The Therapeutic Relationship
The dynamics of a complementary and harmonious client/therapist relationship begin with mutual respect and trust. It is important that neither the client's nor the therapist's boundaries are crossed, and each have a duty to the other to ensure this doesn't happen. Regular communication and feedback (during the treatment) are good ways to clarify ambiguous situations and language, which may threaten to upset this mutual balance. Taking notice of body language as an indicator of communication if the client is not speaking, is also important for the therapist to notice. Since the therapist is providing a paid service to the client there is an element of needing to be treated respectfully and having their needs met by the therapist: this is explored further in client centred care.
Client centred care
Despite what the therapist may personally believe, to be successful professionally the client must always be the focus of the therapist's energies and intentions during the treatment. As a result of this client centred focus, the therapist is generally rewarded with money, as a form of energy exchange.
Considering the client has made a concession (by removing their clothes and being covered only by a sheet), it is the therapist's duty to respond to this by consciously aiming to improve the wellbeing of the client through touch.
When it becomes obvious that the client's issues are beyond the scope of practice of the MT, it is necessary to refer the client on to a relevant healthcare professional. As always, the aim of the therapist is to ensure the client's interests are the foremost priority.
Ethics & the Meaning Response: Honesty vs. client's best interests.
In most cases it is best to act with integrity as this may inevitably be in your client's best interests, even if at the time it does not appear that way. There are times when it is preferable to place the client's best interests above honesty, as a short-term solution. However honesty is generally the most important value to cultivate.
According to Benjamin et al (2004), the conflict here regards duties versus rights.
A duty is a moral obligation set in place by social custom, and is often enforceable by law. As healthcare practitioners we are bound by various duties outlined by the law and general social belief, integrating ethics and awareness.
A right includes basic human freedoms, such as the right to equal treatment, and the right to self-determination (a right which could potentially conflict with a practitioners duty of assisting others on the course of better health). This duty may for example, include referring a client intent on physically harming themselves or another on to an appropriate healthcare professional (thus interfering with their right), as opposed to allowing the client the right to self-determination in this instance.
Due to the increased vulnerability the client has had to put themselves in so as to receive the massage, the client may feel subconsciously that the practitioner has more power and control then them, as they are fully clothed and standing over them while massaging. The client is literally physically powerless, as they lie on the massage table and may feel more vulnerable without their clothes on as a form of outer layer defence. In order to fully relax into their role, the client must be able to trust that the practitioner will not abuse this perceived power. Therefore it is crucial the practitioner ensures the client does not feel threatened when they are on the table, by acting in a way that allows the client to feel in control to some degree. Asking for regular feedback and giving the client control mechanisms (e.g. the pain/pressure scale) will not only allow the client to control aspects of the massage resulting in a more enjoyable and tailored treatment, but will subconsciously reaffirm the client's status as an equal to the practitioner (as seen in the therapeutic relationship) and in control. Regular feedback will assist with preventing and clarifying misunderstandings that could be the basis for lawsuits based on malpractice.
Transference and Counter-transference
Transference is where the client is not correctly 'seeing' the therapist as the separate, individual human being they are, but rather is transferring an archetype onto them, of someone who has had a deep emotional and/or physical connection to them, in a positive or negative way (For example, an idolized mother or an abusive father). McIntosh (2005) explores this theory of transference further by proposing that due to the higher proportion of domestic and sexual abuse carried out by males against females (as opposed to females against males), this may explain why some women are less comfortable in the presence of a male massage practitioner, particularly if they were abused in the past by a male figure. Of course, this situation can correlate to a male client and female practitioner, a male client with a male practitioner, or a female client with a female practitioner, depending on the client's history. The past issues relating to this transference may be more likely to be triggered when the client is receiving the massage and therefore is in an extremely vulnerable position, with the therapist in control by default.
Counter-transference involves the same distortion of reality as transference by replacing the client as an individual with a gendered archetype from the practitioner's past. In the case of unresolved issues from childhood related to gender or personality traits, it is vital that the therapist ensures they receive supervision as part of their ongoing professional development to prevent this from negatively affecting the client/therapist relationship, and to assist them in consciously realising why they are having the reactions they are having to their client (Elluminate, 2009).
Boundaries - personal and professional
Therefore, due to the possible complications that can arise due to phenomena such as transference, boundaries are essential to ensure that these do not violate the ethical considerations that should be in place.
Personal boundaries are necessary to safeguard ourselves and provide a clear line between where one person ends and the other begins. Confidence and a developed awareness of ourselves are the result of having clear and defined personal boundaries.
Professional boundaries ensure that clients are protected and feel safe, and the professional integrity of the practitioner is not compromised. Professional boundaries ensure the level of care delivered by the practitioner to the client is consistent. With the assistance of supervision, the practitioner does not cross the client's boundaries, but rather maintains an objective professional distance so that once again the client's best interests are top priority (Benjamin & Sohnen-Moe, 2004).
- Creating professional boundaries
Maintaining a professional appearance (tidy, non-suggestive clothing)
Keeping a professional distance, e.g. not sharing too many personal details
Being aware of and respecting a client's personal space by observing their body language and touching base with them about this in the instance that their boundaries have been crossed
Using respectful language, ie. no slang, not sexist, racist, ageist or in any other way discriminatory language
Touch boundaries: exercising caution when touching them any other time than on the massage table (e.g. pat on the arm)
Maintaining a professional looking massage environment and clinic
Enforcing fair and prompt payment for sessions (when necessary)
Keeping to scheduled session times.
- Crossing client's boundaries
Common ways in which the therapist may cross the client's boundaries include:
- Working outside the MT scope of practice
- Acting as their psychologist/counsellor
- Unsolicited comments about their appearance, beliefs, decisions
- Treating a client presenting with contraindications
- Inviting the client into a friendship or other form of relationship
In the instance that the therapist has crossed the client's boundaries, the best tactic to use is for the therapist to explain to the client that they have become aware of this situation, clarify what happened (from their point of view), apologise if it appears they did in fact cross the client's boundaries and progress on with the treatment once the client has given their consent.
A dual relationship occurs when the boundaries within a client-therapist relationship blur into a friendship, making these boundaries more difficult to enforce.
According to McIntosh (2005), dual relationships can be avoided by clearly defining and separating social and professional time. By practicing setting boundaries around one's time and one's therapeutic relationship with clients (even friends who have become clients), dual relationships will present less of an issue.
In the words of Snyder (2007), malpractice regards the negligent behaviour of the therapist when treating a client with whom there exists a therapeutic relationship, and this negligence results in the direct injury of the client.
In a malpractice suit, the actions and intentions of the therapist are examined and compared to the actions and intentions expected of a standard massage therapist when treating a client (as outlined within the Code of Ethics, MNZ, 2009): "Serve the best interests of their clients and provide best practise quality of service". In the case of a registered healthcare professional, a successful malpractice suit can result in the sanctioning of the practitioner and possibly a revocation of their practitioner's license as the most severe form of sanction.
Benjamin, B. & Sohnen-Moe, C. (2004) The Ethics of Touch: the hands-on practitioner's guide to creating a professional, safe and enduring practice. New York: Lippincott Williams & Wilkins.
Elluminate 1 & 2 (12th - 13th August, 2009) Otago Polytechnic Massage Therapy Diploma Course.
Massage New Zealand (2009) Code of Ethics. Retrieved on the 10th of August, 2009 from: http://massagenewzealand.org.nz/about-us/code-of-ethics/
McIntosh, N. (2005) The Educated Heart: Professional Boundaries for Massage Therapists. New York: Lippincott Williams & Wilkins, p. 126.
My own thoughts.
Snyder, L. (2007) Complementary and Alternative Medicine: ethics, the patient, and the physician. New York: Humana Press, p. 169