The relationship we form with clients can be much more significant to the client than we might realize, and ending that relationship must be done with consciousness and care. I received a letter from a woman who wrote to me about her experience with a massage therapist, and it addresses this issue. The letter, my reply and my thoughts on the topic follow. Names and locations are withheld for privacy.

Dear Dianne,
I have been reading your Ethically Speaking column with great interest. I hope you don’t mind my taking just a moment of your time to ask a question on client ethics. It involves an extremely disturbing incident I recently experienced with my AMTA massage therapist of [several] years. I realize that your column is directed toward massage therapists and not necessarily clients, but I would be profoundly grateful for your input.

My general question is: Are massage therapists trained in, or bound by, specific ethics and policies regarding client termination? My specific situation is more complex, but the termination ethics are what concern me most.

Here is the full scenario, just for background. A few weeks ago, I walked into my massage therapy session and was informed by the massage therapist that it would be my last. She claimed we had reached the end of what we could do together, that we weren’t making the progress she wanted to see, and that she sensed I was ambivalent about our work together.

There was no room for negotiation, and no prior discussion of termination. She stated her diagnosis of the situation, and she terminated my ability to continue to see her. We had never discussed whether or not I felt the bodywork was effective, if we were making progress, or if I felt ambivalent about the work. Her bodywork had focused on the physical manifestation of multiple traumas I have survived in an attempt to release them through bodywork.

More than a year ago, she had introduced the idea of working collaboratively with a psychotherapist so that there would be a safe environment in which I could work through psychological issues released through any of the bodywork. It was working very well for me, and I was receiving psychotherapy in tandem with massage.

The massage therapist put an abrupt halt to my massage sessions without even consulting this psychotherapist. Even worse, she terminated on the day this psychotherapist was leaving for a weeklong vacation, and would be unavailable to meet with me. They did finally meet at my request to discuss the reasons for the termination; the massage therapist told my psychotherapist that she knew I would be upset, but that I was an adult and was responsible for my own actions. If I had decided to injure myself, it was my own decision. She also admitted to similar abrupt terminations in the past with other clients.

Needless to say, this leaves me deeply, deeply concerned, and it does not reflect well on the practice of massage in general. She advertises expertise in healing mind/body/energy work, yet she has clearly demonstrated a capacity for knowingly damaging a client and refusing to accept responsibility for the consequences.

My point is that if a massage therapist chooses to delve into deeper, healing-oriented mind/body work, she should be fully aware of, and ready to commit to, the deeper responsibilities that come along with it. Once a massage therapist makes that commitment to deeper work, she just can’t quit without some form of client preparation or termination process. And this becomes even more critical the more time she spends with that client, and the more she lowers defenses and invests her trust.

I would so appreciate any feedback from you. I am not a spiteful or vindictive person, but I am deeply concerned that she is still practicing and could do this again with less fortunate consequences. Is there anything I can do to prevent this from happening to another trusting client?

Sincerely,
Susie Client

 

Dear Susie Client,
Thank you for writing to me about this situation. Training in professionalism surely covers such matters, but as an educator, I can tell you that a school has no control over what graduates do once they begin practicing in the field.

What I hear is that you feel traumatized by this abrupt termination, and that you don’t feel satisfied by her explanation. This causes me concern for you, and I hope you have had a chance to discuss this with your psychotherapist by now.

You do have an option to file a grievance with the AMTA for ethical misconduct. They would hear your complaint and investigate the matter, and it could result in the massage therapist’s AMTA membership being suspended. AMTA typically mandates ethics training in such cases. That is the only action I know of for making a formal complaint. You might want to check into the licensing laws for massage therapists in your state to see if there are any provisions for filing complaints.

I hope this is helpful. Contact me if I can be of further assistance.

Sincerely,
Dianne Polseno


Client Termination
Terminating a relationship, be it personal or professional, can be a very challenging task. This is often evidenced by personal and professional relationships that are dysfunctional, damaging and no longer productive to either party, yet they continue because it seems easier than facing the discomfort of ending them. Still, because it is an absolute necessity that we are able to recognize our professional and personal limits and boundaries in order to take care of ourselves, we may find the need to terminate our working relationship with a client. Or, it may be appropriate to end the professional relationship because the client’s work with us is complete.

When the time comes to do the termination work, regardless of the reason for the decision, our ethical skills will be honed as we face the task of being true to ourselves while considering the effect the termination can have on the client. Our obligation is not only to ourselves; we also have an obligation to the client to do no harm. Of course, I am not speaking here of any situation where the client is sexually or otherwise inappropriate, or in any case where our physical safety is in jeopardy. If such critical incidents arise, immediate termination without discussion may be the most appropriate response. In those situations, the client’s emotional response to the termination is not our first concern. However, when we are working with a client for any length of time, even if the client did not seek our services to address emotional issues, the client’s emotional reaction to the termination is a very important consideration. Termination must be planned and carried out with great care to minimize the effects that may occur.

The most effective way to ensure that termination work will be as safe and uncomplicated as possible is by framing every client/massage therapist relationship with informed consent. (See Page 136 in the Spring 2001 Massage Theapy Journal issue for an article on informed consent.) At the very least, this means that there will be ongoing dialogue about the intention, goals and progress of the treatment course. This way, when goals are not being met, or the treatment course is not going well and a change needs to occur, there are no major surprises or abrupt cessations.

Termination Tips
The following tips may help you carry out a client termination with ethical poise and minimal offense:

Dialogue. Minimize the surprise potential by keeping an ongoing dialogue with clients about their progress. Review your plan, goals, concerns and professional perspective with clients regularly. Offer them an opportunity to ask questions, have input, and be part of the planning and terminating process.

Document. If you are keeping written records of client pro-gress, or lack thereof, it can be easier to substantiate a need for termination or referral. For each session, document the subjective statements a client makes, as well as your objective findings, and document your plan that results from the subjective and objective findings. If, for example, a client reports for consecutive weeks that he or she is not experiencing any improvement, and your plan states that you will assess for the appropriateness of continuing treatment, these documented statements prove that you are conscientious and are working with a plan for the client’s best interest.

Get supervision. Talking with a colleague or mentor about a problem client or difficult case offers us another perspective, and can give us more options for action that we might not have considered. Two heads are usually better than one in solving an ethical problem, such as how to effectively terminate a relationship with a client.

Consider the client’s perspective. Two people involved in a situation can have totally different interpretations of reality, and it can be helpful to bridge the gap between your perspective and the client’s by acknowledging the disparity. Put yourself in the client’s shoes, and ask yourself how you would feel if you were the client. Ask yourself how you would want a professional relationship to be terminated if it were happening to you.

Give the client room to react, respond and recover. We can help make the shift less traumatizing if we are available to listen to clients, allow them to ask questions and help them understand the reasons for the termination.

Final Thoughts
There are times when it is necessary and appropriate to terminate our relationship with a client. If we have invested time in working with a client, handling the situation ethically and empathetically is vital. In The Educated Heart, Nina McIntosh writes: “We want to do our best to end our professional relationship with clients in a way that doesn’t leave them with negative feelings that could color how they evaluate their entire time working with us. If we terminate with a client carelessly, we leave them with a bad feeling about the whole experience of working with us or make them wary of going to another practitioner.”

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Dianne Polseno, former chair of the National Ethics Subcommittee, is a practicing massage therapist, practical nurse, academic director and teacher at the Bancroft School of Massage Therapy. She is the author and publisher of Comprehensive Review Manual For Massage Therapists. She can be reached at: 1 Raymond St., North Smithfield, RI 20896-8215, or at: dipol@aol.com.