship. Ifthere is a strain in the familial relationship, there will likely be a strain in thetherapeutic relationship. For example, if you have always wanted your sister’sapproval, you may use massage as a way to gain it. This places unrealisticexpectations on the therapeutic relationship, removing the focus from yoursister/client to your needs.Other considerations are how appointments and fees are handled. When willyou work on family? During normal office hours or only during your off time?How will you handle missed appointments? Will you charge family members? Ifso, is this fee different than you charge other clients? And if you work with onefamily member and not another, will this negatively impact family dynamics? Ifso, how?Elliot Greene in Psychology of the Body, further limits working with familymembers. Greene advises that if you have been abused sexually, physically, orotherwise by a family member, then do not massage that person or anyone elseassociated with the abuse. Greene points out that many people who have beenabused deny or minimize the abuse, and may not fully understand theimplications and impact of touching these people.Dating ClientsWhat if therapists and clients want to date each other and move the therapeuticrelationship into a more romantic or sexual relationship? National CertificationBoard of Therapeutic Massage and Bodywork (NCBTMB) Standards of Practice(Standard VI. A) require discontinuing the client-therapist relationship for aminimum of 6 months before initiating these kinds of relationships. This timeperiod is a minimum and, in some cases, 6 months is not enough. There are somecases where no amount of time is adequate.Issues that need consideration include: the length of time both parties were inthe therapeutic relationship; the level of client disclosure while in therelationship; and whether transference occurred and if the client still sees you inan authoritative role. When the latter occurs, it may be difficult for the client tosee themselves as an equal partner in the new relationship.Compare the level of disclosure with a client who you have been seeing for 2weeks for a hamstring tear and a client you have been seeing weekly for 3 years,during which time he went through a divorce and lost a parent. It is easy toimagine that the second client may have leaned on you more for emotionalsupport. In fact, you may be a major part of his support network. There may besignificant transference and no amount of time will put the two of you on equalfooting because of the deep bond your client experienced. This client may alwayssee you as his savior, even as you attempt to establish a different role. He mayenter into a romantic relationship with you willingly, but later feel takenadvantage of because of previous disclosure. No matter who initiated the changein the relationship, if the client later feels harmed by it, licensing and certificationboards will most often agree with the injured client and discipline the therapist.The decision to date an ex-client should be considered carefully. Such situationscan easily damage relationships with other clients, and damage your reputationprofessionally. The best and safest decision is to not become romantically orsexually involved with ex-clients.Sexual MisconductSexual misconduct is behavior used to obtain sexual gratification against anotherperson’s will or at their expense. It includes sexual harassment, nonconsensualsexual contact, and any sexual activity between someone in an authoritative roleand a subordinate. According to NCBTMB, sexual activity includes verbal andnonverbal behavior for the purpose of soliciting, receiving, or giving sexualgratification. Although therapeutic relationships consist of a person in anauthoritative role and a person in a subordinate role, other relationships fit thisdescription. These include health care providers and their patients, clergy andtheir congregants, teachers and their students, and employers and theiremployees. If therapists introduce sex into professional relationships, they abusetheir position of authority. It exploits the trust the client has in us and takesadvantage of the client’s vulnerability.Sexual harassment is a type of sexual misconduct and consists of nonconsensualsexual advances, requests for sexual favors, or other conduct of a sexual nature.Telling a client that you are sexually attracted to them is sexual harassment. Sexualharassments can occur in the therapist’s place of business or offsite. Both sexualmisconduct and sexual harassment may be found in a single episode or aspersistent behavior.Examples of sexual misconduct are (1) flirtatious behavior and comments madeabout a client’s body or clothing; (2) seductive or sexual gestures or expressions;(3) sexual innuendos or sexually provocative remarks; (4) telling sexually-explicitjokes; (5) discussing sexual problems, sexual performance, sexual preferences, orfantasies; (6) kissing a client; (7) unnecessary examination or treatments overfemale breasts or pelvic area; (8) filming a client without permission; (9) enteringthe room before clients are completely draped or dressed; (10) failure to ensureproper draping; (11) offering sexual services to clients; (12) asking a client on adate; (13) sexual self-arousal or stimulation in the presence of clients includingrubbing part of your body against the client’s body or on the table; and (14)genital, oral, or anal sex with clients.Sexual misconduct is of particular concern to the massage profession becausetouch is our primary therapeutic tool and our methods often involve treatment ona client’s bare skin. The sensual pleasure inherent in massage is one of its greatestassets, but also one of its liabilities and can lead to situations of seduction andexploitation. Because therapists are likely to deal with issues of sexuality, talkingabout them early is best done while in school. Through talking about these issues,we obtain the know-how to make sound judgments and good decisions. Classdiscussions are important as we learn from instructors and classmates’experiences. William Greenberg, the former grievance chairman for the AmericanMassage Therapy Association, states that complaints filed against therapists forsexual misconduct have decreased recently. Greenberg attributes this reduction tothe fact that schools are giving more instruction on boundaries in general andsexual boundaries in particular.Negative Perception of MassageSome people have negative perceptions about massage and believe it is aeuphemism for prostitution. Much of this illusion is perpetuated by movies,television shows, magazines, newspapers, the Internet, prostitutes, and humantraffickers who use the terms massage and massage parlor. In some parts ofcountry, the terms massage and massage therapist are listed side-by-side with theformer often used to describe unlicensed individuals offering adult entertainmentand sexual services. Some media do not separate the two entities; for example, adsfeaturing Tootsie’s Tantric Massage or Candy’s Erotic Massage are next to adsfeaturing legitimate massage therapy services. This confuses consumers.As massage therapy becomes mainstream and available everywhere from theairport to hospitals, the negative perceptions will fade. However, it is important toaddress the subject, empowering students to skillfully and respectfully respond tonegative perceptions about massage, whether from potential clients or the publicat large.Risk ManagementThere are a number of things that we can do to prevent sexual misconduct. This iscalled risk management and includes identifying potential risks and takingprecautionary steps to reduce their likelihood of occurring. An ounce ofprevention is worth a pound of cure. The potential for sexual misconduct is inevery profession, not just in massage. And even with proactive measures,closeness felt by a client may lead to misunderstandings and false accusations.Our touch may be misinterpreted. We are touching clients sometimes with thegentleness and attentiveness that might be commonly shared with a lover. Youmay have clients who are survivors of sexual abuse. These individuals may behypersensitive to seduction and may misinterpret your touch. Conversely, somepeople with abuse in their past dissociate (a kind of numbing both mentally andphysically) and are unable to detect or stop therapist’s inappropriate behaviorbecause they feel they were unable to stop it from happening before. Therapistswho are survivors themselves may not realize that they are being sexuallyinappropriate with a client.As with other professions, most complaints are against male therapists andmen are more at risk for being accused of sexual misconduct. Although everytherapist should be watchful and alert with regard to sexual boundaries, maletherapists need to take extra precautions. Ways to reduce the risk of sexualmisconduct are:• Avoid terms of endearment (e.g., honey, sweetie) because they may be misreadby clients.• Avoid words in ads such as release, available anytime, open 24 hours, my place oryours, total relaxation, complete relaxation, full service, full body massage, and happyendings.• Note the demeanor, tone of voice, and language used when booking new clients.Note any discomfort you are feeling. Be leery of clients who ask about the age ofthe therapist or distinct features such as hair color.• Avoid sexual signals you may be sending inadvertently, such as wearing tight orrevealing clothing. When you start dressing for work as though you are going ona date, you are asking for trouble.• Avoid working on a client if you cannot put your feelings of sexual attractionaside.• Realize problems associated with a home office. Leading clients through yourhome to the bedroom (now treatment room) can make clients feel uneasy andmay give mixed messages.• Be aware of body contact during the massage. Pay attention to the way you leaninto your client’s body. Be conscious of what part of your body touches the clientduring massage techniques including joint mobilizations and stretches.• Screen clients carefully and use special consideration with out-calls. Perhapsaccept out-call requests with clients who have been referred by someone youknow and trust.• Obtain separate written consent before starting the session when working on ornear female breasts is clinically indicated. Work should be conducted over thedrape. It is strongly recommended that only female therapists work on femalebreasts. If male therapists are massaging female breasts, ask another female tobe present in the room. Know and adhere to your state’s laws regarding femalebreast massage. Provide this service only if you have specific training in thiswork.Massage and Sexual ResponsesSexual activity has no place in the therapeutic relationship. However, you or yourclient may experience a sexual response to touch. Su Fox points out in her bookentitled Relating to Clients that sexuality is a biologic fact, rooted in our brains,neural pathways, and hormones. Sexual response or arousal is a neurologic andreflexive response that happens to all of us. Fox says that just like our mouthwaters in response to the sight and smell of certain foods, certain people willtrigger neural circuits and the rush of hormones that spell sexual arousal. Menwho are concerned about getting an erection during massage are quite aware ofthis response. This is not sexual misconduct. Acting on a sexual response is sexualmisconduct.Sexual responses such as erections can occur naturally from the massage and betriggered by sights, sounds, smells, and without actually thinking sexual thoughts.Sexual response can occur as the body releases tension held elsewhere in the body.And sometimes more is going on—it can be the client is intentionally sexualizingthe massage. Your response to these situations will depend on many factors.If you feel that the erection is just a reflex response (we are not suggesting thisis easy to determine), you can simply ignore it. You can ask questions to distractthe client from thoughts or feelings or sensations leading up to the erection. Forexample, “Tell me about your mother?” or “What type of work did your father dowhen you were a child?” Even if you do not know his parents, you can ask.Referencing parents often reduces erections caused by reflexes.Or you can ask him to roll over and continue the massage. Be sure to avoid anyareas that might restimulate this response, such as the lower abdomen, innerthighs, and lumbosacral region.If your client has an erection followed by inappropriate behavior, he is likelysexualizing the massage. Behavior ranges from subtle to overt and includes noisessuch as moaning, repetitive movements of the pelvis, touching his pelvis or penis,or removing some or all the drape. Inappropriate behavior includes sexuallysuggestive comments, questions, or jokes; touching you; or positioning you forsexual activity.If you have discussed how these situations will be addressed when obtainingconsent for therapy (see Chapter 10), proceed with those actions, such asterminating the session (see Terminating a Session section). If measures taken forthese situations were not discussed previously, consider removing your handsfrom the client, stepping back and toward the door, and saying something like “Ido not like the way in which you are behaving (talking). If you do not stopimmediately, I will end this session.” If he agrees to stop, you may continue withthe massage if you feel comfortable. However, if you feel uncomfortable or if hemakes excuses about his behavior or tries to minimize your reaction, it is best toterminate the session. You have the right to refuse massage to a client who makesyou feel uncomfortable, unsafe, or continues to sexualize the massage.Terminating a SessionIt is rare that you will terminate a session because of inappropriate behavior, butyou need a protocol to use when the need arises. This decision should not betaken lightly. Once the decision has been made, it must be carried out. Here aresome guidelines:• Remove your hands from the client; step back and toward the door.• Tell the client that the massage is over.• Inform the client that you will wait outside while he or she gets dressed.• Avoid answering questions until the client is dressed and has stepped out of themassage room.• If the circumstances leading to the session are extreme, or if you are alone andbecome frightened, lock yourself in a room until the client has left or call 911 andstay on the telephone until the client leaves.Document the events that led to the decision to terminate the session. Be sureto document statements verbatim and describe the situation in detail. Thisinformation can be used should the situation become libelous.If you feel fearful as a result of the session termination, some form ofintervention should be taken such as filing a police report. Also, file a policereport if you feel sexually harassed or stalked by the client.Sexual Misconduct and Professional Liability InsuranceProfessional liability policies do not cover damages resulting from sexualmisconduct.Sexual Misconduct by ColleaguesEvery massage therapist should contemplate possible consequences ofinappropriate behavior, particularly sexual misconduct. If a therapist intentionallyor unintentionally violates a client sexually, the client’s realization of whathappened rarely occurs during the session. Only after the massage does the clientreflect on the events and inappropriate behavior of the therapist. Many acts ofsexual misconduct go unaddressed. The violated client may be silent and blamethemselves for what happened.If we hear allegations of a colleague who engaged in sexual misconduct, wehave a professional responsibility to take action. The first step is to speak to thetherapist and let him or her know the nature of the allegation. If your colleagueconfirms the allegation and wishes to change the inappropriate behavior, suggestthat he or she seek professional help and refer the client to another therapist.If you cannot speak to your colleague directly, or if your colleague does notrecognize the problem, speak to his or her supervisor. Be sure to document yourconcerns and include a description of the event that suggested the boundaryviolation. The next step may be to file the report with the proper authorities. Thisis often the state board that regulates licensure and professional affiliations ofwhich the therapist is a member.In many states, there is “duty to report” sexual misconduct by other therapists.If we have firsthand knowledge (i.e., witnessed it ourselves or told to us by theoffending therapist), we are required to file a report with the state licensing board.If we fail to do so, we are in violation of the law. If allegations are second-hand orobtained by hearsay (i.e., learned from other persons such as the client) our role isto encourage the client/victim to file a report. Licensing boards and professionalorganizations are most able to act when they have a complaint filed by the victim.Some boards and organizations do allow anonymous complaints, but these arenot as strong as ones filed by victims, and are harder to take action on.Therapists who are not concerned or are indifferent about the damage causedby their sexual misconduct must be stopped. Behind sexual misconduct lies ablatant disregard of ethics, morals, and disregard for the entire profession ofmassage therapy. There is no excuse for sexual misconduct. Remember that thetherapist is always responsible and liable for his or her actions, even if the clientinitiates the situation.BibliographyAmerican Massage Therapy Association: Code of ethics, (website):http://www.amtamassage.org/About-AMTA/Core-Documents/Code-ofEthics.html. 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Ethics for massage therapists. Lippincott Williams & Wilkins:Philadelphia; 2006.Zur O: Dual Relationships, Multiple Relationships & Boundaries inPsychotherapy, Counseling & Mental Health.http://www.zurinstitute.com/dualrelationships.html. Retrieved onDecember 10, 2013.Activities and AssessmentsMatching OnePlace the letter of the answer next to the number of the term or phrase that best describesit.A. AbuseB. CongruencyC. BoundariesD. ConfidentialityE. CountertransferenceF. DisclosureG. Dual relationshipsH. EmpathyI. NeglectJ. RespectK. Sexual misconductL. Transference_____1. Emotional reactions of the therapist toward the client; may occur fromunmet personal needs, unresolved emotional issues, or internal conflicts thatare brought into the relationship unconsciously_____2. External presentation of words and actions that coincide with theinternal world of thoughts and feelings_____3. Sexual activity between someone in an authoritative role and asubordinate_____4. Guidelines, rules, and limits that we create in relationships to identifywhat are reasonable, safe, and acceptable ways to interact with others_____5. Transfer of client’s feelings, thoughts, and behavior that they have for asignificant person in their life onto the therapist_____6. Act of keeping information private or secret_____7. Situations when two or more different relationships exist betweenclients and therapists_____8. Treating someone with value and consideration_____9. Intentional and deliberate improper treatment of someone for personalgain or benefit_____10. Client sharing his or her personal information_____11. Ability to understand the unique world of another_____12. Unintentional improper treatment of someone for personal gain orbenefitMatching TwoPlace the letter of the answer next to the number of the term or phrase that best describesit.A. AttunementB. ConflictsC. Emotional boundariesD. Emotional releaseE. Financial boundariesF. Intellectual boundariesG. ProfessionalismH. Risk managementI. Sexual activityJ. Sexual harassmentK. Therapeutic relationshipL. Unconditional positive regard_____1. Relationship between therapists and clients in which therapists provideservices that benefit clients_____2. Boundaries that encompass our beliefs, thoughts, and ideas as well assafeguard our self-esteem_____3. Boundaries that protect feelings and separate our feelings from thefeelings of others_____4. Identifying potential risks and taking precautionary steps to reducetheir likelihood of occurring_____5. Verbal and nonverbal behavior for the purpose of soliciting, receiving,or giving sexual gratification_____6. Situations in which one person feels that someone or something iskeeping them from achieving their goals and is incompatible with their needsand concerns_____7. Acceptance of another regardless of what that person says or does_____8. Experience of connectedness shared between two people_____9. A form of sexual misconduct that consists of nonconsensual sexualadvances, requests for sexual favors, or other conduct of a sexual nature_____10. Boundary that includes letting your clients know upfront about feesand forms of payment you accept_____11. Adherence to a set of values and obligations, formally agreed-uponcodes of conduct, and reasonable expectations of clients, colleagues, and coworkers_____12. Letting go or releasing suppressed emotionsThink about ItProfessional Dual RelationshipsAlice has been your accountant for 7 years. Two years ago, she needed help with astiff shoulder. Alice was so pleased with the other benefits of massage therapythat she now receives weekly massages by you. Her standing appointing isThursday at 4 PM. On Monday, you receive a letter from the IRS stating that amistake was made on your last year’s tax returns and you have overpaid by $800.How do you handle this situation?WebquestGot Boundaries?Do you have good boundaries? Well, do you? Take the quiz and find out how yourank at making decisions in difficult relationship situations. Visithttp://www.boundariesbooks.com/boundaries-quiz/.Do you feel the quiz ranked you accurately? Why or why not? Post yourreflections on an Internet-based discussion board monitored by your instructor.State why you feel this is the most important guideline.DiscussionNCBTMB’s Code of EthicsGiven the complexity of therapeutic relationships, how can they be managedethically? NCBTMB’s Code of Ethics give us guidelines and supports professionaljudgment (http://www.ncbtmb.org/code-ethics). Visit their webpage that lists thecode of ethics. After reading them, select the one you feel is most important andstate why you feel this way.