Maintaining and upholding an ethical practice is important for any profession, but especially so for massage therapy. While working with your clients, complicated issues may arise, and knowing how to handle these problems in a professional, ethical manner can be the key to a successful practice.
Massage therapy is a profession built on the idea of trust. Trust in your client and their trust in you are vital to creating a strong therapist/client relationship and, ultimately, your ability to help your clients.
Ethical standards are at the center of building trust with your clients, and creating and maintaining a therapeutic environment that is beneficial for both you and your clients. According to Jean Middleswarth, a licensed massage therapist and ethics instructor, by behaving ethically, massage therapists are acting as responsible role models who help build public trust and establish a “standard of expectation for a professional therapeutic massage.” Ethical conduct also helps provide consistency in the professional behavior of massage therapists, thus maintaining the integrity of the profession, she adds.
That’s not to say, however, that ethical dilemmas don’t occur. In fact, Kathy Ginn, a massage therapist who studied ethics under Cedar Barstow at the Right use of Power Institute in Boulder, Colorado, believes they are fairly common because of the nature of the massage therapy profession. “The relationship between client and practitioner can be complicated and confusing for both parties,” warns Ginn. The complex nature of maintaining a professional relationship, Ginn explains, is compounded because of the intimacy inherent in massage therapy.
Recognizing Ethical Dilemmas
Ethics is not always a clear cut, black and white matter. Sometimes, the ethical waters are a little muddied, so you need to be diligent, recognizing potential ethical pitfalls and regularly reassessing your ethical standards. Following are a few areas where massage therapists commonly encounter ethical dilemmas:
Balance of Power. Ginn explains that the most common ethical dilemmas are often subtle and overlooked. Many ethical gray areas concern what Ginn calls the power differential: The complex balance of power between client and therapist. “The key is to acknowledge the complexity,” says Ginn, “and understand one’s own history of power.”
According to Ginn, massage therapists can create ethical dilemmas by overusing their power. Sometimes the overstepping of the use of power is obvious, as with inappropriate touch, for example. Other times, however, the overuse of power is more subtle, like being late for a client’s massage therapy appointment, or not listening to your clients concerns and questions carefully.
In addition to overusing power, massage therapists can also underuse their power according to Ginn. This idea may seem counterintuitive, but can be just as damaging to the therapeutic relationship. Some examples of this situation include massage therapists who don’t have any established practice policies or fail to directly establish boundaries when working with clients. Not being able to quickly and properly address conflict is another way massage therapists underuse their power.
Similarly, clients can over- or underuse their own power, too, though Ginn is quick to point out that massage therapists need to take more responsibility than their clients. The dynamic is similar to the relationship between a doctor and their patient or a student and their teacher. A healthy client-massage therapist relationship is not equal, but balanced.
In order to achieve a balanced relationship, Ginn explains, massage therapists must learn to “teach your clients to be clients.” Before beginning a massage therapy session with a new client, you should clearly state who you are, how you work and what your practice policies are. Additionally, you should create guidelines for the session room and explain to your clients what you and they should expect from one another. Let your clients know what their responsibilities are in the relationship: to pay at the time of service, to arrive on time, and to speak up if something makes them uncomfortable, for example.
Boundaries: Another important aspect of an ethical practice is maintaining proper boundaries—the line between client and therapist. “Boundary issues are common, and every client has different issues,” explains Middleswarth. “Know what the boundaries are so they can be respected.” According to Middleswarth, if you find yourself thinking that something doesn’t feel quite right or that you spend too much time thinking about a particular client, you might be in danger of overstepping your bounds.
And that’s something she has some experience with herself. After becoming rather close friends with a client, Middleswarth noticed the line between client and friend started to blur, making maintaining a professional therapeutic relationship difficult. To rectify this problem, Middleswarth shored up the boundaries again by reinforcing the client-therapist relationship, talking to the client and agreeing to no longer discuss personal matters during massage therapy sessions. “If a client asks something too personal,” Middleswarth says, “I won’t answer.”
This example illustrates how crucial it is for you to be mindful of the nature of your relationship with your clients in order to avoid any compromising situations or conflicts of interest. Furthermore, when treating clients with whom you have a personal relationship, like friends and family members, you need to establish the therapist-client relationship within the treatment room—without exception.
Remember, too, that you should establish any touch boundary issues a client may have before beginning a session. “Boundary issues should be addressed directly,” Middleswarth advises. “Tell them they should undress only to the level of their comfort.” Even for clients you see regularly, you may want to remind them of this fact every now and again, as comfort levels may change from massage session to massage session.
Ask, too, if there are any areas the client doesn’t want you to work on, and then check in with them during the session to make sure they’re comfortable. “Their body will tell you when it’s not okay,” Middleswarth says. For example, a client who tenses up when you work on a certain area is probably a good indication that they are uncomfortable.
Scope of Practice: Additionally, massage therapists need to know their scope of practice and be aware of their professional limitations. This includes knowing when to terminate treatment and refer out. “When progress has stopped, but pain persists, it might be time to refer them to a different health care provider,” Middleswarth notes. Recognizing and admitting when you are no longer able to help your client may be one of your toughest challenges professionally, but in order to practice ethically, you need to know when your clients need something other than massage therapy.
Written Policies: Finally, things like contracts and office policies can lead to tricky situations and ethical dilemmas when the terms and conditions are not clearly spelled out. For example, your policies regarding late clients and cancellation fees need to be clearly communicated to your clients at the time of booking. There are many options regarding cancellation policies, but no matter what policy you institute, make sure your clients are fully aware of the consequences of a missed session.
Effectively communicating your policies can help you avoid losing time, money and potential clients. Additionally, if you are an employer, having written policies that outline the expectations you have of your employees is very helpful. Things like mandatory staff meetings and professional expectations should be covered in your employee agreement in order to prevent any misunderstandings between you and your staff. It is also best practice to discuss ethics with your employees to protect the reputation of your practice.
According to Middleswarth, massage therapists can better navigate the muddied waters of ethical dilemmas by practicing self-awareness. Ask yourself some basic questions: Am I stressed? Am I tired? Am I emotionally running empty? Do I have a supportive social network? “If we are needy in any way,” Middleswarth warns, “we are particularly susceptible to stepping over boundaries.”
Although you’ve heard this advice before countless times: You need to take care of yourself in order to properly take care of your clients. Sometimes that means firing a difficult client who is taking up more of your energy than you can afford to spend. Or, making sure that at the end of your work day, you are leaving your professional life at the office. When you are feeling overstretched and depleted, keeping your boundaries firm and in place can be much harder than when you are well-rested and practicing self-care.
Self-assessment allows us to be better with our self-care. If you know the areas where you might be particularly vulnerable you can better find ways to manage what you find challenging. Massage therapists should be self-assessing continually, asking yourself some of the following important questions on a regular basis:
- What are my strengths?
- What do I need to work on?
- Is there a type of client that I am not comfortable working with (children,
- Am I holding to my boundaries with all my clients?
You understand the importance of ethics, for the safety and well-being of your clients, as well as yourself and your practice. As clear cut as many ethical standards are, there are those, too, that are less so—and it’s these gray areas that massage therapists really need to pay attention to in order to maintain professional and therapeutic relationships with their clients. Having some tools and resources to negotiate these issues is a great start.
Related: Drawing A Line—Defining Boundaries | Massage Therapy Journal
Ethics Continuing Education for Massage Therapists
Creating Healthy Boundaries | 3 Credit Hours - AMTA's best-selling course!
A Holistic Model for Ethical Practice | 2 Credit Hours
Ethical Dilemmas Fully Exposed | 1 Credit Hour
More massage ethics courses »