Ethics in the Massage Therapy Profession

Long-time massage therapists highlight common ethical dilemmas among massage therapists and offer guidance for tricky terrain.

 By Maureen Salamon, November 1, 2021

A year of uncertainty due to a global pandemic and more focus on the importance of self-care have merged to create a greater need for stress relief, one of massage therapy’s most-touted benefits. Yet Megan Lavery, who is dual licensed in massage therapy and professional counseling in Georgia, knows at least one person who confided that they are hesitant to schedule a massage for fear of being peppered by her therapist’s personal opinions in what should be a safe and therapeutic environment. The scenario, Lavery contends, would be a clear violation of ethics, not honoring the lopsided balance of power between therapist and client.

“Massage therapists should never be talking about their life, their personal issues or their beliefs,” Lavery says. “It’s really disheartening this (potential client) thought this was a normal part of getting a massage.”

The spillover of personal into professional—whether by the therapist or the client—is far from the only muddy boundary facing massage therapists today.

A 2017 paper in the International Journal of Therapeutic Massage and Bodywork1 underscores the connection between ethical principles and boundaries in the practice of massage therapy.

Moreover, ethics are typically part of entry-level massage education for a compelling reason: “To help give guidance to safeguard (clients) and protect the profession,” the authors wrote. “I feel like we need an overall rule of thumb, something to guide us as we move forward as an industry that joins all our modalities together to make the client feel safe and keeps us safe as well,” says Corri Flaker, a massage therapist based in Columbia, Mo., who taught ethics at Columbia Career Center. “Our profession and service is really about trust, about someone literally putting their care in our hands in a private setting. Trust is the keystone of what we do.”

Clients Can Cross the Line

Obtaining informed consent from patients is fundamental to the ethical delivery of health care, including massage therapy, according to a 2014 paper2. The small analysis found that a consent process that recognizes and accommodates the obvious information gap between client and therapist, also guided by clearly defined goals within the relationship, may be most effective.

But sometimes it’s the client who violates ethical boundaries, and not just by expecting more than a therapeutic massage, says Michael Cruz Kim, a massage therapist and company educator for a day spa employing more than 800 massage therapists in Hollywood, CA.

Kim says clients can show a “lack of respect for the session” by using a massage therapist as a sounding board or by looking to their therapist for personal validation. A careful intake process can counter this possibility and set the tone for the therapeutic relationship, he notes.

Establishing ethical boundaries starts with the first interaction, including website presence and how a therapist dresses, Kim says. Massage therapists at his spa wear a plain uniform and no makeup or cologne.

“We don’t want to distract from what this is,” Kim explains. “Every question, every word I speak to the client, has a purpose. I ask them to talk about their pain and how they’re using their body, because everything I respond to is related to that.”

Major Quandries and Advice

Massage therapists face ethical dilemmas frequently, according to Dennis Dickinson, who practices in Raleigh, N.C., and previously taught ethics at the School of Health Sciences at ECPI University in Virginia.

Here, long-term massage therapists share common predicaments in the massage therapy profession, offering tips on how therapists might respond and what to avoid.

Dilemma: Maintaining professional boundaries
Advice: This effort starts with immediately and properly draping the client at the start of a session. No touching should occur that isn’t part of the massage, even patting a client’s forearm. “It’s always possible they may misinterpret that and build their own narrative,” Kim explains. “You have to build boundaries before you even massage the person.”

Additionally, don’t allow clients to bend ethical lines. “Don’t let them keep being late or changing times, either—that’s another way of keeping professional boundaries,” Flaker advises. “Don’t let one client get away with something you wouldn’t want all of your clients to do.”

Dilemma: Being honest about massage benefits
Advice: Mounting clinical evidence supports the therapeutic benefits of massage for many health conditions, particularly low back pain, according to a 2018 paper3 in Complementary Therapies in Clinical Practice. But, as author Rosemary Chunco points out,4 some supposed benefits—such as its ability to help release lactic acid from muscle tissue after exercise—have been overturned by more recent research. This is why massage therapists need to stay up-to-date and transparent.

“We need to live within a code of ethics so we’re not telling clients we can do something out of the scope of what we can do, or diagnose them with something we know nothing about,” Flaker says. “If someone asks a question about nutrition or chiropractic or another specialty we’re not in—or starts talking about their feelings—we need to refer them appropriately. We can’t be everything for everyone.”

Dilemma: Navigating friendships with clients
Advice: Friends who become clients “may be unable to tell you the pressure’s too hard or they feel uncomfortable with the way you’re touching them,” Flaker points out. “That could damage the friendship and damage their experience with massage. Better to find someone for them to see that isn’t you, and you can keep your friendship.”

But other massage therapists disagree, and Kim says it’s possible to “still stay friends and be professional in a massage room.”

“It requires a leader,” he says. “You set ground rules and expectations and clarify your intentions.”

Dilemma: Handling well-known clients, such as athletes
Advice: While it’s hard to resist the temptation to tell others your client is a household name, many massage therapists are bound by confidentiality. Even asking a celebrity to make an exception might be viewed as an ethical violation because of a power differential in the therapist-client relationship, Lavery notes.

“Just because they’re famous doesn’t make them a tabloid in the massage world,” Flaker says.

Kim agrees: “You’re a therapist before you’re a fan. The fan has to take a back seat; you’re on the bench. The therapist is the one calling the shots.”

Dilemma: Maintaining rules about social media usage
Advice: Keep professional and personal social media accounts separate, and don’t post any personal viewpoints or information on professional sites, Lavery advises. “This isn’t rocket science,” she adds. “It’s discouraging that people are still making those mistakes.”