Professional Practice

Blog 7: Multi-disciplinary Work - Discuss the Place of Multi-disciplinary Work in Professional Practice.

What does it mean to be a massage therapist and a multi-disciplinary healthcare provider?

Multi-disciplinary practice among healthcare practitioners including massage therapists is becoming standard practice in the holistic treatment of patients/clients seeking professional help on a physical, emotional and/or spiritual level.

According to Opie (1997), multi-disciplinary teams of healthcare providers can deliver a cost-effective and resourceful service to a client whose needs may require the specializations of several practitioners with sufficiently different yet complimentary scopes of practice. The inevitable outcome of this is the overlapping of defined or implied roles, potentially causing conflict, due to the blurring of professional barriers defining respective scopes of practice (Robinson & Cottrell, 2005).

Furthermore, the healthcare hierarchy of professional dominance must involve mutual respect and understanding of others scopes of practice by massage therapists and practitioners generally, the boundaries defining these (by law or otherwise) and the respective roles that can lead to an interactive and successful multi-disciplinary team. The intention of reaching consensus in decisions and utilising other practitioners' strengths and specializations within the team results in optimum and cost-effective treatment, and can assist in the removal of barriers naturally arising between rival professions.

The incorporation of C.A.M (Complementary Alternative Medicines) into the standard medical healthcare system as recommended by W.H.O (World Health Organisation) is a step forward in the direction of holistic multi-disciplinary practice more in line with massage therapy and its expected route.
However, the biggest concern facing massage therapy as a profession in New Zealand is the current limited scope of practice that has been defined by our national representative body: Massage New Zealand. This is potentially restricting the crucial stage of growth our profession is in, where we are primarily interested in expanding rather than confining our scope of practice.

The main elements of successful multi-disciplinary practice within the field of massage therapy is the ability to refer to other practitioners with the relevant scope of practice (e.g. physio, osteopath, GP, counsellor) and to identify when it is clear that the client requires care outside of your scope of practice.
That said, this really depends on one's individual areas of professional strength as a massage therapist: a practitioner may be primarily trained in massage, but may also be a qualified and registered acupuncturist, immediately changing their position on the healthcare hierarchy and boundaries defining their scope of practice, challenging the strictly defined barriers of who can and can't refer to you/be referred to by you. The boundaries of scope of practice may also overlap, questioning the need for two practitioners with similar skills and specialisations in a multi-disciplinary team (e.g. a physiotherapist and a massage therapist, who are both trained in advanced assessment techniques and soft-tissue manipulation).

Maintaining positive multi-disciplinary relationships and mutual respect for your fellow healthcare colleagues, fosters an excellent environment for the implementation and growth of multi-disciplinary teams, when treating patients with requirements that span more than one practitioner's limited scope of practice. Both knowledge of our position in the established healthcare hierarchy and the existing boundaries of the massage therapy scope of practice are paramount to the professional image of our modality and reputation amongst other healthcare providers.

References:

Elluminate: Multi-Disciplinary Practice (28th October 2009). Otago Polytechnic Massage Therapy Diploma Course.

My own thoughts.

Opie, A. (1997) Effective Team Work in Healthcare: A Review of Issues Discussed in Recent Research Literature. Health Care Analysis, 5 (1).

Robinson, M. & Cottrell, D. (2005) Health Professionals in Multi-Disciplinary and Multi-Agency Teams: Changing Professional Practice. Journal of Interprofessional Care, 19 (6).

Professional Practice

Blog 6: Professional Development, Reflective Practice & Supervision - Discuss the Place of Supervision in Professional Practice.

How does professional development, reflective practice & supervision act to support professional practice?

Professional development, reflective practice and supervision actively undertaken by the massage practitioner can assist in the development of professional practice by adding to pre-existing knowledge and concepts, refining self-awareness and assisting the practitioner to better hone their interpersonal and situational skills in a workplace setting, within a predominantly people-oriented profession.

The massage practitioner may choose to develop their professional skills via further formal education, attending conferences, workshops or additional courses on related modalities (e.g. acupressure, Reiki, cranio-sacral therapy). Educating the wider public on aspects of massage therapy that are not common knowledge will add to the general perception of the therapeutic massage industry and career path. This can be done through the publication of journal articles relevant to the sphere of healthcare, giving talks/guest speeches on related aspects of massage therapy, printing personal opinion pieces and having a personal blog, all of which educate and improve awareness of massage therapy and what we hope to achieve as practitioners of this modality.

I personally believe that written articles on massage outlining the benefits to the individual/society as a whole may be more beneficial, due to the wider range of people likely to interact with this piece (read it/reference it) and the longevity of it (considering it is immortalised in a publication).

Reflective practice can be enhanced by allowing clients to voice their comments and observations in an anonymous way, such as via the use of anonymised feedback forms and boxes in which observations can be placed, as these will assist in refining the practitioner's processes by adding a valuable third party perspective.

Supervision is also crucial in the professional development of the massage practitioner, and can assist by following an eight step process that identify areas needing improvement, using the following stages:

Practice - The reflective practitioner needs to develop their self-awareness, reactions to their environment and look at how they personally deal with situations that arise. It is through practising that the practitioner can identify the areas that can be worked on, and be alerted to any need for reflection and/or supervision in their practices.

Select - identify a clinical situation that stands out from the rest as being particularly significant and useful to the practitioner's professional development via reflection. This situation may be emotionally charged, and appear intuitively important to the practitioner as something that must be addressed.

Describe - Remember the experience and its details, see from both the observer's point of view as well as first hand experience, fill in the knowledge gaps experienced then, and potentially, now.

Reflect - With the knowledge and clarity you now have regarding the situation, reflect on what happened, your role, the role of any other individual and how you felt about this/what you perceive they have felt, continually looking from all angles.

Research - Investigate the situation further, identify whether this is a common situation when the variables are kept constant, or an unusual situation. Were the actions of all parties involved typical/consistent with what occurred in the situation? Where can I as the practitioner improve my interactions to achieve a more favourable future result?

Plan - Identify strategies for improving the expected outcome of a potential situation, particularly ways in which altering or becoming aware of personal behavioural patterns/ways of interacting can affect this outcome.

Alter practice - The actual implementation of these strategies into the existing operational processes and personal ways of interacting in particular situations, especially ones similar to those outlined above.

Monitor - Methods of feedback and observation of the alteration and improvement of operational processes, regular supervision to give a third party perspective on the situation, and to assist with self-awareness in the outlined situations.

By actively choosing to improve on their pre-existing knowledge, skill base, interpersonal skills and self-awareness, the practitioner is in the best possible position to effectively develop their professional abilities and simultaneously support the massage industry via conscious self-improvement and public awareness of massage therapy as a viable and effective healthcare modality.

References:

Elluminate: Multi-Disciplinary Practice (21st & 22nd of October 2009). Otago Polytechnic Massage Therapy Diploma Course.

My own thoughts.

Professional Practice

Blog 5: Legalities - Consider legal requirements relevant to massage practice in New Zealand.

How the future of Massage Therapy will be determined via law, lies in the hands of current and future massage therapists, and can be strongly influenced by these individuals should they decide to lobby for or against any proposals made by parliament affecting the healthcare industry.  Massage Therapists are currently bound by several laws relating to healthcare provision, namely the Privacy Act, Health & Safety in Employment Regulations Act, Consumer Guarantees Act, Medicines Act, Health & Disability Commissioner Act, HPCAA and the Injury Prevention, Rehabilitation and Compensation Act.

The Privacy Act 1993 is relevant to Massage Therapists due to the need to keep clients details and information confidential and holding personal information securely.  Accuracy/correction of information and limited use/disclosure of information all matter greatly under the Privacy Act 1993 and must be adhered to by Massage Therapists for the simple reason that they are legally bound by the Act, as they are providing a healthcare service (massage).  

The Health & Safety in Employment Regulations Act 1995 outlines basic workplace safety, OSH principles, hazard identification and job competency, which in the context of massage therapy mainly applies to a situation in which more than one therapist works and outlines the duties of employees and employers.

Of course, this legislation would additionally apply to sole traders due to the need for safe workplace practices in all business forms.

Under the Consumer Guarantees Act 1993, the section most relevant to MTs would be Part 4: Supply of Services.  This again states the requirement that the service provided is of acceptable quality and performed with at least an average level of competency on the part of the therapist.  It also outlines the rights of the consumer in relation to the service they are under the impression they will receive according to advertising and other promotional material.

The Medicines Act 1981 restricts the prescription of medications by MTs (as we are not authorized prescribers) but outlines the rights of massage therapists in advising clients of alternative natural health products or herbal remedies under the exemptions clause in Part 2 of the Act: Dealing with Medicines and Medical Devices.

Another Act of note is the Health and Disability Commissioner Act 1994 which is in place to "promote and protect the rights of health consumers and disability services consumers", and covers relevant sections such as the rights of the massage client when receiving a health/disability service, advocacy, complaints and investigation procedures related to said service.  Therefore, adhering to this particular act is paramount to the integrity and legitimization of Massage Therapy as a healthcare profession.

Lastly, the Injury Prevention, Rehabilitation and Compensation Act 2001 covers the claims and entitlements process in the case of workplace accident or injury in New Zealand (ACC).  This debars lawsuits related to the above situation, and provides cover for those who suffer a workplace-related injury and subsequently require individual, social and vocational rehabilitation.  In the therapeutic massage industry this is more relevant to employees and clients.

How can I as an individual MT influence the development of government policy & laws that are supportive of the profession?

The Health Practitioners Competence Assurance Act 2003 remains a recent topic of some debate, around which massage therapists are often divided, as they are with the Therapeutic Products and Medicines Bill.  These examples address issues we may face in the future relating to the standardization of an industry currently in its infancy, of which the main appeal is the often intuitively guided processes and relaxed approach to holistic health.

There are however, massage practitioners serious for recognition as registered healthcare providers with an equal level of professional clout as physiotherapists, chiropractors and other medical professionals.  Recognition under the HPCAA would allow this, but in doing so would standardize many of the processes currently non-standardized (e.g. pay rate) which could jilt massage from its position in the alternative healthcare field into a more mainstream medical position.

The Therapeutic Products and Medicines Bill 2006 (Trans-Tasman regulation of therapeutic products bill) main listed aims are to regulate complementary medicines and medical devices.  This is intended to meet international best practice standards, and to improve international reputation by "enhancing closer economic relations and facilitating trade".  However, the drawbacks of this bill are the augmented compliance costs which may result in the removal of many smaller businesses trading in alternative health products, and thus favouring corporate providers and pharmaceutical companies.

The main argument of the New Zealand Health Trust (2009) is that natural health products are different in chemical composition (Gagnier et al, 2006) to pharmaceutical medications, and are relatively low risk, so therefore do not require regulation.  

Knowledge of the current laws binding massage therapists are crucial to professional conduct as healthcare practitioners, and it is only through active participation and solidarity on the part of all Massage Practitioners in an association (MNZ) that any real change can be effected in the future, that will subsequently shape and alter our profession.  

References

Elluminate: Understanding Legal Process (24th September, 2009) Otago Polytechnic Massage Therapy Diploma Course.

Gagnier, J., Boon, H., Rochon, P. & Moher, D.  (2006) Reporting Randomized, Controlled Trials of Herbal Interventions: An Elaborated CONSORT Statement.  Annals of Internal Medicine, 144 (5).

My own thoughts.

NZ Health Trust.  (2009) NZ Health Trust Proposed Bill.  Retrieved on the 7th October, 2009 from: http://www.nzhealthtrust.co.nz/proposed_bill.html

Parliamentary Counsel Office (2009) Consumer Guarantees Act 1993.  Retrieved on the 7th October, 2009 from: http://www.legislation.govt.nz/act/public/1993/0091/latest/viewpdf.aspx

Parliamentary Counsel Office (2009) Health and Disability Commissioner Act 1994.  Retrieved on the 7th October, 2009 from: http://www.legislation.govt.nz/act/public/1994/0088/latest/DLM333584.html

Parliamentary Counsel Office (2009) Health and Safety in Employment Regulations 1995.  Retrieved on the 7th October, 2009 from: http://www.legislation.govt.nz/regulation/public/1995/0167/latest/viewpdf.aspx

Parliamentary Counsel Office (2009) Health Practitioners Competency Assurance Act 2003.  Retrieved on the 7th October, 2009 from: http://www.legislation.govt.nz/act/public/2003/0048/latest/DLM203312.html

Parliamentary Counsel Office (2009) Injury Prevention, Rehabilitation and Compensation Act 2001.  Retrieved on the 7th October, 2009 from: http://www.legislation.govt.nz/act/public/2001/0049/latest/DLM99494.html

Parliamentary Counsel Office (2009) Medicines Act 1981.  Retrieved on the 7th October, 2009 from: http://www.legislation.govt.nz/act/public/1981/0118/latest/DLM53790.html

Parliamentary Counsel Office (2009) Privacy Act 1993.  Retrieved on the 7th October, 2009 from: http://www.legislation.govt.nz/act/public/1993/0028/latest/DLM296639.html

Parliamentary Counsel Office (2009) Therapeutic Products and Medicines Bill 2006.  Retrieved on the 7th October, 2009 from: http://www.legislation.govt.nz/bill/government/2006/0103/latest/versions.aspx

Professional Practice

Blog 4: Sustainability - Discuss Issues of Sustainability and How They Relate to Massage Practice.

Central to issues of sustainability in massage practice are the three main elements of Economic, Social and Environmental Sustainability. A balance of these three lead to a satisfied massage practitioner, a wider positive community/social network and environmental awareness, aiming to positively impact the world on a global scale.

Economic Sustainability

This refers to the ability to make enough money to result in profit and reasonable quality of life for the practitioner, thus affecting the practitioner's mood, and everyone they come into contact with (explored more in social sustainability). The idea of business is that a profit is made, and that the business is not running at a loss, as most likely this is the main source of income for the practitioner, assisting with their survival (food/accomodation) and general expenses. In some ways, being imbalanced in the environmental and social areas of sustainability (buying products that end up being too expensive to realistically make a reasonable profit, e.g. expensive organic cotton sheets) may lead to a need to address this imbalance by purchasing in this case, cheaper sheets which may have been made by slave labour. However, this depends on the views of the practitioner. It is very possible to use and buy products that are both environmentally and socially sustainable, without a massive price tag (e.g. eco-friendly laundry powder, fair trade teas/coffee/sugar). These products may be marginally more expensive, but that entirely depends on whether you make the most of supermarket discounts, sales offers, bulk buys and wholesale prices when ordering these in. In some cases, it is cheaper to buy fair trade/eco-friendly (e.g. trade aid green tea, eco-friendly products that are on special), so it comes back to the intention of the practitioner.

Social Sustainability

This refers to the effect that the massage practitioner and their massage practice has on the wider community network that they contact (via their clients).

The very intention of massage is to improve and maintain people's wellbeing by relaxing & treating them physically, helping them psychologically and generally assisting them on a holistic level. This has the trickle down effect of affecting all other people in that person's network that they contact in some way, usually positively. This as a whole affects society positively, leading to better relationships within the community, greater tolerance of others, lower crime rates and conflict, and more altruistic behaviour.

From a survival point of view, a society with a more functional interpersonal network will have a greater chance of surviving, a higher birth rate, lower premature death rate (due to lower crime levels/conflicts), and be more egalitarian: not have so many issues related to inequality, which can lead to riots and strikes.

In relation to the massage practice, practitioners can actively use their consumer power by choosing to purchase products that support social sustainability locally and overseas, by choosing items that donate a percent of the profit to charity, fair trade items and products, slave-free linens and furniture as a few examples.

The massage practice could also network with grassroots businesses and local organisations that have socially conscious goals to contribute to social sustainability.

Environmental Sustainability

To practice environmental sustainability within a massage business, the easiest ways to address this is by reducing power usage, using environmentally friendly laundry products, recyclable paper and buying recyclable packaging whenever possible, so mainly aiming to reduce throwaway plastic. The therapist can try using small glass bowls for mixing the oil in, for use during the massage rather than plastic bottles (this would be particularly beneficial for practitioners mixing aromatherapy oils prior to the massage) and storing oils in glass bottles.

The massage therapist can look at using soy candles (instead of paraffin which is carcinogenic and adds to air pollution - Rezaei, Wang & Johnson, 2002) during the massage rather than electrical lighting, and switching off lights/appliances when not in use. By using more sheets rather than towels, and line drying linen where possible, this will reduce electricity usage and waste byproducts. Recycling grey water (water that has been used to wash dishes/linen) to use on the garden or potentially in the cistern is another method of conserving water. Again, using the power of active consumer choice, selecting an environmentally friendly power company and advocating for the use of eco-friendly practices and products in the massage industry will have an effect on a wider scale, particularly when networking with a group of like-minded practitioners, in an effort to lobby for positive, sustainable change.

The three spheres of economic, social and environmental sustainability interlink with each other, contributing to sustainable practices and awareness on the part of massage therapy as a whole. The implementation of strategies that address these spheres of sustainability have a beneficial effect at a personal, social and finally global level, reaching far beyond the practitioner and the practice.

References:

Elluminate: Sustainable Practice (23rd September, 2009) Otago Polytechnic Massage Therapy Diploma Course.

My own thoughts.

Rezaei, K., Wang, T. & Johnson, L. (2002) Combustion Characteristics of Candles Made from Hydrogenated Soybean Oil. Journal of the American Oil Chemists' Society, 79 (8).

Pathology: Condition 3

Pathology: Immune, endocrine, gastrointestinal & renal systems

Condition 3: Jaundice

Final due: 16th October, Peer assessment due: 23rd October 2009.

Description:

Jaundice (Icterus) is the yellowing of the skin as a result of uncommonly high amounts of bilirubin in the blood plasma.  Bilirubin affects skin pigment, is a byproduct of broken down haemoglobin and is metabolised in the liver.  Therefore, blood disorders, diseases of the liver and gall bladder problems can affect the metabolism of these organs/tissues resulting in an unusually high level of bilirubin (Premkumar, 1999).

Jaundice is the physical symptom of a more serious underlying condition.  Hepatic jaundice which is the most common type, is often co-morbid with other serious internal diseases affecting the liver, most often hepatitis (Brienza et al, 2006).

Etiology:

Hepatic jaundice is typically caused by liver disease/failure, which can be caused by prescription drugs including antibiotics (Hussaini et al, 2007), alcohol leading to cirrhosis of the liver and other toxic substances, hepatitis, viral diseases such as malaria (Werner, 2005) and other chronic liver conditions (Suman & Carey, 2006).  In very rare cases, there may be abnormal liver enzyme activity present from birth, this is known as congenital jaundice (Werner, 2005).

Signs & Symptoms:

The most obvious signs that jaundice is present are that the whites of the eyes, skin and mucous membranes will appear yellow (due to the pigment change caused by elevated levels of bilirubin).  There may be a dull aching pain in the upper right quadrant of the abdomen and enlargement of the spleen in addition to jaundice in the case of co-morbid hepatitis (Premkumar, 1999)

Light coloured stools and dark urine also indicate abnormal levels of bilirubin in the blood and the presence of jaundice (Werner, 2005).

Morphology:

Jaundice may eventually result in bleeding disorders if the underlying condition responsible is left untreated, as the higher levels of bilirubin indicate that bile is not being adequately secreted, preventing the absorption of fats and therefore inhibiting the access of fat soluble vitamins (such as Vitamin K) that assist in normal blood clotting (Werner, 2005).

Incidence & Prevalence:

Incidence and Prevalence of jaundice will depend entirely on the underlying hepatic condition, as jaundice is only a physically manifested symptom.

In a study undertaken in France, medical researchers found that the incidence of drug-related hepatic injury was 14 in 100,000 citizens each year (Navarro & Senior, 2006).  According to Wasley et al (2007) 20 - 30% of recently infected American hepatitis patients additionally presented with jaundice in 2005.

Indications for MT:

The therapist must first identify the underlying condition resulting in the presence of jaundice, and take the necessary precautions according to this condition (Werner, 2005).  Generally, reduced session length, relaxation style massage with light pressure only and avoidance of the liver and spleen areas (upper abdomen) are advised.  If the patient presents with any form of hepatitis (including viral hepatitis) in addition to jaundice, the therapist must take stringent hygiene precautions, ask the client to leave their underwear on during the massage and preferably be vaccinated against all Hepatitis strains, particularly Hepatitis B (Premkumar, 1999).

Contraindications for MT:

Avoid moderate to heavy massage of the abdomen due to possible enlargement of the liver and spleen or do not massage this area at all (depending on their underlying condition/s).  Do not use heavier than relaxation pressure as this can easily lead to bruising, if the client presents with underlying bleeding disorders (Werner, 2005).

 Massage is generally contraindicated when jaundice is apparent (and the cause unknown), as this is a warning sign of a more serious hepatic illness and massage could inflame the liver further.

References:

Brienza, N., Dalfino, L., Cinnella, G., Diele, C., Bruno, F. & Fiore, T.  (2006) Jaundice in Critical Illness: Promoting Factors of a Concealed Reality.  Intensive Care Medicine, 32 (2).

Hussaini, S., O'Brien, C., Despott, E. & Dalton, H.  (2007) Antibiotic Therapy: A Major Cause of Drug Induced Jaundice in Southwest England.  European Journal of Gastroenterology & Hepatology, 19 (1).

Navarro, V. & Senior, J.  (2006) Drug-Related Hepatotoxicity.  The New England Journal of Medicine, 354 (7).

Premkumar, K.  (1999) Pathology A-Z: A Handbook for Massage Therapists.  Calgary: Lippincott Williams & Wilkins, pp. 209 - 211

Suman, A. & Carey, W.  (2006) Assessing the Risk of Surgery in Patients With Liver Disease.  Cleveland Clinic Journal of Medicine, 73 (4).

Werner, R.  (2005) A Massage Therapist's Guide to Pathology.  Philadelphia: Lippincott Williams & Wilkins.

Wasley, A., Miller, J. & Finelli, L.  (2007) Surveillance for Acute Viral Hepatitis - United States 2005.  MMWR: Surveillance Summaries, 56 (SS03).

Professional Practice

Blog 3: Ethics - Reflect on Ethical Principles Relevant to Massage Practice.

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.

Power Differentials

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

This includes:

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.

Dual Relationships

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.

Malpractice

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.

References:

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

Pathology: Condition 2

Pathology: Integumentary, circulatory & nervous systems

Condition 2: Papulosquamous Dermatoses

Draft due: 27th July, Final due: 14th August, Peer assessment: 28th August 2009.

Description:

Contagious papulosquamous dermatoses are a group of skin diseases with various etiological factors, the most common types of which include tinea pedis (athlete's foot), tinea corporis (ringworm), scabies, and impetigo.

Considering that there are a wide variety of non-contagious papulosquamous dermatoses with similar signs and symptoms, it is best to ask the client if they are aware of their skin disorder and ask to see their medical records or refer on to get medical clearance before massaging them.

Etiology:

Ringworm & Tinea are both fungal infections caused by a group of fungi known as dermatophytes. Warmth and humidity are optimum factors for the onset of these conditions, ringworm can be transmitted from animals to humans, whereas athlete's foot can be transferred via skin contact and infected objects (Premkumar, 1999).

Scabies is caused by an infestation of the parasitic female scabies mite (sarcoptes scabiei) which is also transferred by skin to skin contact and close contact with contaminated towels, bedding, or hairbrushes.

Impetigo is caused by a streptococcus or staphylococcus bacterial infection which has breached the integumentary barrier (Schenck, 1999).

Signs & Symptoms:

Papulosquamous dermatoses are typified by a papule, inflammation and usually the development of a plaque on the surface (Mondofacto, 1998).

In the case of Ringworm a distinct red circular rash appears, resembling a ring. This lesion can be itchy or present a burning sensation.  

Athlete's foot is identified by pale weeping skin between the toes and red, flaky crusted skin at the site of the infection.  Again, this may itch or burn, and the plaque formed by this crusted skin can weep a clear discharge.

The presence of Scabies can be identified on close inspection as a tiny greyish burrow no more than 2-3mm in length which may have a visible mite at the end - usually a tiny dark dot (Fleisher, Ludwig & Silverman, 2002).  This may not be visible to the naked eye, so the MT may look at other symptoms such as intense itching and as a result redness, where the affected skin has been repeatedly scratched.  A skin scraping is the usual medical procedure for determining whether a scabies infestation is present.

When impetigo is present, flat blisters are visible which rupture and as a result, crusts may emerge in a clustered group (Schenck, 1999).

Morphology:

If left untreated, the fungal infections of ringworm and athlete's foot can complicate, resulting in secondary bacterial infections particularly in the case of an impaired immune system.  The itching may lead to repeated scratching at the lesions which will irritate them, potentially spreading the fungus via the fingers and nails, and further destroying the integumentary barrier of the skin (Thiers, Sahn & Callen, 2009).

The female scabies mite lays eggs at the end of its burrow in the skin, thus rapidly increasing the scabies population over a relatively small time.  Optimum warmth and during night hours while the client is sleeping tend to encourage the growth of the infestation population, as this is when they are most active (Fleisher et al, 2002).

As Impetigo is contagious, it is most often transferred to the face via the hands and vice versa.  In the case that it reoccurs after treatment, it may be that the bacteria have been lying dormant in the nostrils, in which case a topically administered antibiotic is necessary (Fry, 1997).

Incidence & Prevalence:

The incidence for Impetigo and similar fungal infections is higher in warm, humid and tropical climates providing an optimum breeding ground for bacterial infection, occurring most commonly in school age children and teenagers (Bracker, 2001).

In the US and Europe, Scabies appears to occur in cycles of infestation spanning 3-4 decades, in 0-6% of the population (Nelson & Woodward, 2006).

Indications for MT:

If the skin disorder has been examined and cleared by a medical professional as being non-contagious (e.g. psoriasis, pityriasis rosea, excema) the patient may benefit from massage, provided the total area of affected skin is not large (Mitchell & Penzer, 2000).  In this case, massage over the unaffected areas can assist with the patient's healing process (Werner & Benjamin, 1998), allowing for the circulation of lymph, and the positive result this could have on non-contagious skin disorders which may have an underlying immune connection, ie. sores that appear as a result of the immune system in distress (Thiers et al, 2009).

Contraindications for MT:

Tinea Corporis (Ringworm), Tinea Pedis (Athlete's Foot), Scabies and Impetigo are all contagious skin disorders, therefore if the client presents with any of the symptoms listed here (such as itching, redness and the appearance of crusted lesions), all skin to skin contact is contraindicated until treatment has ended and medical clearance is obtained.

Reference List:

Bracker, M.  (2001) The 5-minute Sports Medicine Consult.  US: Lippincott Williams & Wilkins, p. 460.

Elluminate session 2.  (18th June, 2009) Otago Polytechnic Massage Therapy Diploma Course.

Fleisher, G., Ludwig, S. & Silverman, B.  (2002) Synopsis of Pediatric Emergency Medicine.  US: Lippincott Williams & Wilkins, p. 203.

Fry, L.  (1997) An Atlas of Dermatology.  London: Taylor & Francis, p. 83.

Mitchell, T. & Penzer, R.  (2000) Psoriasis at your fingertips: the comprehensive and medically accurate manual on managing psoriasis.  London: Class Publishing Ltd, p. 74.

Mondofacto.  (1998) Skin Diseases: Papulosquamous.  Retrieved on the 8th July, 2009 from: http://www.mondofacto.com/facts/dictionary?query=skin+diseases%2C+papulosquamous&action=look+it+up

Nelson, A. & Woodward, J.  (2006) Sexually Transmitted Diseases: A Practical Guide for Primary Care.  New York: Humana Press, p.269.

Premkumar, K.  (1999) Pathology A - Z: A Handbook for Massage Therapists.   Calgary: Lippincott Williams & Wilkins.

Schenck, R.  (1999) Athletic Training and Sports Medicine.  New York: Jones & Bartlett Publishers, p. 572.

Thiers, B., Sahn, R. & Callen, J.  (2009) Cutaneous Manifestations of Internal Malignancy.  CA: A Cancer Journal for Clinicians, 59 (2).

Werner, R. & Benjamin, B.  (1998) A Massage Therapist's Guide to Pathology.  Michigan: Williams & Wilkins.